*Purpose: We estimated the effect that expansion of living donor liver transplantation (LDLT) would have on mortality for individuals added to the waitlist.

*Methods: Using data from the Scientific Registry of Transplant Recipients, our analysis included all waitlisted adults in the US. We used a novel inverse probability weighted estimator, which can estimate the effect of interventions in the setting of finite resources, such as transplantation.

*Results: From 2005 to 2015, 93,812 eligible individuals were added to the waitlist – 51,322 received deceased donor grafts while 1,970 received LDLT. Individuals who received LDLT had more favourable prognostic factors, including lower mean MELD score at transplant (14.6 vs 20.5). The 1-year, 5-year, and 10-year cumulative incidence of death under the current level of LDLT utilization were 18.0% (95% CI: 17.8,18.3%), 41.2% (95% CI: 40.8,41.5%), and 57.4% (95% CI: 56.9,57.9%) compared to 17.9% (95% CI: 17.7,18.2%), 40.6% (95% CI: 40.2,40.9%), and 56.4% (95% CI: 55.8,56.9%) under a strategy which doubles LDLT utilization. Utilization would need to be increased by 6-fold to reduce 10-year mortality by 5%.

*Conclusions: Although LDLT may benefit individual patients who receive living donor grafts, even considerable expansions in LDLT would have a small impact on average survival for patients placed on the waitlist in the US. This may be because expanding the current pattern of utilization will not help those most in need.

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