*Purpose: The ongoing shortage of livers in the setting of a growing waiting list remains a challenge in transplantation. First introduced in 1996, domino liver transplantation offers an option for patients with metabolic diseases to undergo a deceased donor liver transplant and utilize their native liver for a different patient with liver failure. Long-term analysis from a national US cohort is yet to be described.

*Methods: Between 1996 to 2019, 210 domino liver transplants were reported to UNOS from 45 centers. Donor and recipient characteristics were analyzed. Overall actuarial survival and liver graft failure were estimated using Kaplan-Meier. The 20-year study period was divided into 4 eras (1996-01, 2002-08, 2009-14, 2015-19) and overall and graft survival were compared using log-rank tests.

*Results: Donor and recipient characteristics are summarized in Table 1. Most recipients (94%) underwent a primary transplant. The most common underlying disease in adult donors was amyloidosis (85%); in pediatric donors, maple syrup urine disease (84%). The most common reason for transplant in adult recipients was cirrhosis (69.3%), followed by liver malignancy (21.2%), and metabolic disease (2.2%). Of the adult recipients, 90% received the liver from an adult donor; in children, 45% of liver grafts came from adult donors. Overall survival and graft failure rates were similar between recipients and donors. Although there was a trend towards improved overall and graft survival in later years (2009-19), the differences were not statistically significant.

*Conclusions: Domino liver transplants are a safe strategy for increasing availability of livers with patient and graft survival and graft rates comparable to deceased donor liver transplants.

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