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Volume: 17 Issue: 1 January 2019 - Supplement - 1


Gender Imbalance and the Relationship Between Living Donors and Recipients in Liver Transplantations in an Organ Transplant Center in Turkey

Objectives: Because of the scarcity of publications on gender differences and the relationship between living donors and recipients in liver transplant procedures, we carried out this study with the objective to examine the gender distribution of donors and recipients and the relationships between donors and recipients in living related-donor liver transplants performed in a university hospital in Ankara, Turkey.

Materials and Methods: We retrospectively evaluated the data of 549 patients who underwent living related-donor and deceased-donor liver transplant procedures conducted in a university hospital between 1988 and 2017 and the 409 living donors.

Results: Males constituted 53.1% of the 409 living related liver donors and 63.6% of the living liver recipients. We found that 72.9% of the deceased-donor liver transplant recipients were also male. Of living related donors, 91.4% were blood relatives, with 74.8% being first-degree relatives. The most common donor-recipient relation was mother to son. Analyses of interspousal donations showed a significant difference between husband to wife and vice versa (7 vs 17; P < .05).

Conclusions: Most recipients and donors in living related-donor liver transplants were males with a young predominance. It is not known whether this might be related to biologic, psychologic, or socio-cultural features of patients, gender issues, or economic factors. Further research with qualitative components on the influential factors, including gender, is needed.

Key words : Donor-recipient relation, Living-related donor liver transplantation


Liver transplantation is an important intervention to reduce mortality in patients with terminal liver disease.1 However, because of insufficient postmortem donations, living organ donations have become an important option.1,2 In 1990, the first pediatric segmental related living-donor liver transplant (LDLT) in Turkey and in the Middle Eastern region was performed by Haberal and colleagues.3-5 During 27 years of LDLT history in Turkey, 8279 LDLTs (69.0% of all 11 999 liver transplants) have been performed nationwide in 99 different centers.6

Organ donation is influenced by legislation, cultural values, and religious beliefs, as well as by health considerations.7 Surveys have shown that, in LDLT, living liver donors are generally healthy family members or individuals with emotional ties to the recipient. They are also exposed to high levels of psychologic pressure to make a decision. In addition to being able to save someone’s life, they will also be exposed to some health risks.1

Although results of studies worldwide have indicated that women comprise two-thirds of all organ donations, slightly more males are living liver donors, with two-thirds of recipients also being male.1,7 Gender issues in organ donation can also be explained by the donor’s relationship to the recipient. Living donors usually donate to a loved one such as a spouse, child, sister/brother, parent, or other relative.7 When donor and recipient relationships were examined, it was found that 80.0% were relatives, 11.0% were not relatives, and 9.0% were spouses.1

Because of limited research on gender issues and the relationship between LDLT donors and recipients in Turkey, we carried out a study with the objective to examine male-female distribution and relationships between donors and recipients in LDLT performed in a university hospital in Ankara, Turkey.

Materials and Methods

In this descriptive study, we retrospectively evaluated hospital records of the living liver donors (409 cases) and all 549 liver recipients who underwent LDLT and deceased-donor liver transplant in a university hospital between 1988 and 2017. We analyzed data of all liver transplants performed until December 31, 2017. Data on the number of male and female donors and recipients, donor-recipient relationship, and age at the time of the liver transplant were taken from Nucleus Program records used for the Hospital Registration System. The study protocol was approved by the Institutional Review Board.

Statistical analyses were performed with SPSS software (SPSS: An IBM Company, version 25.0, IBM Corporation, Armonk, NY, USA). Descriptive statistics, averages, frequency tables, and dependent group t tests were used to analyze the variables. Statistical significance was identified by a two-sided P value of < .05.


Between 1988 and 2017, 549 liver transplants were performed at our hospital. Of these, 74.5% (409/549) were from living donors and 25.5% (140/549) were from deceased donors. During the analyzed period, the annual mean number of LDLTs increased from 3 to 26 cases (total 409 cases) per year, and the annual mean number of deceased-donor liver transplants increased from 3 to 6 per year.

Males constituted most living donors (53.1%; 217/409) and most LDLT recipients (63.6%; 260/409). Most deceased-donor liver transplant recipients were also male (72.9%; 102/140) (Table 1). The median age of LDLT recipients was 13.0 ± 20.6 years (range, 0-68 y; mean age of 21.4 ± 20.6 y), with 60.0% (245/409) of LDLT recipients being younger than 18 years (Table 1). In addition, 44.9% (110/245) of LDLT recipients were under the age of 5 years. In contrast, 99.2% (406/409) of all donors were 19 years or older (range, 19-66 y), with an average donor age of 34.7 ± 9.2 years (Table 1). Female living donors donated more often to pediatric LDLT recipients (32.0% females [131/409] vs 27.9% males [114/409]), whereas male living donors often donated to recipients who were over 19 years (25.2% males [103/409] vs 14.9% females [61/409]).

Most living donors were blood relatives (91.4%; 374/409), with 55.6% (208/374) being male and 44.4% (166/374) being female (Table 2). Only 8 donors (5 female and 3 male donors) were nonblood relatives, and 3 female donors were not relatives. First-degree blood relatives accounted for 74.8% (306/409) of living donors. Most were parents (68.0%; 208/306), as the most common donor-recipient relationship was mother to son (23.5%; 72/306). Fathers donated less than mothers did (28.4% vs 39.5%, respectively). Brothers and sisters donated more frequently to brothers than to sisters. Only 8 brothers (2.6%) donated livers to sisters, whereas 25 brothers (8.2%) donated livers to brothers. Second-degree blood relatives accounted for 14.2% (58/409) of living donors, with the predominant donor-recipient relationship being male to male (50.0%; 29/58). Although the numbers were small, interspousal donations showed a significant difference between husband to wife and vice versa (7 vs 17) (Table 2).


In our center, the average number of LDLTs increased from 3 to 26 cases (total 409 cases) per year during the past 14 years. The annual average number of deceased-donor liver transplants did not change significantly during the analyzed period. Worldwide, the number of LDLTs has increased yearly due to the chronic shortage of livers from deceased donors.8 According to the literature, education and socioeconomic levels, culture, and religious beliefs affect the attitudes of communities toward deceased organ donation. In Turkey, in addition to these factors, deceased organ donation is low due to lack of knowledge or misinformation and because most families do not allow organ donation.9-11

In our study, the specific distributions of LDLT between males and females showed that slightly more males (53.1%) were donors and more males (63.6%) were recipients (Table 1). These results are similar to the distribution of 2360 LDLTs performed between 2016 and 2017 in Turkey, in which 62.4% of living donors were males and 64.9% of recipients were males.6 Our findings are similar to results of a study presenting data of 19 countries and 3 single transplant centers (8933 living donors and 9108 LDLT recipients). In 11 countries (Austria, China [Beijing], France, Lebanon, Italy, Japan [Tokyo], Korea, Mexico, Romania, Australia/New Zealand, and the United Kingdom), 53.1% to 65.0% (8933) of living donors were males, and in 7 countries (Belgium, China [Hong Kong], The Netherlands, Poland, the United States, Lebanon, and Croatia) more women were living donors.12 In 12 countries (Belgium, France, China [Beijing], China [Hong Kong], Korea, Germany, Italy, Japan [Tokyo], Lebanon, the Netherlands, the United States, and the United Kingdom), 59.4% to 70.0% (9108) of the LDLT recipients were males, whereas in 4 countries (Mexico, Poland, Romania, and Austria), females were the more frequent recipients.12 In Asian countries, 70.0% of recipients were male. The distribution between males and females was quite balanced in Europe and the United States.1 At a transplant center in Egypt, 64.7% (125/193) of living donors were male, and most recipients were male.12

There are few studies investigating the underlying reasons for gender imbalance in LDLT donors and recipients. The disparity observed between the sexes in transplant is influenced by many intertwining biologic and social factors. The epidemiology of diseases leading to transplant is not equal for men and women. Genetically determined immunologic differences also play a role.13 Male individuals tend to be more prone to hypertension or ischemic heart disease; therefore, they may not be appropriate as donors. In addition, the most frequent indications for liver transplant are alcohol- and hepatitis C-induced liver cirrhosis, which are both more frequently observed in men. Males have a higher incidence of end-stage diseases that necessitate a transplant, and this could be the reason why men are more frequent recipients.14,15 Women and men are ascribed different social, economic, and cultural roles, and a disparity of knowledge may exist.7 Women generally feel responsibility and tend to be caregivers. Because of these psychosocial factors, women are much more likely to be living organ donors than men. In many countries, due to the traditional gender roles of women in the family, women are also obligated to take care of sick family members.12,13,16,17

These traditional roles of women as caregivers in the family and the psychologic factors could also be the reason why female living donors donated more often to pediatric LDLT recipients (32.0% females vs 27.9% males) in our center. However, we did not examine the underlying reasons for their decision.

Motherhood may also give women a sense of duty to volunteer for donation to save their spouses, children, and other family members. Sisters, mothers, and wives have been shown to more frequently donate their living organs to children, brothers, fathers, and husbands.16 In our study, most living donors were blood relatives (91.4%) (Table 2). Most first-degree blood relative donors were parents (68.0%), followed by siblings (15.6%) and children (13.1%). Second-degree blood relatives such as uncles, aunts, cousins, and grandparents accounted for 14.2% of living donors. According to Eurotransplant’s annual statistical report of 2017, first-degree relatives accounted for 89.1% (82/92) of LDLTs, as the most common donor-recipient relation was mother to child (42.4%) and father to child (32.6%).18 The report showed that only 6 donors had a spouse/partner relationship.18 In a study that included 11 countries by Hermann and associates, 86.0% of living donors and LDLT recipients were blood relatives. Most blood relative donors were parents (46.0%), followed by children (24.0%), siblings (18.0%), and other relatives (12.0%), including uncles, aunts, cousins, and grandparents.1 At a transplant center in Egypt, 32.1% (62/193) of blood relative donors were children, followed by siblings (16.5%) and parents (15.0%). There were 11 wives (5.7%) who donated to their husbands. Interestingly, there were no husbands who donated to their wives.12

In our study, although few in number (only 5.9% [24/409] of all cases; Table 2), interspousal donation showed a significant difference between husband to wife and vice versa (7 versus 17). In a report from the United Network for Organ Sharing, wife to husband transplants accounted for 73.0% of 360 spousal pairs of living organ donations.15 One study showed that more than 30.0% of eligible wives were willing to donate to their spouse, whereas less than 7.0% of husbands were willing to donate to their wives.7

In conclusion, we observed male and younger age predominance among donors and recipients of LDLTs in our center. It is not known whether this was related to biologic, psychologic, or sociocultural features of patients and gender issues or to economic factors. Although there was a significant male predominance among donors when the relationship between donors and recipients was analyzed, in families, women more frequently donated to their spouses and children. Further research studies with qualitative components on the influential factors, including gender issues as underlying causes for decisions and biological factors for organ compatibility, are needed.


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Volume : 17
Issue : 1
Pages : 131 - 134
DOI : 10.6002/ect.MESOT2018.O82

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From the Departments of 1Public Health and 2Transplantation, Baskent University, Ankara, Turkey
Acknowledgements: This work was supported by the Research Fund of Baskent University (KA18/64). The authors have no conflicts of interest to declare.
Corresponding author: Sare Mıhçıokur, Baskent University Department of Public Health, 79.Sokak (Eski 12.Sokak), No 7/7, Bahçelievler, Ankara, Turkey
Phone: +90 5352760977