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Background and Aims  Previous recommendations suggested living donor liver transplantation (LDLT) should not be considered for patients with Model for End‐Stage Liver Disease (MELD) > 25 and hepatorenal syndrome (HRS).    Approach and Results  Patients who were listed with MELD > 25 from 2008 to 2017 were analyzed with intention‐to‐treat (ITT) basis retrospectively. Patients who had a potential live donor were analyzed as ITT‐LDLT, whereas those who had none belonged to ITT‐deceased donor liver transplantation (DDLT) group. ITT‐overall survival (OS) was analyzed from the time of listing. Three hundred twenty‐five patients were listed (ITT‐LDLT n = 212, ITT‐DDLT n = 113). The risk of delist/death was lower in the ITT‐LDLT group (43.4% vs. 19.8%,  P  < 0.001), whereas the transplant rate was higher in the ITT‐LDLT group (78.3% vs. 52.2%,  P  < 0.001). The 5‐year ITT‐OS was superior in the ITT‐LDLT group (72.6% vs. 49.5%,  P  < 0.001) for patients with MELD > 25 and patients with both MELD > 25 and HRS (56% vs. 33.8%,  P  < 0.001). Waitlist mortality was the highest early after listing, and the distinct alteration of slope at survival curve showed that the benefits of ITT‐LDLT occurred within the first month after listing. Perioperative outcomes and 5‐year patient survival were comparable for patients with MELD > 25 (88% vs. 85.4%,  P  = 0.279) and patients with both MELD > 25 and HRS (77% vs. 76.4%,  P  = 0.701) after LDLT and DDLT, respectively. The LDLT group has a higher rate of renal recovery by 1 month (77.4% vs. 59.1%,  P  = 0.003) and 3 months (86.1% vs, 74.5%,  P  = 0.029), whereas the long‐term estimated glomerular filtration rate (eGFR) was similar between the 2 groups. ITT‐LDLT reduced the hazard of mortality (hazard ratio = 0.387‐0.552) across all MELD strata.    Conclusions  The ITT‐LDLT reduced waitlist mortality and allowed an earlier access to transplant. LDLT in patients with high MELD/HRS was feasible, and they had similar perioperative outcomes and better renal recovery, whereas the long‐term survival and eGFR were comparable with DDLT. LDLT should be considered for patients with high MELD/HRS, and the application of LDLT should not be restricted with a MELD cutoff.

Analysis of Survival Benefits of Living Versus Deceased Donor Liver Transplant in High Model for End‐Stage Liver Disease and Hepatorenal Syndrome