BACKGROUND: Few published reports have addressed the feasibility of living-donor liver transplantation (LDLT) using elderly donors. We aimed to examine LDLT outcomes in elderly donors and identify clinical factors impacting safely conducted LDLT. METHODS: This study was conducted in collaboration with the Japanese Society of Hepatobiliary-Pancreatic Surgery. Data were collected from 140 patients who underwent LDLT using donors aged ≥50 years between 2013 and 2017 at nine collaborating hospitals. RESULTS: The 1-, 3-, and 5-year graft survival rates in recipients after LDLT employing elderly donors were 84.3%, 78.5%, and 76.3%, respectively, with 6-month mortality of 12.1%. Specific recipient-donor age combinations did not emerge as adverse prognostic factors. A total of 32 recipients (22.9%) had major complications requiring reoperation after LDLT, and 15 donors (10.7%) had major complications of Clavien-Dindo grade ≥II. Multivariate analysis revealed that graft-to-recipient weight ratio (GRWR) <
0.84% and neutrophil-to-lymphocyte ratio (NLR) >
6.6 were independent predictors of 6-month graft loss after LDLT. CONCLUSION: LDLT using elderly donors aged ≥50 years has acceptable graft survival and morbidity rates, and donor age >
50 years should not be an absolute contraindication for LDLT. In LDLT involving elderly donors, it is crucial to consider that GRWR <
0.84% and NLR >
6.6 are adverse prognostic factors. Addressing these factors is necessary to enhance the prognosis, aligning with the increasing public demand for this surgical procedure.