Living donor liver transplantation is a critical treatment for end-stage liver disease, with numerous advantages over deceased donor liver transplant. However, living liver donors face potential long-term physical, psychological, and social challenges. This review summarizes the long-term impact of donation and highlights the ethical need for lifelong follow-up. While major complications occur in 2-8% of donors, evidence on outcomes beyond one year remains limited. Biliary complications remain the most frequent serious morbidity, and are generally managed endoscopically, rarely requiring hepaticojejunostomy. Incisional hernias occur in up to 20% of donors, and diaphragmatic hernias are uncommon but potentially life-threatening. After the first postoperative year, many donors report persistent incisional numbness, and 27% experience chronic pain. Cosmetic concerns affect body image and mental health, though minimally invasive techniques improve these outcomes. Nearly 80% of donors return to work within 3 months, and physical quality of life usually returns to baseline within 6-12 months. However, one-quarter report ongoing activity limitations. Financial burden persists for 22-40% of donors, even two years post-donation. Psychologically, the majority of donors express no donation-related regret, although depression and anxiety affect approximately 8% of donors. Perioperative mortality is extremely low, with further improvements over time, and long-term survival parallels matched controls; however, donors have a higher risk of suicide and certain cancers. Current evidence supports extending donor monitoring beyond one year, with particular emphasis on psychiatric screening and targeted health surveillance. A global registry of long-term donor outcomes would strengthen risk stratification and optimize donor care.

BACKGROUND:Thrombocytopenia is prevalent in living donor liver transplantation (LDLT), resulting from underlying liver disease and perioperative factors. Although platelet transfusions are frequently required, their response is variable and may be associated with adverse outcomes. This study evaluated the prevalence and severity of thrombocytopenia, platelet transfusion practices, assessed post-transfusion response using corrected count increment (CCI), and predictors of poor CCI in adult LDLT recipients. STUDY DESIGN & METHODS:This prospective observational study was conducted at a quaternary care center after ethical committee approval. Adult LDLT recipients were enrolled, and clinical, biochemical, intraoperative, and transfusion data were collected. Platelet transfusion response was assessed using CCI post-transfusion; CCI <5,000 was considered a poor response. RESULTS:Among 100 LDLT recipients (median age 52 years; 88% male), preoperative thrombocytopenia was observed in 91% of patients (17% severe). Intraoperative platelet transfusions were administered in 18% of cases. Postoperatively, 66 platelet transfusions were given to 23 patients, with a mean CCI of 9.0×109/L. Poor CCI was observed in 10 patients and was associated with higher bilirubin levels, prolonged INR, longer ICU stay, and increased 30-day mortality. Early allograft dysfunction (EAD) at postoperative day 7 was an independent predictor of poor CCI (OR 10.2, 95% CI 2.4-43.1). An absolute platelet count ≤71,000/mm3 on day 7 predicted EAD with 85% sensitivity (AUC 0.79). CONCLUSIONS:Thrombocytopenia is highly prevalent in LDLT recipients. Poor CCI is associated with graft dysfunction and adverse outcomes, suggesting that CCI monitoring may help to prognosticate and anticipate worser outcomes.

BACKGROUND:Early and precise assessment of graft health is vital for pediatric liver transplant patients; however, current monitoring methods depend largely on invasive biopsies and non-specific biochemical tests. Donor-derived cell-free DNA (ddcfDNA) has emerged as a promising non-invasive biomarker for detecting graft injury, but data on its early post-transplant kinetics, baseline levels, and the influence of donor and recipient factors in stable pediatric populations remain limited. OBJECTIVE:To prospectively characterize the early postoperative patterns of ddcfDNA and explore baseline ranges in clinically stable pediatric recipients of living donor liver transplants (LDLT), while evaluating the influence of recipient and donor demographic and clinical variables on ddcfDNA dynamics for improved non-invasive graft monitoring. METHODS:In a cohort of 22 stable pediatric LDLT recipients, ddcfDNA levels were measured longitudinally using the Trunome GrafAssure assay at postoperative days 1-2, 7, 10-14, and 30-31. Concurrent liver function tests and clinical data were also collected. Statistical analyses were performed to evaluate correlations and determine the significance of the observed relationships. RESULTS:ddcfDNA peaked on days 1-2 (~9.0%, 2.3 ng/mL), declined sharply by day 7 (~2.4%, 1.0 ng/mL), and stabilized by days 30-31 (~2.0%, 0.2 ng/mL). Liver enzymes decreased gradually. The absolute quantification values and the ddcfDNA percentage correlated with AST and ALT early post-transplant, with associations diminishing over time. Recipient and donor characteristics did not significantly affect ddcfDNA levels. CONCLUSION:dd-cfDNA demonstrates rapid postoperative clearance and stable longitudinal trends in clinically stable pediatric liver transplant recipients. The baseline values and kinetic patterns characterized provide a preliminary reference framework for future comparative studies evaluating dd-cfDNA behavior during graft dysfunction, rejection, or other adverse events in the early postoperative and surveillance periods.

BACKGROUND:The adoption of technical variant grafts has expanded the donor pool for pediatric liver transplantation, but it also poses a risk of portal vein thrombosis (PVT). This study evaluated risk and prognostic factors of PVT in children undergoing liver transplantation with technical variant grafts. METHODS:A total of 3137 pediatric patients from 19 centers were included: 470 received split/reduced deceased donor grafts and 2667 received living donor grafts. Multivariable logistic regression was used to identify risk factors, whereas time-dependent Cox models were used to assess the impact on survival. RESULTS:PVT occurred in 102 patients (3.3%) and was associated with increased mortality (adjusted hazard ratio, 2.86; 95% confidence interval [CI], 1.13-7.25; P  = 0.027) and graft loss (adjusted hazard ratio, 9.97; 95% CI, 4.90-20.3; P  < 0.001). Risk factors included younger age, lower weight, higher Pediatric End-Stage Liver Disease score, longer cold ischemia and operation times, higher graft-to-recipient weight ratio, increased red blood cell transfusions, and biliary atresia. After adjusting for center, lower weight (odds ratio, 0.84 per kg; 95% CI, 0.71-1.00; P  = 0.047) and biliary atresia (odds ratio, 2.34; 95% CI, 1.10-5.00; P  = 0.027) remained predictors. Five-year patient (88.4% versus 93.1%) and graft survival (82.7% versus 96.3%) were significantly inferior in patients with PVT. CONCLUSIONS:Low-weight children with biliary atresia constituted a high-risk group, highlighting the necessity for early detection and management.

Early allograft failure (EAF) after living donor liver transplantation (LDLT) remains a clinical challenge. Existing prediction models developed for deceased donor transplantation poorly apply to LDLT due to distinct surgical and physiological factors. This study identifies clinical determinants of EAF and develops an LDLT-specific prediction model. We conducted a multicenter retrospective cohort study from 17 high-volume LDLT centers (January 2016-December 2020) with external validation at a tertiary center in Saudi Arabia (January 2015-December 2022). The primary outcome was EAF (graft loss or patient death ≤90 d). Multivariable mixed-effects logistic regression identified preoperative/intraoperative risk factors. The EAGLE-LDLT model was constructed using postoperative laboratory values. Performance was compared against established models (EAD, MEAF, A2ALL) using ROC analysis and decision curve analysis. The development cohort included 2944 adult LDLT recipients (67.7% male; median age 55 y; median MELD 14) with a 5.5% EAF rate. External validation included 1020 recipients (median MELD 21, 6.7% EAF). Independent risk factors for EAF were MELD (OR 1.06, 95% CI 1.04-1.08), donor BMI (OR 1.05, 95% CI 1.00-1.10), portal vein thrombosis (OR 1.73, 95% CI 1.13-2.63), and hepaticojejunostomy (OR 1.58, 95% CI 1.06-2.36). The EAGLE-LDLT model incorporating peak ALT (>468 U/L), peak INR (>1.9), and bilirubin (>3.5 mg/dL) and INR (>1.3) at POD7, demonstrated superior discrimination (AUC=0.81) compared with MEAF (AUC=0.77, p =0.004), EAD (AUC=0.67, p <0.001), and A2ALL (AUC=0.65, p <0.001). EAGLE-LDLT achieved balanced sensitivity (75.0%) and specificity (73.7%), effectively stratifying patients into high-risk (15% of patients; 40.4% EAF incidence) and low-risk groups. Preoperative and intraoperative clinical factors predict EAF in LDLT. The EAGLE-LDLT model accurately identifies LDLT recipients at the highest risk for EAF postoperatively.

Living donor liver transplantation (LDLT) is an established therapy with curative intent for pediatric and adult patients with acute liver failure and end-stage liver disease. Donor safety remains paramount and commences during preoperative evaluation and assessment. Given the importance of the topic, the International Liver Transplantation Society and International Living Donor Liver Transplantation Group consensus conference on Living Liver Donor Safety was convened in March 2025 (Toronto, Canada). Recommendations were based on the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system for assessment of recommendations, and the Danish model of consensus was followed. This report presents 28 recommendations from the working group focused on addressing clinically relevant questions related to the preoperative aspects of living donor safety including assessment of donor acceptability (age, body mass index and hepatic steatosis; medical conditions and contraindications), medical and surgical workup (liver function and procoagulant workup; anatomical considerations and safe remnant), and psychosocial evaluation (timing and team; underlying conditions; non-directed, paired, and anonymous directed donors; urgent living donor workups for acute liver failure).

Vascular reconstruction remains one of the most important and challenging considerations in living donor liver transplantation (LDLT), and a standard anatomy is observed in only two-thirds of the donors. Several techniques have been described for the reconstruction of multiple portal veins (PVs); however, there is no evidence on an ideal technique to ensure optimal inflow to the graft. In this study, we evaluate 3 different PV reconstruction techniques and compare them with the outcomes of a single PV allograft in right lobe LDLT. From 2012 to 2023, 1276 right lobe LDLT recipients were reviewed, of whom 173 (13.79%) had PV anatomical variations requiring reconstruction. Y-interposition graft venoplasty, conjoined unification venoplasty, and graft venoplasty with extension were performed in 66 (38.2%), 51 (29.4%), and 56 (32.4%) patients, respectively. Intraoperative outcomes, early postoperative outcomes, and long-term survival rate were comparable across techniques. Propensity score match analysis with single PV recipients revealed significantly higher early allograft dysfunction (23.8% vs. 10.9%, p =0.02) and biliary leak (14.9% vs. 5%, p =0.01) in this cohort; however, vascular complications and survival rates were comparable. Overall, the findings suggest that when reconstruction is tailored to the individual vascular anatomy, all 3 techniques are safe, effective, and feasible, enabling broader safe utilization of donors with PV variations.

Liver transplantation (LT) provides the best long-term survival outcomes for patients with liver cancer. As a result, the field of transplant oncology has grown greatly over the past few decades, and many centers have expanded their criteria to allow increased access to LT for liver malignancies. Center-level guidelines and practices in transplant oncology significantly vary across the world, leading to debate regarding the best course of treatment for this patient population. An international consensus conference was convened by the International Liver Transplantation Society and the International Liver Cancer Association on February 1-2, 2024, in Valencia, Spain, to establish a more universal consensus regarding LT for oncologic indications. The conference followed the Delphi process, followed by external expert review. Consensus statements were accepted regarding patient assessment and waitlisting criteria, pretransplant treatment (including immunotherapy) and downstaging, living donor LT, post-LT patient management, and patient- and caregiver-related outcomes. The multidisciplinary participants in the consensus conference provided up-to-date recommendations regarding the selection and management of patients with liver cancer being considered for LT. Although participants deferred to center protocols in many cases, there was great interest in safely expanding access to LT for patients with larger tumor burden and biologically amenable lesions.

Background/Aims:ABO incompatible liver transplant (ABOi-LT) is an essential alternative to blood-group-compatible liver transplant (LT) in children, and there is limited experience with this, especially from the developing world. The current analysis focuses on our experience of ABOi-LT in children. Method:A retrospective analysis of all children undergoing ABOi-LT at our centre from January 2011 to February 2024 was performed. Their clinical profile, desensitisation protocol, post-transplant complications, patient and graft survival were analysed. Results:We performed 35 (5%) ABOi-LTs during the above-mentioned time period. The median (interquartile range [IQR]) age at ABOi-LT was 15 (10-72) months, and the commonest aetiology was biliary atresia in 22 (63%) patients. Nineteen (54%) patients were below 18 months of age. Pre-LT plasmapheresis was offered to 24 (64%) patients, and 24 (64%) received rituximab. In children less than 18 months of age, 8 (42%) received pre-LT rituximab. None of the patients had major infections secondary to rituximab in the pre-LT period. Post-LT plasmapheresis was offered to 20 (57%) patients and 5 (15%) required immunoadsorption for persistently high antibody titres. Acute T-cell-mediated rejection was seen in 6 (17%) and 2 (5.5%) patients developed antibody-mediated rejection (AMR). No patients had hepatic artery thrombosis, anastomotic biliary strictures or bile leaks and 1 (2.7%) had chronic portal vein thrombosis. The median (IQR) duration of hospital stay was 16 (14-19.5) days. After a median follow-up of 24 months, overall survival was 34 (97%). Two patients with AMR were successfully treated and have normal graft function on follow-up. Conclusion:Excellent outcomes post-ABOi-LT can be achieved in children by using effective desensitisation protocols.