Basics of Living Donor Liver Transplant

A living donor liver transplant (LDLT) replaces a failing liver with part of a healthy liver from a living relative: usually the right lobe for an adult, a smaller left-sided segment for a child. Both the graft and the donor's remnant regrow. Liver transplantation is the only cure for end-stage liver disease and an established option in acute and acute-on-chronic liver failure, and the earlier the referral, the better the result.

Dr. Sandeep Jha, Consultant, Liver Transplantation, Shalby Sanar International Hospital, Gurugram, India, treats patients who travel from across the world, many of them from Africa. His masterclass for referring doctors set out the basics: which patients need a transplant, how a living donor is chosen and protected, how the operation is planned, and why care after the patient returns home decides much of the long-term outcome.

Living donor vs deceased donor liver transplant

Two techniques dominate liver transplantation worldwide: the deceased donor and the living donor model.

• Deceased donor liver transplant (DDLT): the whole liver is recovered from a brain-dead donor and transplanted into the recipient. This model prevails in developed countries, where organ-sharing networks are robust and deceased organs are relatively plentiful.
• Living donor liver transplant (LDLT): a healthy relative donates part of his or her liver. Across Asia and much of South-East Asia, the scarcity of deceased donors pushed transplant teams towards this approach, and it has developed tremendously as a result.

Other variants exist, but these two account for the great majority of transplants. Dr. Jha's practice, and his masterclass, centred on the living donor model, which places a second patient, the healthy donor, on the operating table and therefore raises the standard of every decision that follows.

Which patients receive a living donor liver transplant

Dr. Jha described three groups of recipients.

1. Decompensated cirrhosis. End-stage chronic liver disease remains the largest group. The common causes are chronic hepatitis B, chronic hepatitis C, alcohol-related liver disease and metabolic liver disease (formerly called non-alcoholic steatohepatitis, or NASH, which arises in people with uncontrolled diabetes and obesity). About 10% of patients have no identifiable cause and are classed as cryptogenic; autoimmune hepatitis accounts for others. In children, the most common cause is biliary atresia, a condition in which the bile ducts are blocked or absent from birth.
2. Acute liver failure. A previously healthy person's liver fails suddenly, typically from viral hepatitis or drug-induced liver injury. In India, hepatitis E and anti-tubercular treatment are frequent culprits; in Western countries, paracetamol poisoning is the common trigger.
3. Acute-on-chronic liver failure (ACLF). A patient with chronic liver disease deteriorates abruptly. These patients are fewer, but ACLF has become an established indication.

Dr. Jha expects metabolic liver disease, now termed metabolic dysfunction-associated steatotic liver disease (MASLD), to become the most common reason for transplant in the future, as hepatitis B and C decline and uncontrolled diabetes and obesity rise.

The scoring thresholds, the specific indications and the conditions that rule a patient out are covered in depth in liver transplant indications, contraindications and referral.

Why timing matters

A cirrhotic liver is shrunken, hard and nodular; blood can no longer flow through it freely, and that obstruction drives most of the complications of cirrhosis, from ascites (fluid in the abdomen) to variceal bleeding and persistent jaundice.

Once those complications appear, the prognosis turns sharply: in Dr. Jha's figures, more than half of patients who bleed and have ascites die within a year, and decompensated cirrhosis leaves a lifespan of one to two years without a transplant. At that stage, he stressed, long-term survival is possible only with one.

Delay also erodes the result of the transplant itself. A patient who carries on with cirrhosis grows weaker and becomes prone to infection, and both worsen the outcome of surgery. Dr. Jha's message to referring doctors was to identify decompensated cirrhosis early and refer early if the patient is to gain the full benefit.

Donor safety in living donor liver transplant

Because a healthy person undergoes major surgery for someone else's benefit, donor safety is the foundation of any living donor programme. Dr. Jha's team rejects a donor at any stage if there is even a suspicion that the donor could come to harm.

Suitable donors are healthy adults with a compatible blood group who are related to the recipient: under Indian law only related donors are eligible, and cousins qualify. Donation by a relative who is not a near relative is approved by an Authorisation Committee, not a court.

Dr. Jha put the risk to the donor's life at 0.5%, and described even that figure as old data: donors today are very safe because his team does not proceed whenever it senses a problem. Donors, in his experience, return to normal life and work, with the only lasting restriction a three-month ban on heavy lifting.

The full work-up, from blood group matching and triple-phase CT to the fatty liver threshold that disqualifies a donor, is set out in living liver donor evaluation and right lobe surgery.

How the living donor liver transplant operation works

In an adult recipient, the surgeon transplants the right lobe of the donor's liver, around 60 to 70% of its volume, after removing the recipient's diseased liver; children, whose metabolic demand is lower, receive a left lateral segment or the left lobe. The vessel connections and the Doppler check that completes the operation are described in the donor evaluation guide linked above.

Dr. Jha closed with a case that illustrates how far the technique can be adapted. A small child with cirrhosis from biliary atresia received part of his mother's left lobe; because an adult's left lobe was still too large for the child's abdomen, the team cut it down further before implantation. About a month after the transplant, the child went home.

Living donor liver transplant success rate and value

Dr. Jha called the results of living donor liver transplant one of the best outcomes in the field, measured against the natural course of decompensated cirrhosis. He put one-year survival at 90 to 95% and five-year survival at 70 to 80%: of 100 patients transplanted today, around 70 to 80 will live five years or longer, against one to two years for decompensated cirrhosis without a transplant. Asked in the discussion about effectiveness, he added that around 80 to 85% of recipients are doing well at the end of one year, patients who would not have survived without a transplant. He cited a child who received a liver transplant at the age of two and, widely reported in the Indian media, went on to qualify as a doctor at 25.

Asked whether the operation is cost-effective, he answered that it is extremely so: for a patient dying of cirrhosis, a transplant can buy 40 to 50 years of life. Most complications occur in the first few months, mostly in the first month, and he noted that many recipients carry more than bleeding or ascites (cancer, encephalopathy or severe sarcopenia, the loss of skeletal muscle mass), which makes their survival without a transplant even poorer. Taking such patients to 15 or 20 years of life is, in his words, the miracle of liver transplant. For indicative pricing, see the liver transplant cost page.

What the success of a living donor programme depends on

Dr. Jha summarised the requirements in four points:

• Meticulous planning, from donor imaging to graft volume calculations.
• Good anatomy, which he called mandatory; a donor with unsuitable vascular or biliary anatomy is declined.
• Demanding post-operative management, in which infection and rejection are the principal threats.
• Long-term follow-up and compliance, which he identified as the weakest link for patients who travel from other countries.

His team tries to follow international recipients after they return home, but its reach over immunosuppression, complications and disease recurrence is limited. That is where the doctor in the home country becomes decisive, working in collaboration with the transplant team in India. The intensive care period, the complication profile, immunosuppression and the diseases that can recur in the new liver are covered in liver transplant complications, from ICU care to long-term follow-up. The questions referring doctors raised, including donor safety and a fatal post-transplant infection, are answered in the Live Discussion.

Dr. Jha also conducted a separate Jivo Masterclass on liver cirrhosis, covered in liver cirrhosis: a complete guide. For other transplant procedures and specialists, see hepatobiliary and liver transplant surgery.