Live donor liver transplantation in adults

Live donor liver transplantation (LDLT) was initiated in 1988 for children recipients. Its application to adult recipients was limited by graft size until the first right liver LDLT was performed in Hong Kong in 1996. Since then, right liver graft has become the major graft type. Despite rapid adoption of LDLT by many centers, many controversies on donor selection, indications, techniques, and ethics exist. With the recent known 11 donor deaths around the world, transplant surgeons are even more cautious than the past in the evaluation and selection of donors. The need for routine liver biopsy in donor evaluation is arguable but more and more centers opt for a policy of liberal liver biopsy. Donation of the middle hepatic vein (MHV) in the right liver graft was considered unsafe but now data indicate that the outcome of donors with or without MHV donation is about equal. Right liver LDLT has been shown to improve the overall survival rate of patients with chronic liver disease, acute or acute-on-chronic liver failure and hepatocellular carcinoma waiting for liver transplantation. The outcome of LDLT is equivalent to deceased donor liver transplantation despite a smaller graft size and higher technical complexity.     

Comprehensive cost comparison of adult-adult right hepatic lobe living-donor liver transplantation with cadaveric transplantation

BACKGROUND: An important long-term consideration for living-donor liver transplantation (LDLT) is the expense compared with cadaveric-liver transplantation. LDLT is a more complex procedure than cadaveric transplantation and the cost of donor evaluation, donor surgery, and postoperative donor care must be included in a cost analysis for LDLT. In this study, we compare the comprehensive cost of LDLT with that of cadaveric-liver transplantation. METHODS: All costs for medical services provided at our institution were recorded for 24 LDLT and 43 cadaveric recipients with greater than 1 year follow-up transplanted between August 1997 and April 2000. The donor costs include donors evaluated and rejected, donors evaluated and accepted, donor right hepatectomy costs, and donor follow-up costs (365 days postdonation). LDLT and cadaveric recipient costs include medical care 90 days pre-LDLT, recipient transplant costs, and recipient follow-up costs (365 days posttransplant) including retransplantation. Cost is expressed as an arbitrary cost unit (CU) that is a value between $500 to $1,500. RESULTS: Total LDLT costs (evaluations of rejected donors+evaluations of accepted donors+donor hepatectomy+donor follow-up care for 1 year+pretransplant recipient care [90 days pretransplant]+recipient transplantation+recipient 1-year posttransplant care)= 162.7 CU. Total mean cadaveric transplant costs (pretransplant recipient care [90 days pretransplant]+recipient transplantation [including organ acquisition cost]+recipient 1-year posttransplant care)= 134.5 CU, (P =ns). CONCLUSIONS: The total comprehensive cost of LDLT is 21% higher than cadaveric transplantation, although this difference is not significant.     

Donor evaluation and hepatectomy for living-donor liver transplantation

In the past decade, considerable technical advances have been accomplished in living-donor liver transplantation (LDLT). The procedure has become accepted globally as a standard modality for the treatment of end-stage liver disease and hepatocellular carcinoma in both pediatric and adult populations. During the period of this procedure’s development, however, tragedy has occurred. Serious morbidity and even mortality have been experienced and reported in live donors. The transplant community has been very much aware of its responsibilities toward live donor care, and much effort has been made to improve and secure the overall outcomes of donors. Unlike in deceased-donor liver transplantation (DDLT), opportunity or chance plays a lesser role in the availability of an organ for LDLT. Judgment calls are often made by individuals; therefore, the evaluation process includes social and ethical aspects not encountered among the usual indications for hepatobiliary surgical disease. Thus, the selection of live donors should be made from a wider perspective compared with that for conventional patient care. The approach to selecting live donors may vary slightly between the West, where a large number of DDLTs are performed daily, and the Far East, where they are much less frequent. However, the recognition that the transplant community has a responsibility to provide care to living donors is common. This review provides an overview of the current donor evaluation and surgical procedures involved in LDLT, with the recognition that an open and educated debate is key to ensuring public confidence and maintaining ethical standards in the field.     

Living donor versus deceased donor liver transplantation: a surgeon‐matched comparison of recipient morbidity and outcomes

Informed consent for living donor liver transplantation (LDLT) requires that patients are provided with accurate information on the relative benefits and risks of this procedure compared with deceased donor liver transplantation (DDLT). There is strong evidence to suggest that LDLT facilitates timely transplantation to patients; however, information on the relative morbidity and death risks after LDLT as compared with DDLT is limited. A matched cohort comparison was performed matching recipients for age, MELD, date of transplant, gender, primary diagnosis, and recipient surgeon. A total of 145 LDLT were matched with 145 DDLT. LDLT had a higher overall rate of perioperative surgical complications (P = 0.009). Most of this difference was caused by a higher rate of biliary complications. However, the complications that occurred in the DDLT group tended to be more serious (P = 0.037), and these complications were strongly associated with graft loss in multivariate analysis. The 3‐ and 5‐year graft and patient survivals were similar. In conclusion, DDLT and LDLT have different complication profiles, but comparable hospital stays and survival rates. In areas of deceased donor organ shortages, LDLT offers an excellent alternative to DDLT because it facilitates access to a liver transplant without compromising short‐ or medium‐term recipient outcomes.     

Adult Living Donor Liver Transplantation

Adult living donor liver transplantation (LDLT) begun in response to deceased donor organ shortage and waiting list mortality, grew rapidly after its first general application in the United States in 1998. There are significant risks to the living donor, including the risk of death and substantial morbidity, and two highly publicized donor deaths have led to decreased LDLT since 2001. Significant improvements in outcomes have been seen over recent years that have not been reported in single center studies; however, LDLT still comprises less than 5% of adult liver transplants, significantly less than in kidney transplantation where living donors now comprise the majority. The ethics, optimal utility and application of LDLT remain to be defined. In addition, studies to date have focused on post-transplant outcomes and not included the potential impact of LDLT on waiting time mortality. Future analyses should include appropriate control or comparison groups that capture the effect of LDLT on overall mortality from the time of listing. Further growth of LDLT will depend on defining the optimal recipient and donor characteristics for this procedure as well as broader acceptance and experience in the public and in transplant centers.     

Selection of liver-transplant candidates for adult-to-adult living donor liver transplantation as the only surgical option for end-stage liver disease.

The selection of living donor liver transplantation (LDLT) recipients in regions where deceased donor liver transplantation (DDLT) is rarely performed might be different from that in other centers at which LDLT is an alternative option to DDLT. Records of adult (age > or = 18 yr) patients referred to our center were reviewed to analyze the selection process of LDLT candidates. Among the 533 LDLT candidates, 165 (31%) were rejected due to recipient issues. Advanced hepatocellular carcinoma (HCC) was the most common reason for rejection (n = 55). Among the remaining recipients, 120 patients (22%) were rejected due to donor issues. LDLT was eventually performed in 249 (47%) of the evaluated recipients. There are few options for candidates who are unable to find live donors in regions where DDLT is unrealistic. A more effective and precise approach to recipient and donor evaluation should be pursued.     

Toward 300 liver transplants a year

The technical success of cadaveric whole-size liver transplantation and better immunosuppressive drugs has extended the application of this life-saving procedure to include patients with irreversible acute and chronic liver diseases. However, because of the scarcity of cadaveric liver grafts, living-donor liver transplantation (LDLT) has emerged as an alternative to cadaveric-donor liver transplantation (CDLT), especially in Asia. In Korea, 8% of the population are hepatitis B virus (HBV) carriers, and the resultant HBV cirrhosis, with or without hepatocellular carcinoma (HCC), is common in the 40- to 60-year-old generation. Accordingly, many patients require orthotopic liver transplantation (OLT). In 1992, we started performing CDLTs in the Asan Medical Center. In 1994, the first successful pediatric LDLT was performed in Korea, on a 9-monthold infant with biliary atresia. In 1997, the first successful adult LDLT was performed in our department, using a left lobe, on a 37-year-old patient with HBV cirrhosis associated with HCC. Even after the first successful right-lobe LDLT, we faced the obstacle of anterior segment congestion of a right-lobe graft, and initiated reconstruction of the middle hepatic venous tributaries of a right-lobe graft in 1998. In 1999, we performed more than 100 OLTs a year. Insufficient graft size has hindered the expansion of adult LDLT, when the remaining left-lobe of potential donors is too small to assure donor safety. Dual two-left-lobe graft LDLT (transplanting from two donors into one recipient) was developed in 2000 to solve graft-size insufficiency and minimize donor risk. More than 200 OLTs a year have been performed since 2004, while broadening the indications for adult LDLT to near complete obstruction of the portal vein, with the application of intraoperative portography (IOP) and portal vein stenting. In 2007, 320 LTs were performed, including 276 adult LDLTs, 10 pediatric LDLTs, and 34 CDLTs (including 7 adult and 1 pediatric split-liver transplant). There has been no donor mortality in LDLT. With technical refinement and advanced perioperative care, the in-hospital mortality of recipients has dropped to 4%: attributed to the dedication of our liver transplantation team members.     

Adult living donor liver transplantation: body mass index and MELD score of recipients are independent risk factors for hospital mortality

Background and aims  Adult living donor liver transplantation (LDLT) has been established as elective procedure or urgent procedure to save the life of patients with terminal liver diseases. The outcome of LDLT varies between transplant centers. Here, we aim to evaluate the outcome of LDLT in our center and to identify the risk factors that are associated with hospital mortality of recipients. Patients and methods  A cohort study with 32 consecutive cases of adult living donor liver transplantation was conducted in two cooperated medical centers. Perioperative data, incidence of postoperative complications, and hospital mortality were analyzed. Results  No major surgical complications and no hospital mortality were observed in all 32 donors. All donors were discharged with normal liver function with median intensive care unit (ICU) stay of 1 day and median hospital stay of 10 days. All recipients had normal liver function in early posttransplant period. Eighty-one percent of the recipient survived with normal liver function for more than 1 year. The pretransplant ICU stay, renal failure, international normalized ratio (>1.8), and Model for End-stage Liver Disease (MELD) score (>20) were independent risk factors for hospital mortality of recipients. Conclusions  Adult living donor liver transplantation should be reserved to less “sick” patients in the era of organ allocation based on MELD score. Hans J. Schlitt and Aiman Obed shared the senior authorship of this work.     

成人间双供体活体肝脏移植成功2例报告

目的供肝短缺是影响肝脏移植发展的主要因素之一，活体供肝是解决这一矛盾的重要措施，供者提供足够的肝脏是影响活体肝脏移植的重要因素。方法施行成人间双供体活体肝移植2例，1例由受者的两位姐姐分别提供左半肝作为供肝，另1例由受者母亲提供右半肝，由无心跳供者提供左半肝(采用劈裂方式，其另一部分肝脏同时为另一成人受者实施肝脏移植)作为供肝。结果术后供、受者肝功能均恢复良好。结论成人问双供肝活体肝脏移植可以为受者提供更大重量的肝脏，又可减少供者提供较多肝脏所带来的风险；双供肝一受者肝脏移植手术操作复杂。     

Living donor liver transplantation in Egypt

In Egypt there is no doubt that chronic liver diseases are a major health concern. Hepatitis C virus (HCV) prevalence among the 15−59 years age group is estimated to be 14.7%. The high prevalence of chronic liver diseases has led to increasing numbers of Egyptian patients suffering from end stage liver disease (ESLD), necessitating liver transplantation (LT). We reviewed the evolution of LT in Egypt and the current status. A single center was chosen as an example to review the survival and mortality rates. To date, deceased donor liver transplantation (DDLT) has not been implemented in any program though Egyptian Parliament approved the law in 2010. Living donor liver transplantation (LDLT) seemed to be the only logical choice to save many patients who are in desperate need for LT. By that time, there was increase in number of centers doing LDLT (13 centers) and increase in number of LDLT cases [2,400] with improvement of the results. Donor mortality rate is 1.66 per 1,000 donors; this comprised four donors in the Egyptian series. The exact recipient survival is not accurately known however, and the one-year, three-year and five-year survival were 73.17%, 70.83% and 64.16% respectively in the International Medical Center (IMC) in a series of 145 adult to adult living donor liver transplantation (AALDLT) cases. There was no donor mortality in this series. LDLT are now routinely and successfully performed in Egypt with reasonable donor and recipient outcomes. Organ shortage remains the biggest hurdle facing the increasing need for LT. Although LDLT had reasonable outcomes, it carries considerable risks to healthy donors. For example, it lacks cadaveric back up, and is not feasible for all patients. The initial success in LDLT should drive efforts to increase the people awareness about deceased organ donation in Egypt.     

Impact of human leukocyte antigen mismatching on outcomes of living donor liver transplantation for primary biliary cirrhosis.

Patient selection criteria of deceased donor liver transplantation for primary biliary cirrhosis (PBC) are almost completely established. The aim of this study was to establish selection criteria for both patients and donors of living donor liver transplantation (LDLT) for PBC. We used univariate and multivariate analyses to examine patient and donor characteristics of our first 50 cases of LDLT for PBC to elucidate factors that significantly impacted patient survival or disease recurrence after LDLT in the univariate and/or multivariate analyses. Multivariate analysis demonstrated that the presence of persistent ascites before LDLT, a higher number of human leukocyte antigen (HLA)-A, -B, and -DR mismatches between donor and recipient, and donor age >or=50 years were factors significantly associated with early posttransplant death. Independent risk factors for PBC recurrence after LDLT were a lower number of HLA mismatches between donor and recipient, and a lower average trough level of tacrolimus within 1 year after LDLT. Specifically, the lower the number of HLA-A, -B, and -DR mismatches or the average trough level of tacrolimus within 1 year after LDLT, the higher the possibility of developing a recurrence of PBC. In conclusion, the absence of persistent ascites before LDLT, a lower number of HLA-A, -B, and -DR mismatches between donor and recipient, and a younger donor (<50 years) are preferred for gaining acceptable survival outcomes for the transplant. However, a lower number of HLA-A, -B, and -DR mismatches between donor and recipient may be a risk factor for PBC recurrence.     

Motivation for living-donor liver transplantation from the donor's perspective: an in-depth qualitative research study

BACKGROUND: There has been a lack of systematic in-depth research on the motives of living liver donors before transplantation that could contribute to an advanced understanding of their situation and to a more precise psychosocial evaluation, to protect the autonomy for decision, and to prevent psychosocial complications. METHODS: Twenty-eight living liver donors were assessed preoperatively through a semistructured clinical interview. The taped and transcribed interviews were analyzed using a combination of grounded theory and empirically grounded type construction. RESULTS: Various factors contribute to the donor's motivation for donation: the relationship to the recipient, the personal attitude of the donor, his or her personal history, family dynamics, the donor's personal profit, and the exceptional situation of the recipient's life-threatening disease combined with the life-rescuing possibility of living-donor liver transplantation (LDLT). In reference to this, five "ideal types" of living donors emerged from the authors' data. CONCLUSIONS: A complete absence of coercion on the decision to donate seems unrealistic because of the dynamics initiated by the life-threatening condition of the recipient. It is important that donors feel they are gaining something by donation to be sufficiently motivated and that their profit is of an emotional or moral nature (i.e., the donation being set in an emotionally meaningful context). A mature relationship with the recipient usually provides such a context. The role of the clinician as a part of LDLT dynamics has a decisive influence.     

Safety of donor in adult-to-adult living donor liver transplantation using right lobe graft

BACKGROUND: The growing gap between the number of patients awaiting liver transplantation and available organs has continued to be the primary issue facing the transplant community. To overcome the waiting list mortality, living donor liver transplantation has become an option, in which the greatest concern is the safety of the donor, especially in adult-to-adult living donor liver transplantation (A-A LDLT) using a right lobe liver graft. OBJECTIVE: We evaluated the safety of donors after right lobe liver donation for A-A LDLT performed in our center. METHODS: From January 2002 to March 2006, 26 patients underwent A-A LDLT using right lobe liver grafts in our center. Seven donors were men and 19 were women (range, 19-65 years; median age, 38 years). The right lobe liver grafts were obtained by transecting the liver on the right side of the middle hepatic vein without interrupting the vascular blood flow. The mean follow-up time for these donors was 9 months. RESULTS: These donor residual liver volumes ranged from 30.5% to 60.3%. We did not experience any donor mortality. Two cases (7.69%) experienced major complications: intra-abdominal bleeding and portal vein thrombosis in one each and three (11.54%), minor ones: wound steatosis in two, and transient chyle leak in one. All donors were fully recovered and returned to their previous occupations. CONCLUSIONS: A-A LDLT using a right lobe liver graft has become a standard option. The donation of right lobe liver for A-A LDLT was a relatively safe procedure in our center.     

Living donor liver transplantation for hepatitis C

Liver cirrhosis and hepatocellular carcinoma related to chronic hepatitis C virus (HCV) infection are currently the most common indications for liver transplantation. The number of living donor liver transplantation (LDLT) procedures has increased given the shortage of donor organs from deceased donors. However, recurrence of HCV infection is universal and affects graft survival. This mini-review compared the outcomes for HCV-positive recipients after LDLT with those after deceased donor liver transplantation.     

Living donor liver transplantation for noncirrhotic inheritable metabolic liver diseases: impact of the use of heterozygous donors

BACKGROUND: In living donor liver transplantation (LDLT), the liver donor is almost always a blood relative; therefore, the donor is sometimes a heterozygous carrier of inheritable diseases. The use of such carriers as donors has not been validated. The aim of the present study was to evaluate the outcome of LDLT for noncirrhotic inheritable metabolic liver disease (NCIMLD) to clarify the effects of using a heterozygous carrier as a donor. METHODS: Between June 1990 and December 2003, 21 patients with NCIMLD underwent LDLT at our institution. The indications for LDLT included type II citrullinemia (n = 7), ornithine transcarbamylase deficiency (n = 6), propionic acidemia (n = 3), Crigler-Najjar syndrome type I (n = 2), methylmalonic acidemia (n = 2), and familial amyloid polyneuropathy (n = 1). Of these 21 recipients, six underwent auxiliary partial orthotopic liver transplantation. RESULTS: The cumulative survival rate of the recipients was 85.7% at both 1 and 5 years after operation. All surviving recipients are currently doing well without sequelae of the original diseases, including neurological impairments or physical growth retardation. Twelve of the 21 donors were considered to be heterozygous carriers based on the modes of inheritance of the recipients' diseases and preoperative donor medical examinations. All donors were uneventfully discharged from the hospital and have been doing well since discharge. No mortality or morbidity related to the use of heterozygous donors was observed in donors or recipients. CONCLUSIONS: Our results suggest that the use of heterozygous donors in LDLT for NCIMLD has no negative impact on either donors or recipients, although some issues remain unsolved and should be evaluated in further studies.     

Right-liver living donor transplantation for decompensated end-stage liver disease

Adult-to-adult living donor liver transplantation (LDLT) for patients with decompensated end-stage liver disease (DELD) is controversial. Nevertheless, these patients are most in need of a timely liver transplant. We present the results of 7 patients who underwent transplantation with this procedure and discuss the rationale for its possible broader application. Seven of 51 patients who underwent right LDLT (segments 5 to 8) between August 1998 and April 2001 had DELD, defined as Child-Pugh-Turcotte score greater than 13 or Model for End-Stage Liver Disease score greater than 30. All patients also were listed for cadaveric liver transplantation. Mean age of the 7 transplant recipients was 54 years (range, 44 to 63 years). Three patients had ethyltoxic cirrhosis; 2 patients, hepatitis C; 1 patient, hepatitis B; and 1 patient, autoimmune hepatitis cirrhosis. The average intensive care unit stay was 23 days (range, 3 to 88 days), and average hospital stay was 77 days (range, 27 to 132 days). Three patients are alive 31, 21, and 17 months after LDLT. At a mean follow-up of 15.1 ± 10 months, patient and graft survival rates are 43%. Four transplant recipients died day 30, 60, 117, and 180 after transplantation. Three of the seven donors (43%) experienced a complication. At present, all donors are well and have returned to their normal activities. No donors had regrets about the procedure, and all donors stated that they would donate again if presented with the same decision. In conclusion, with the lack of other therapeutic options, LDLT represents a timely and effective alternative to cadaveric liver transplantation. Better outcome is foreseeable with a decrease in posttransplantation complications and more experience in predicting survival of these critical patients. (Liver Transpl 2002;8:340-346.)     

Preoperative imaging evaluation of potential living liver donors: reasons for exclusion from donation in adult living donor liver transplantation

Accurate pretransplant evaluation of a potential donor in living donor liver transplantation (LDLT) is essential in preventing postoperative liver failure and optimizing safety. The aim of this study was to investigate the reasons for exclusion from donation of potential donors in adult LDLT. From September 2003 to June 2006, 266 potential donors were evaluated for 215 recipients: 220 potential donors for 176 adult recipients; 46 for 39 pediatric recipients. Imaging modalities including Doppler ultrasound, computerized tomography (CT), and magnetic resonance (MR) angiography provided vascular evaluation and MR cholangiopancreatography to evaluate biliary anatomy. Calculation of liver volume and assessment of steatosis were performed by enhanced and nonenhanced CT, respectively. In the adult group, only 83 (37.7%) potential donors were considered suitable for LDLT. Of the 137 unsuitable potential donors, 36 (26.2%) candidates were canceled because of recipient issues that included death of 15 recipients (10.9%), main portal vein thrombosis (8%), recipient condition beyond surgery (5%), and no indication for liver transplantation due to disease improvement (2%). The remaining 101 (73.8%) candidates who were excluded included steatosis (27.7%), an inadequate remnant volume (57.4%), small-for-size graft (8.9%), HLA-homozygous donor leading to one-way donor-recipient HLA match (3%), psychosocial problems (4%), as well as variations of hepatic artery (4%), portal vein (1%), and biliary system anatomy (5%). Anatomic considerations were not the main reason for exclusion of potential donors. An inadequate remnant liver volume (<30%) is the crucial point for the adult LDLT decision.     

The challenge of finding donors for living donor liver transplantation in Saudi Arabia

INTRODUCTION: Organ shortage remains the main limiting factor for expanding liver transplantation (LT) in Saudi Arabia. Therefore, living donor liver transplantation (LDLT) was recently undertaken by our team at King Faisal Specialist Hospital and Research Center (KFSH&RC), in an effort to meet the increasing demand for LT in Saudi Arabia. OBJECTIVE: Analysis of donors assessed for LDLT at KFSH&RC. METHODS: Between September 2002 and May 2003, 39 potential donors were assessed for LDLT. First- or second-degree relationship to the recipient was an essential precondition. Assessment included biochemical testing, radiological studies (computed tomography: magnetic resonance angiography, magnetic resonance cholangiography), and thorough psychosocial analysis. Liver biopsy and hepatic angiogram was performed in some but not all donors. RESULTS: Male:female ratio was 28:11. Median age was 27 (18 to 34). Of 39 potential donors, only three underwent LDLT. The remaining 36 were rejected for different reasons including: psychosocial in 8 (20.5%), fatty liver in 7 (17.9%), recipient issues in 6 (15.4%), refusal after initial approval in 3 (7.7%), unfavorable anatomy in 2 (5.1%), inadequate liver volume in 2 (5.1%), abnormal liver functions in 2 (5.1%), hepatitis C virus in 2 (5.1%), liver pathology in 1 (2.6%), and other medical concerns in remaining 3 donors (7.7%). CONCLUSION: In Saudi Arabia, donor availability as well as recipient characteristics may limit the value of LDLT in overcoming organ shortage. Therefore, efforts should be directed to improve the number and quality of available cadaveric organs. Until then, LDLT may be the only way forward to save patients from dying on the waiting list.     

Living liver donors: a coordinator's perspective

Living donor liver transplantation is an acceptable alternative for many patients awaiting a liver transplant. The benefits of living donor liver transplantation to the recipient are many; however, there is also an appreciable risk to the donor. Many people, including healthcare professionals, believe that living donor liver transplantation is not ethically justified because any risk to a donor outweighs the benefit to the recipient. Recent studies show adverse events in this population do not include only medical complications; any complication-medical, social, psychological, financial, or other--must be examined to analyze the true incidence of adverse outcomes in living liver donors.     

Psychosomatische Aspekte der Leberlebendspende

Living donor liver transplantation (LDLT) offers the option to reduce organ scarcity and thereby waiting list mortality. The crucial ethical problem of LDLT is the fact that the well being of a donor is being jeopardized for the improvement of quality of life of the recipient. To preserve mental health of the donors, psychosomatic evaluation should be conducted including examination of the coping capacity, the mental stability of the donor and the voluntary nature of the donation. Thus a comprehensive disclosure of information to donors is necessary. Realistic outcome expectations, family relationships without extreme conflicts, sufficient autonomy of the donor-recipient relationship and social and familiar support are predictors facilitating a favorable psychosocial outcome for the donor. Before and after LDLT the health-related quality of life of the donors is similar or increased in comparison to the general population. Psychiatric complications following LDLT can occur in 13% of the donors. Female donors, donors who have surgical complications themselves and donors with unrealistic outcome expectations should be given psychotherapeutic support before they are admitted to living liver donation. Urgent indications in the case of acute liver failure and the donation by adult children for their parents are particular stress factors. For the safety of the donor, these combinations should be avoided whenever possible.