: Living donor liver transplantation (LDLT) in adults emerged in response to an effective donor organ shortage created by the critical discrepancy between donor graft supply and demand. Due to the scarcity of deceased donor liver graft in most of Asia, the utilization of LDLT has grown exponentially however, this growth has not been reproduced in North America and Europe where LDLT still remains a small percentage of total liver transplants performed. Despite a growing body of evidence demonstrating superior survival outcomes in LDLT in addition to a multitude of other advantages including shorter cold ischemia times, opportunity for pre-transplant medical optimization, and expansion of transplant eligibility, concern over donor risk and technical challenges of the procedure still pose significant hurdles to increasing rates of LDLT. Overcoming these hurdles not only requires increasing center experience and minimization of donor risk, but also a major change in mentality by the Western transplant community to embrace LDLT as a compulsory, rather than discretionary, part of liver disease surgical management. Changing the paradigm to a “LDLT-first” approach at experienced, capable centers by routinely offering an LDLT option for the majority of patients undergoing transplant evaluation will reduce an unacceptably high waitlist mortality and drastically increase patients’ access to liver transplantation.