Living Donor Liver Transplantation Program Research Articles

Preparing for the inevitable: The death of a living liver donor

Living donor liver transplantation (LDLT) is associated with a low but finite and well-documented risk of donor morbidity and mortality, so organizations and individuals involved in this activity must accept the fact that a donor death is a question of when and not if. Studies in the field of crisis management show that preparing for the inevitable not only is critical in preparing institutions to better respond to catastrophic events but more importantly plays a crucial role in preventing them. This article describes the background of crisis management with specific reference to the death of a living liver donor and proposes a general framework that can be adopted by LDLT programs around the world.

Liver retransplantation for adult recipients.

Living donor liver graft can be used for the first or second liver transplantation. The timing of retransplantation also should be stratified as 2 types according to the reoperation timing. Combination of these two classifications results in 6 types of living donor liver transplantation (LDLT)-associated retransplantation. However, late retransplantation to LDLT might have not been performed in most LDLT programs, thus other 4 types of LDLT-associated retransplantation can be taken into account. The most typical type of LDLT-associated retransplantation might be early living donor-to-deceased donor retransplantation. For early living donor-to-living donor retransplantation, its eligibility criteria might be similar to those of early living donor-to-deceased donor retransplantation. For early deceased donor-to-living donor retransplantation, its indications are exactly the same to those for aforementioned living donor-to-living donor retransplantation. Late deceased donor retransplantation after initial LDLT has the same indication for ordinary late deceased donor retransplantation.

Analysis of Evaluation of Potentail Donors for Living Donor Liver Transplantation

Introduction: Living Donor Liver Transplantation (LDLT) is the commonest form of Liver Transplantation in India. The key to the success of a LDLT program is the safety of the donor. A thorough donor evaluation encompasses all aspects from social to medical and this determines the number of donors who actually donate from the entire group of potential donors who are evaluated.AIMTo analyse the entire number of potential donors evaluated for LDLT and to assess the rate of actual donation from the evaluated group of donors. Method: A retrospective analysis of the recipients and donors evaluated at our center from August 2009 to January 2012 was done. Recipients were given the option of Deceased donor or Living Related Liver Transplantation. If a suitable and voluntarily consenting donor came forward from the relatives of the recipient, they underwent the evaluation process which involved psycho- social counseling and medical evaluation. Results:TableTable: [Results in ALF]Conclusion: A very thorough donor evaluation is imperative to the success and safety of a Living Donor Liver Transplant program. When both the psycho social and medical aspects are evaluated, only about 40% of potential donors who underwent evaluation actually donated. The rate for donation was higher in the setting of Acute Liver Failure in a pediatric patient.

2500 Cases of Adult Living Donor Liver Transplantations in Single Institution

Background: Although there has been continuing concern about donor safety, living donor liver transplantation (LDLT) has been settled as feasible therapeutic option for end-stage liver disease. In this study, we introduce fifteen-year experience in adult living donor liver transplantation and present evolving steps in technical advancement in donor and recipient surgery. And we analyzed survival results and the risk factors affecting short-term and long term outcome of recipient. Method: We analyzed the data of 2500 adult LDLTs which have been performed from February 1997 to August 2011, retrospectively. Result: We started adult LDLT program from February 1997 with left lobe LDLT. The mean age of recipient was 49.6±8.8 (18˜76) years. The sex ratio was 1870 (74.8%)/630 (Male/Female). The most common cause of LDLT was HBV-LC (74.6%). Total 1103 (44.1%) were accompanied by HCC. The mean MELD score was 20.1±10.4 (3˜40). The most commonly used graft type was modified right lobe graft (73.6%). The mean GRWR 1.06±0.21 (0.49˜2.43)%. The overall in-hospital mortality (IHM) was 5.6%. The IHM in early experience was significantly higher (33.3%) but has been lowered to around 5% recently by the refinement of surgical techniques and advancement of postoperative care. The 1-, 3-, 5-year patient survival rate was 90.4, 84.2 and 78.7%, respectively which was significantly higher than that of deceased donor liver transplantation during same period. When we analyzed risk factors affecting recipient outcome, preoperative recipient condition (MELD>30, recipient age >60, preoperative ventilator support or renal replacement therapy), GRWR (< 0.7%) and donor age (>50 years) were significant risk factors. The most common postoperative complication during immediate postoperative period (< 1month) was postoperative bleeding but overall most common complication was biliary stricture (13.2%). The most common cause of early death (< 3 month) was septic complication and that of late death was HCC recurrence. During this period, total 321 dual graft LDLT were performed. Therefore, 2819 living donors excluding 2 deceased donors were involved. The mean age of donor was 27.8±8.1 (16˜57). There was no donor mortality. The incidence of donor morbidity was higher (8.1%) during early experience and significantly higher in right lobe donor (10.7%) than left lobe donor (2.6%). But, it has been decreased to around 1% and no difference in graft type. Conclusion: Adult LDLT is most useful and effective therapeutic option for end-stage liver disease in the country with scarcity of deceased donor. However, the special concern should be paid for the safety of donor. We should improve recipient outcome by continuing refinement of surgical techniques and postoperative care to justify the inevitable donor risk.

Volumetry-based selection of right posterior sector grafts for adult living donor liver transplantation

To determine the feasibility of volumetric criteria without anatomic exclusion for the selection of right posterior sector (RPS) grafts for adult-to-adult living donor liver transplantation (LDLT), we reviewed and compared our transplant data for RPS grafts and right lobe (RL) grafts. Between January 2008 and September 2010, adult-to-adult LDLT was performed 65 times at our institute; 13 of the procedures (20%) were performed with RPS grafts [the posterior sector (PS) group], and 39 (60%) were performed with RL grafts (the RL group). The volumetry of the 13 RPS donor livers showed that the RPS volume was 39.8% ± 7.6% of the total liver volume. Ten of the 13 donors had to donate RPS grafts because the left liver volume was inadequate. All donor procedures were performed successfully, and all donors recovered from hepatectomy. However, longer operative times were required for the procurement of RPS grafts versus RL grafts (418 ± 40 versus 345 ± 48 minutes, P < 0.001). The postoperative recovery of liver function was smoother for the donors of the PS group versus the donors of the RL group. The RPS grafts had significantly smaller hepatic artery and bile duct openings than the RL grafts. All recipients with RPS grafts survived LDLT. No recipients experienced vascular graft complications or small-for-size graft dysfunction. There were no significant differences in the incidence of posttransplant complications between the donors and recipients of the PS and RL groups. The 3-year graft survival rates were favorable in both groups (100% in the PS group versus 91% in the RL group). In conclusion, the selection of RPS grafts by volume criteria is a feasible strategy for an adult-to-adult LDLT program.

The Attitude Toward Living Liver Donation Among the Hospital Personnel in a Northeast China Center With a Liver Transplant Program

China has the largest population of end-stage liver disease patients, but the acceptance of liver donation is really poor. Our objective was to analyze the attitudes toward living liver donation among hospital workers in a hospital with an authorized living donor liver transplant program in northeast China. A random sample stratified by department of service and job category ( n = 800) evaluated attitudes using a modified psychosocial questionnaire, which was self-administered and completed anonymously. The factors were divided into subcategories of psychosocial variables, family variables, and attitudes toward other types of organ donation and willingness to accept an organ if needed. The results showed favorable attitudes toward living liver donation among hospital personnel. Family factors were closely related to this attitude as were altruistic activities and feelings of reciprocity.

Small-for-size graft: Not defined solely by being small for size

The phrase small-for-size (SFS) graft came into use in clinical liver transplantation in the 1980s. There had already been discussions about graft size mismatching in liver transplantation in the era of whole or split liver transplantation, in which initially right trisegments were used for adults. Interest in the issue flourished when living donor liver transplantation (LDLT) was extended to adult patients. Controversies included the pathogenesis and clinical manifestations of SFS grafts and strategies for successful SFS graft transplantation. On the other hand, the definition of SFS graft has always been ambiguous, and it has been defined tentatively in respective studies by the graft weight relative to the body weight or to the estimated whole liver weight (a value derived from the body size). Furthermore, the phrase SFS syndrome, which is also ambiguous and is often defined arbitrarily, is widely used to define SFS graft (and vice versa). One of the early clinical studies attempting to elucidate the impact of graft size mismatching in LDLT has been frequently cited in later articles on the topic: it has been cited 350 times for 11 years according to the Web of Science. This study used 0.8%, 1.0%, 3.0%, and 5.0% of the recipient body weight as graft size category borders to show the prognostic impact. However, the study design had several pitfalls. Children younger than 15 years composed the vast majority of the study population; older patients represented only 10%. The graft sizes encountered in pediatric LDLT are highly variable, in contrast to adult LDLT, in which the range is relatively narrow (0.5%-1.5% of the body weight). Furthermore, the body weight of patients with end-stage liver disease fluctuates with the occurrence of ascites or edema or the use of diuretics. Even the actual graft weight is potentially influenced by the presence of blood or preservation solution with a high viscosity. Hence, it was uncertain whether the impact of small differences in the graft weight was not masked by the wide range of variables in the recipients, donors, and surgical techniques in adult LDLT. Actually, multiple successive clinical studies of adult LDLT have failed to demonstrate a negative prognostic impact of small differences in the graft weight, although the concept of SFS graft or syndrome has survived. This is partly because most clinical studies are performed in an intent-to-treat fashion; that is, a clinical practice is coupled with appropriate safety measures for graft selection and technical modifications, including outflow maximization and inflow modification. Many confounding factors potentially interfere with the true negative effect of SFS grafts. In this context, Moon et al. should be congratulated for their article. They have shown that older donor age, presumably accompanied by low adaptability of the graft tissue, affects graft prognosis only when it is combined with an SFS graft. Unfortunately, there remains some room for discussion concerning their analytical method. They censored patient death due to pneumonia as unrelated to graft function and included graft failure due to surgical complications or disease recurrence as potential results of graft function. The definition of graft loss

Exchange living donor liver transplantation to overcome ABO incompatibility in adult patients

ABO incompatibility is the most common cause of donor rejection during the initial screening of adult patients with end-stage liver disease for living donor liver transplantation (LDLT). A paired donor exchange program was initiated to cope with this problem without ABO-incompatible LDLT. We present our results from the first 6 years of this exchange adult LDLT program. Between July 2003 and June 2009, 1351 adult LDLT procedures, including 16 donor exchanges and 7 ABO-incompatible LDLT procedures, were performed at our institution. Initial donor-recipient ABO incompatibilities included 6 A to B incompatibilities, 6 B to A incompatibilities, 1 A to O incompatibility, 1 A+O (dual graft) to B incompatibility, 1 O to AB incompatibility, and 1 O to A incompatibility. Fourteen matches (87.5%) were ABO-incompatible, but 2 (12.5%) were initially ABO-compatible. All ABO-incompatible donors were directly related to their recipients, but 2 compatible donors were each undirected and unrelated directed. After donor reassignment through paired exchange (n = 7) or domino pairing (n = 1), the donor-recipient ABO status changed to A to A in 6, B to B in 6, O to O in 1, A to AB in 1, A+O to A in 1, and O to B in 1, and this made all matches ABO-identical (n = 13) or ABO-compatible (n = 3). Two pairs of LDLT operations were performed simultaneously on an elective basis in 12 and on an emergency basis in 4. All donors recovered uneventfully. Fifteen of the 16 recipients survived, but 1 died after 54 days. In conclusion, an exchange donor program for adult LDLT appears to be a feasible modality for overcoming donor-recipient ABO incompatibility.

End-stage nonalcoholic fatty liver disease: evaluation of pathomorphologic features and relationship to cryptogenic cirrhosis from study of explant livers in a living donor liver transplant program

In a proportion of liver cirrhosis, the etiology continues to remain elusive. It is uncertain whether and to what extent cirrhosis evolving from nonalcoholic fatty liver disease contributes to this group of cryptogenic cirrhosis because the clinicopathologic features of nonalcoholic fatty liver disease cirrhosis are largely unknown. We explored these facets by examining the explant livers and clinical data in living donor liver transplant recipients. Among 103 adult liver transplant recipients with different types of chronic liver disease, 30 had a pre-liver transplant diagnosis of cryptogenic cirrhosis. A final categorization of the native liver disease was attempted in these cases on the basis of detail pathomorphological findings in adequately sampled explant liver correlated with careful review of pre-liver transplant clinical data. Of the 30 cryptogenic cirrhosis cases, 19 (63.3%) finally labeled as nonalcoholic fatty liver disease cirrhosis showed histologic features in several respects different from those reported for the early and established phases of nonalcoholic fatty liver disease. Steatosis was infrequent and focal or even absent, whereas variable grades of Mallory hyaline and inflammation were consistently present. Ductular proliferation and hydropic change of hepatocytes were also frequent. Only 9 (47%) of the 19 cases had nonalcoholic fatty liver disease associated risk factors like diabetes and obesity. It was concluded that appreciation of quantitative and qualitative differences in hepatic morphology between the cirrhotic and the early/established stage of nonalcoholic fatty liver disease will help in making a correct diagnosis of nonalcoholic fatty liver disease cirrhosis in the proper clinical setting. When appropriate criteria are used, nonalcoholic fatty liver disease appears to account for close to two thirds of cases currently labeled as cryptogenic cirrhosis.

Long-term outcome of ABO-incompatible living-donor liver transplantation: a single-center experience

We report the long-term outcome of ABO-incompatible living donor liver transplantation (LDLT) performed in our hospital. We started the LDLT program in 1991 and from that year up to now (2008) 11 patients have received an ABO-incompatible graft. Nine out of the 11 cases have survived from 3.7 years to 13.9 years (mean 7.3 years) and they are in good conditions at present. Seven patients were subjected to preoperative apheresis. Eight patients experienced acute rejection and of them, 6 experienced steroid-resistant rejection that was treated with deoxyspergualin and apheresis. One patient who suffered rapidly progressing rejection died due to liver failure. Three patients who were administered rituximab did not suffer severe rejection nor adverse effects. During the long-term follow up 5 recipients had major complications such as postoperative lymphoproliferative disease, post-transplantation diabetes mellitus, portal vein occlusion and biliary stenosis. But those complications were controlled under stable conditions. We concluded that long-term survival can be expected after ABO-incompatible LDLT provided perioperative complications such as humoral rejection are overcome.

Impact of a Living Donor Liver Transplant Program for Hepatocellular Carcinoma to the Running Local Deceased Donor Liver Transplant Program

Impact of a Living Donor Liver Transplant Program for Hepatocellular Carcinoma to the Running Local Deceased Donor Liver Transplant Program

Surgical aspects of pediatric liver transplantation. Living donor liver transplant program in Hungary

Because of the long waiting time for pediatric liver transplantation, new techniques of liver transplantation were invented. Split and living-donor related liver transplantation are common today and the Kaplan-Meier (3 years) overall survival is over 80%. By splitting the liver, two recipients can be transplanted. In general, the left lobe is used for the pediatric, the right lobe for the adult recipient. There are a lot of combinations depending on the donor and recipient weight. The accepted liver volume is approx. 1% of the recipient body weight. The results of the Hungarian pediatric program improve, 27 transplantations were done using 14 partial liver grafts and living donor program was started. Using strict protocols and improving surgical skills, the overall pediatric survival was over 80% in the last 5 years.

Attitude of hospital personnel faced with living liver donation in a Spanish center with a living donor liver transplant program

In Spain, despite its high rate of cadaveric donation, death while on the liver transplant waiting list is high. For this reason, living liver donation is being encouraged despite of the risk of morbidity for the donor. The objective of this study was to analyze attitudes toward living liver donation among hospital personnel in a hospital with a recently authorized living donor liver transplantation program. A random sample was taken and was stratified by type of service and job category (n = 1,262). Attitude was evaluated by means of a validated psychosocial questionnaire. The questionnaire was completed anonymously and was self-administered. Statistical analysis included the Student t test, the chi(2) test, and logistical regression analysis. The questionnaire completion rate was 93% (n = 1,168). Only 15% (n = 170) of respondents were in favor of living liver donation if it were unrelated. An additional 65% (n = 766) were in favor if this donation, but only for relatives. Of the rest, 9% (n = 107) did not agree with living liver donation, and the remaining 11% (n = 125) were undecided. The variables related to this attitude were age (P = 0.044); job category (P = 0.002); type of service (according to whether it is related to organ donation and transplantation) (P = 0.044); participation in prosocial activities (P = 0.026); attitude toward cadaveric organ donation (P <0.001); attitude of a respondent's partner toward organ donation (P = 0.010); a respondent's belief that in the future, he or she may need a transplant (P < 0.001); and a willingness to receive a donated living liver organ if one were needed (P < 0.001). There is also a close relationship between attitude toward living kidney donation and living liver donation (P < 0.001). In the multivariate analysis, the only common independent variable from the bivariate analysis was a willingness to receive a living donor liver transplant if one were needed (odds ratio = 9.3). Attitude toward living liver donation among hospital personnel in a hospital with a solid organ transplant program is favorable and is affected by factors related to cadaveric donation, altruistic activity, and feelings of reciprocity. Physicians and the youngest hospital workers are those who are most in favor, which leads us to think that there is a promising future for living liver transplantation, which is essential given the cadaveric organ deficit and the high mortality rate while on the waiting list.

El personal médico ante la donación hepática de vivo. Estudio de opinión en un hospital español con programa de trasplante hepático de donante vivo

Mortality on the waiting list for liver transplants is high. Consequently, alternatives such as living donation are being sought. Therefore, one of the aspects that should be improved is the attitude of healthcare professionals toward this type of donation in order to create a favorable climate. The objective of this study was to identify attitudes toward living liver donation among physicians in a hospital with a living donor liver transplant program and to analyze the variables that affect these attitudes.A random sample stratified by type of service (n = 369) was performed among physicians in the hospital. Attitudes were evaluated using a survey validated in our geographical area. In each service, the head of service, or in their absence, an attending physician, was contacted. This person was given an explanation of the study and was made responsible for distributing the questionnaire in selected work shifts. The questionnaire was completed anonymously and was self-administered. Statistical analysis consisted of chi2 test, Student's t-test, and a logistic regression analysis.The survey completion rate was 93% (n = 345). Of those surveyed, 15% (n = 52) were in favor of living liver donation whether related or unrelated. This percentage increased to 85% (n = 292) if donation was related. Of the remainder, 8% (n = 27) did not accept living liver donation and the remaining 7% (n = 26) were undecided. This attitude was associated with only two factors: the respondent's belief that he or she might need a transplant in the future (p = 0.003) -90% of those who believed that they might need a transplant at some point in the future were in favor-, and the respondent's acceptance (if transplantation were necessary at some point in the future) of a living donated liver from a family member or a friend (p = 0.000). Thus, 96% of those who would be prepared to accept a living organ were in favor. In the multivariate analysis, both variables remained significant: the respondent's belief that he or she might need a transplant in the future (odds ratio [OR] = 2.36) and, if this were the case, the respondent's acceptance of a living donated liver (OR = 7.11).Attitudes toward living liver donation among physicians in a hospital with a living donor transplant program were highly favorable. Consequently, these health professionals may be a key element for the promotion of living donation at the present time when this form of donation is being encouraged to avoid mortality on waiting lists.

Impact of adult-to-adult living donor liver transplantation on access to transplantation and patients' survival: An 8-year single-center experience

While the number of candidates for liver transplantation has increased in the recent years, the pool of cadaveric donor organs has remained constant and the waiting time progressively increases. These facts led us to start a program of adult-to-adult living-donor liver transplantation in 1998. The aim of this study was to compare the outcome of all patients put on the waiting list since 1998. Between January 1, 1998, and January 1, 2005, 505 patients were put on the waiting list in our center, and living donor liver transplantation was considered in 57 cases (11.3%). At the time of evaluation (April 1, 2006), liver transplantation was performed in 377 patients (46 living donor liver transplantations), and 89 patients died on waiting list. On an intention-to-treat basis, the 1-year survival rate from the time of listing was 87.5% in the "living donor" group vs. 76.2% in the "cadaveric donor" group (P < 0.05), whereas the 1-year survival after liver transplantation was similar (92.3% vs. 86.9%). Our living donor liver transplantation program was able to improve the access to liver transplantation by reducing waiting time and the number of deaths on waiting list, despite the fact that these patients were more critically ill (liver failure and/or liver cancer).

Adult-to-Adult Living Related Liver Transplantation: Preliminary Results of the Hepatic Transplantation Group in Algiers

Introduction In the absence of cadaveric grafts, a living donor liver transplant program was started in Algeria in February 2003. The aim of this study is to report the preliminary results. Patients and methods From February 2003 to September 2004, eight adult-to-adult living related liver transplantations were performed. The donors were six women and two men of mean age of 25 years (range, 18 to 48 years). Right hepatectomy was performed in seven patients and left hepatectomy in one patient. The recipients were four women and four men of mean age 33 years (range, 16 to 56 years). Follow-up ranged from 1 month to 18 months (median 7 months). Results All donors survived the procedure. In the immediate postoperative period, two donors experienced complications. One donor underwent reoperation for hemorrhage and one suffered partial portal vein thrombosis, which was treated medically. The eight donors are alive at home without any late complications. One recipient died on postoperative day 43 due to sepsis. Among the seven other recipients, two experienced complications: one bilioma in relation to a biliary-intestinal fistula and one thrombosis of the splenic vein with a left portal embolus. At present the seven recipients are alive with normal liver function and without complications. Conclusion Our results are comparable to other reports suggesting that adult-to-adult living related liver transplantation is feasible with no mortality and low morbidity in donors. However, it is important to develop a cadaveric liver transplant program.

A Comparison of Postoperative Pain Control in Patients After Right Lobe Donor Hepatectomy and Major Hepatic Resection for Tumor

After initiating a living donor liver transplant program at our institution, we observed that donor patients experienced significant postoperative pain despite the use of thoracic patient-controlled epidural analgesia (PCEA) infusion catheters. We retrospectively compared patients who underwent right lobe donor hepatectomy (RLDH, n = 15) with patients who had undergone major hepatic resection for tumor (MHRT, n = 15) to elucidate the cause for this observation. All patients had preoperative thoracic epidural catheters placed, and both groups had similar surgical exposure. Demographic information, intraoperative variables, intensity of postoperative pain by visual analog pain score (VAPS), side effects, total number of requested and delivered PCEA doses, and the total amount of bupivacaine (mg) and volume (mL) of PCEA solution administered through 48 h postoperatively were collected and analyzed. The RLDH group had a significantly longer surgical duration than did the MHRT group. The RLDH group patients had higher postoperative pain scores (P = 0.034), and were 2.76 (1.12-6.82, 95% CI) times more likely to have pain than those patients in the MHRT group. There was no significant difference between patient groups for the amount of bupivacaine and volume of PCEA solution administered. These observations may be explained, in part, by the longer duration of surgery in the RLDH group. The possible role of preemptive analgesia via PCEA infusion and better perioperative teaching of PCEA use are discussed; these may lead to improved early postoperative pain control in RLDH patients.

Progress in living donor liver transplantation

Living donor liver transplantation (LDLT) has the capacity to reduce the current discrepancy between the number of patients on the transplant waiting list and the number of available organ donors. For pediatric patients, LDLT has clearly reduced the number of waiting list deaths, providing compelling evidence for an increase in LDLT programs. This review discusses many of the recent advances in LDLT.

Living donor liver transplantation

Liver transplantation has evolved into the standard treatment for numerous endstage liver diseases. The increase of organ shortages led to living organ donation. In 1988 living donor liver transplantation (LDLT) was performed for the first time. Since then multiple difficulties associated with LDLT have been solved. In Kyoto we can look back on more than 900 transplantations since the initiation of our LDLT program in 1990, which is the oldest in Japan and the largest in the world. In the following we review our extensive experience with special focus on issues such as donor safety, results after LDLT, and potential complications in the recipient. Further, graft size mismatching, venous drainage from anterior segment of the right lobe graft, LDLT for hepatocellular carcinoma, AB0-incompatible transplantation, and recurrence of hepatitis C infection, which are still unsolved problems in LDLT, are described and future directions are indicated.

Preliminary experience with living donor liver transplantation in adults and children

Introduction Living donor liver transplantation (LDLT) is becoming a widespread technique with good results. Its use may sharply decrease waiting list mortality. However, donor safety is of primary concern. The aim of this work was the preliminary evaluation of the LDLT program initiated in our institution in 1995. Patients and methods Among 875 liver transplants (LT) performed from 1986 12 are LDLT in nine adults (50.0 ± 10.0 years) and three children (1.9 ± 1.1 years). All donors were relatives: son/daughter (six), brother (three), and father/mother (three). Results Donor right lobe graft weight was 758.3 ± 137.4 g; left liver 525.3 ± 97.1 g; and left lobe 293.3 ± 30.5 g, with a graft weight/recipient weight ratio of 0.91 ± 0.21 (0.64–1.36) in adults. Complications in five donors (42%) included biliary fistula in the first three cases, two pleural effusions and one intra-abdominal collection. Mean hospital stay was 16.9 ± 15.2 days (median 12). Recipient indications for adults were: four HCV cirrhosis (+ alcoholic in one), one HBV cirrhosis, one cryptogenic, one alcoholic, one PBC, and one retransplant due to cholangiopathy. In children, the etiologies were two biliary atresia and one liver fibrosis. The first case was the only mortality (8.3%). Two patients were retransplanted (16.6%) due to arterial thrombosis (AT) and graft dysfunction. Actuarial survival at 1 year was 91.7% ± 8.0% for patients and 83.3% ± 10.8% for grafts. Complications in the recipients included AT (two), Acinetobacter sepsis, jaundice and upper digestive hemorrhage (due to a “small-for-size” graft), biliary fistula after T-tube removal, volvulus around the T tube, and intra-abdominal collection. Conclusions Our experience suggests that good results can be achieved with LDLT. Standardization of the technique will allow refinement of the operation and decrease waiting list mortality. However, donor safety remains a fearful threat.