What is involved in a liver donation workup?

Liver Donation Workup

Living liver donor evaluation requires a comprehensive, multi-phase assessment including medical screening, anatomic imaging, liver biopsy, and psychosocial evaluation to ensure donor safety and graft suitability. 1, 2

Medical Screening Phase

Initial Laboratory Assessment

• Complete blood count, comprehensive metabolic panel, liver function tests (ALT, AST, bilirubin, alkaline phosphatase, albumin), and coagulation studies must be obtained to establish baseline hepatic function 2, 3
• Serologic testing for hepatitis B, hepatitis C, HIV, CMV, and EBV is mandatory to exclude transmissible infections 2
• Blood type compatibility with the recipient must be confirmed, as ABO incompatibility is an absolute contraindication 3
• Fasting glucose and hemoglobin A1c should be measured to screen for diabetes 2

Anatomic and Volumetric Imaging

• Cross-sectional imaging with CT or MRI is essential to assess liver volume, vascular anatomy, and biliary anatomy 4, 5
• MRI is increasingly preferred as an "all-in-one" imaging package that can evaluate liver volume, hepatic steatosis, vascular anatomy (hepatic artery, portal vein, hepatic veins), and biliary anatomy without radiation exposure 5
• Volumetric analysis must confirm adequate liver volume for both donor remnant (minimum 30-35% of total liver volume) and recipient graft 4, 5
• Identification of anatomic variants in hepatic arterial supply, portal venous anatomy, and biliary drainage is critical for surgical planning 4, 5

Liver Biopsy Assessment

Liver biopsy should be performed routinely in all potential living donors, even when laboratory tests and imaging appear normal. 6

• In a study of 201 apparently healthy donors with normal liver function tests, 53.2% had abnormal pathology findings including steatosis (29.9%), steatohepatitis (3.7%), and other findings like fibrosis or hepatitis (66.4%) 6
• Macrovesicular steatosis >30% is generally considered a contraindication to donation, as it reduces functional graft mass and increases risk of poor graft function 1, 6
• Occult fibrosis or inflammation detected on biopsy may disqualify donors even with normal imaging and laboratory values 1, 6

Psychosocial Evaluation

Independent psychological assessment by a psychiatrist or psychologist is mandatory to ensure informed consent and absence of coercion. 1, 2

• Mental competency must be formally assessed to ensure the donor can understand risks and benefits 2
• Evaluation for external or internal pressure to donate is critical, as family dynamics can create coercive environments 1
• The donor must have the ability to confidentially withdraw from consideration at any time without judgment 1
• Social support systems should be evaluated to ensure adequate postoperative care and recovery support 1, 2

Genetic Considerations for Living-Related Donors

For inherited metabolic liver diseases, genetic testing of related donors is essential to exclude carrier states that could compromise graft function. 1

• Heterozygote donors can be used successfully for conditions like Crigler-Najjar syndrome type 1, Wilson's disease, alpha-1 antitrypsin deficiency, and progressive familial intrahepatic cholestasis 1
• In Alagille syndrome, related donors with bile duct hypoplasia should be excluded due to risk of technical failure from inadequate bile ducts 1
• Genetic counseling should be provided to discuss implications of carrier status 1

Exclusion Criteria During Evaluation

Approximately 73% of potential donors are excluded during the evaluation process. 3

Common reasons for exclusion include:

• ABO blood group incompatibility with recipient 3
• Hepatic steatosis >10% on biopsy (some centers use >30% threshold) 6, 3
• Insufficient liver volume for safe donor remnant or adequate recipient graft 3
• Psychosocial contraindications including coercion, inadequate understanding, or mental health concerns 3
• Medical comorbidities that increase surgical risk 2
• Anatomic variants that preclude safe hepatectomy 4

Timeline and Logistics

Complete donor evaluation typically costs approximately 4,469 euros (2003 data) and requires coordination across multiple specialties. 3

• Initial screening with history, physical examination, and basic laboratory tests occurs first 2
• Advanced imaging follows if initial screening is favorable 4, 5
• Liver biopsy is performed after imaging confirms suitable anatomy 6
• Final psychosocial clearance occurs after medical suitability is established 2

Critical Safety Considerations

Donor safety must be the absolute highest priority, as the donor undergoes major surgery for no personal medical benefit. 1, 2

• Mortality risk to the donor must be low (generally <0.5%) for donation to be ethically appropriate 1
• Informed consent must be thorough, covering all potential complications including bile leak, bleeding, infection, and need for reoperation 2
• Long-term health implications for the donor must be discussed, including potential for hepatic insufficiency if complications occur 1