What is the evaluation checklist for a living liver donor?

Living Liver Donor Evaluation Checklist

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

Ethical Prerequisites

Before initiating any evaluation, confirm these fundamental criteria are met:

• Liver transplantation must be the only therapeutic option for the recipient, OR deceased donor transplantation is not available, OR a deceased donor organ has not become available 2
• The likelihood of recipient survival following living donor liver transplantation must be high 2
• The mortality risk to the donor must be low (generally <0.5%) 1
• Donor safety is the absolute highest priority, as the donor undergoes major surgery for no personal medical benefit 1

Phase 1: Initial Screening

Relationship and Blood Type Compatibility

• Verify donor-recipient relationship (related donors preferred, though non-related donors are acceptable at experienced centers) 2, 3
• Confirm ABO blood group compatibility 4

Basic Medical Assessment

• Complete history and physical examination focusing on:
  • Age (no absolute age limit, but older donors have increased risk) 2
  • Body mass index and obesity status 5
  • Cardiovascular disease history 2
  • Diabetes mellitus 2
  • Chronic medical conditions that increase surgical risk 2
  • Medication use 6
  • Substance use history (alcohol, tobacco, drugs) 2

Laboratory Evaluation

• Complete blood count, comprehensive metabolic panel, coagulation studies 6
• Liver function tests (AST, ALT, alkaline phosphatase, bilirubin, albumin) 6
• Renal function (creatinine, creatinine clearance) 2, 6
• Fasting glucose and hemoglobin A1c 6
• Lipid panel 6

Infectious Disease Screening

• Hepatitis B surface antigen, hepatitis B core antibody, hepatitis B surface antibody 2, 6
• Hepatitis C antibody and RNA if positive 2, 6
• HIV antibody 2, 6
• Cytomegalovirus IgG 2, 6
• Epstein-Barr virus IgG 2, 6
• Rapid plasma reagin (syphilis) 6

Phase 2: Anatomic and Volumetric Assessment

Cross-Sectional Imaging

• CT angiography or MRI/MRCP to evaluate:
  • Hepatic arterial anatomy and variants 2, 6
  • Portal venous anatomy 2, 6
  • Hepatic venous drainage patterns 6
  • Biliary anatomy (MRCP preferred to avoid invasive cholangiography) 6
  • Liver volume measurement (donor remnant must be ≥30-35% of original liver volume) 6
  • Exclusion of hepatic masses or lesions 6

Volumetric Requirements

• Calculate future liver remnant volume (must be adequate to prevent donor hepatic insufficiency) 6
• Assess graft-to-recipient weight ratio (typically ≥0.8% for adequate recipient function) 6

Phase 3: Liver Biopsy Assessment

Liver biopsy should be part of the routine evaluation protocol for all living liver donors, as approximately 50% of apparently healthy donors have abnormal pathology 5

Biopsy Indications and Findings

• Perform liver biopsy even when liver function tests are normal and imaging appears normal 5
• Assess for steatosis: Macrovesicular steatosis >30% is generally a contraindication to donation, as it reduces functional graft mass and increases risk of poor graft function 1
• Evaluate for occult liver disease: fibrosis, hepatitis, steatohepatitis, granulomatous reactions 5
• Document percentage of steatosis, inflammation grade, and fibrosis stage 5

Specific Pathology Considerations

• Steatosis 10-30% requires careful consideration and may be acceptable in select cases 4
• Any fibrosis beyond minimal portal fibrosis should prompt reconsideration 5
• Steatohepatitis is typically a contraindication 5

Phase 4: Cardiopulmonary Evaluation

Cardiac Assessment

• Echocardiography to assess:

  • Left ventricular ejection fraction (must be >50%) 7
  • Valvular function 7
  • Left atrial size 7
  • Estimated pulmonary artery systolic pressure 7

• Dobutamine stress echocardiography for:

  • Chronic smokers 2
  • Donors over age 50 2
  • Those with clinical or family history of heart disease 2
  • Diabetic donors 2

• Cardiac catheterization if stress test is positive 2

Pulmonary Assessment

• Pulmonary function tests 2
• Arterial blood gas if pulmonary disease suspected 2
• Chest radiograph 6

Phase 5: Genetic and Metabolic Considerations

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

Acceptable Heterozygote Donor Conditions

• Crigler-Najjar syndrome type 1 2, 1
• Wilson's disease 2, 1
• Alpha-1 antitrypsin deficiency 2, 1
• Progressive familial intrahepatic cholestasis 2, 1
• Carbamoyl-phosphate synthase 1 deficiency 2
• Propionic acidemia 2
• Arginosuccinic aciduria 2
• Tyrosinemia 2

Special Considerations for Alagille Syndrome

• If the potential donor and recipient share the same mutant Jagged 1 or Notch 2 allele, the donor must be carefully evaluated for bile duct hypoplasia and vascular anomalies 2
• Donor evaluation must include liver biopsy and/or cholangiography to rule out bile duct hypoplasia 2
• Living-related liver transplantation is not advisable in most circumstances when shared mutations exist 2

Phase 6: Mandatory Psychosocial Evaluation

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

Key Assessment Components

• Evaluation for external pressure from family members or social circumstances 1
• Assessment for internal pressure or guilt-driven motivation 1
• Confirmation of donor's understanding of risks, including:
  • Perioperative mortality risk 1
  • Morbidity and complication rates 1
  • Long-term health implications, including potential for hepatic insufficiency 1
  • Impact on future insurability and employment 8

Donor Autonomy Protection

• The donor must have the ability to confidentially withdraw from consideration at any time without judgment 1
• Provide mechanism for donor to decline participation without family knowledge 2
• Address coercive pressures throughout the evaluation process, not just at initial assessment 2

Social Support Assessment

• Evaluate adequacy of postoperative support systems 2
• Assess financial stability and ability to take time off work 8
• Confirm understanding of required follow-up schedule 8

Phase 7: Informed Consent Process

Donor Risk Discussion

• Overall complication rate of approximately 11-17% 3
• Simple complications (wound issues, minor infections): 6-7% 3
• Moderate complications (bile leak, prolonged ileus): 4% 3
• Severe complications (organ failure, death): <1% 3
• Mortality risk: approximately 0.1-0.5% 1, 3

Long-Term Outcomes

• 88% of donors report feeling the same or better after donation 8
• Common physical complaints include malaise, bloating, and scar discomfort 8
• Emotional symptoms (fear and anxiety) occur in 27-29% but typically resolve spontaneously 8
• 93% of donors would recommend donation 8
• High satisfaction rates (61% very satisfied) 8

Common Pitfalls to Avoid

• Do not proceed without liver biopsy, even if imaging and laboratory tests are normal—50% of apparently healthy donors have abnormal pathology 5
• Do not accept donors with steatosis >30%, as this significantly increases risk of poor graft function 1
• Do not minimize psychosocial evaluation—coercion assessment is critical and must be ongoing throughout the process 1
• Do not proceed if donor remnant volume will be <30-35% of original liver volume 6
• Do not accept related donors for Alagille syndrome without genetic testing and careful evaluation for bile duct hypoplasia 2
• Do not rush evaluation in acute liver failure settings—emergent environments may be coercive to potential donors 2
• Do not rely solely on non-invasive imaging for biliary anatomy—MRCP should be performed 6

Rejection Criteria Summary

Approximately 68% of potential donors are rejected during evaluation 4. Common reasons include:

• Incompatible blood group 4
• Steatosis >30% on liver biopsy 1, 4
• Insufficient liver volume or inadequate remnant 4
• Psychosocial concerns or evidence of coercion 4
• Occult liver disease on biopsy 5
• Significant cardiovascular disease 2
• Active substance abuse 6
• Transmissible infections 2