Can a patient with Crohn’s disease who is in clinical remission, off systemic steroids and biologic therapy for at least 3–6 months, has normal liver function tests and imaging, stable weight, and no extra‑intestinal complications be considered a living donor for liver transplantation?

Can Crohn's Disease Patients Be Living Liver Donors?

A patient with Crohn's disease in sustained clinical remission, off systemic steroids and biologics for at least 3–6 months, with normal liver function and no active complications, can be considered as a living liver donor, though this requires exceptionally careful evaluation given the inherent donor risks and the potential for disease reactivation.

Donor Safety Framework

The fundamental principle in living donor liver transplantation (LDLT) is the "double equipoise" concept, which requires balancing the recipient's survival benefit against the donor's risk of complications or death 1. This is particularly critical when evaluating donors with chronic medical conditions like Crohn's disease.

Baseline Donor Risks in LDLT

• The mortality risk for right lobe donation is estimated at 0.5% (approximately 1 in 200-300 donors) 2, 3
• Approximately 20% of donors experience measurable complications 2
• Common complications include biliary leaks, strictures, hepatic artery thrombosis, and portal vein thrombosis 3
• Donors with postoperative complications experience significant declines in physical functioning and quality of life 4

Specific Considerations for Crohn's Disease Donors

Disease Activity Requirements

The donor must demonstrate complete disease quiescence:

• Minimum 3–6 months off all systemic steroids and biologic therapy is essential, as these medications indicate active or recently active disease 1, 5
• Clinical remission must be confirmed with objective markers including normal inflammatory markers (CRP, fecal calprotectin) and endoscopic evidence of mucosal healing 5
• No extra-intestinal manifestations or complications (strictures, fistulas, abscesses) should be present 5

Perioperative Risk Assessment

The major concerns with Crohn's disease donors include:

• Surgical stress may trigger disease flare: The massive physiologic stress of major hepatectomy could reactivate quiescent Crohn's disease, potentially requiring immunosuppressive therapy during the critical postoperative recovery period 1
• Infection risk: Donors face significant infection risk post-hepatectomy, and any disease reactivation requiring immunosuppression would compound this risk 1
• Nutritional compromise: Crohn's disease patients may have baseline nutritional deficiencies or malabsorption that could impair liver regeneration after donation 1

Hepatic Considerations

• Normal liver function tests and imaging are mandatory, as Crohn's disease can be associated with hepatobiliary complications including primary sclerosing cholangitis, though this is more common in ulcerative colitis 1
• The graft volume to standard donor liver volume ratio should be around 50% or less to minimize donor risk, as ratios above 60% are associated with prolonged jaundice and complications 4

Evaluation Algorithm

Step 1: Confirm sustained remission

• Document at least 6 months off all systemic immunosuppression
• Obtain recent colonoscopy showing mucosal healing
• Verify normal inflammatory markers (CRP, fecal calprotectin)

Step 2: Assess for complications

• Cross-sectional imaging (CT or MRI enterography) to exclude strictures, fistulas, or abscesses
• Evaluate for extra-intestinal manifestations
• Screen for hepatobiliary involvement

Step 3: Standard donor evaluation

• Complete liver function assessment and volumetric analysis 6
• Psychosocial evaluation addressing the chronic disease burden 6
• Nutritional assessment with attention to micronutrient deficiencies 1

Step 4: Risk-benefit analysis

• The recipient must have substantial transplant benefit to justify exposing a donor with chronic disease to surgical risk 1
• Consider whether deceased donor transplantation is a reasonable alternative given the recipient's MELD score and waiting time 1

Critical Caveats

LDLT should be restricted to centers of excellence with extensive experience in both liver transplantation and donor hepatectomy to minimize donor risk 1. This is even more critical when considering donors with underlying medical conditions.

The observation period is crucial: A minimum 3-month observation period between evaluation and donation is recommended to ensure disease stability and allow time for tumor biology assessment in HCC recipients, though this principle applies equally to assessing Crohn's disease stability 1.

Avoid donation during any period of disease activity: Patients requiring corticosteroids, immunomodulators, or biologics should be considered absolute contraindications until sustained remission is achieved 1, 5.

Emergency or urgent LDLT should be avoided in donors with Crohn's disease, as emergency hepatectomy is associated with worse donor outcomes and quality of life 4.

Practical Recommendation

While not explicitly contraindicated, Crohn's disease donors represent a higher-risk population that requires exceptional scrutiny. The decision should only proceed if: (1) the recipient has substantial transplant benefit that cannot be achieved through deceased donation, (2) the donor demonstrates unequivocal sustained remission for at least 6 months off all immunosuppression, (3) comprehensive evaluation reveals no complications or extra-intestinal disease, and (4) the procedure is performed at a high-volume center with extensive LDLT experience 1, 6. The potential for disease reactivation from surgical stress must be thoroughly discussed with the donor as part of informed consent 6.