Living donor liver transplantation in adults

INTRODUCTION — The scarcity of donor organs has been a limiting factor in liver transplantation. As an example, in 2018 in the United States, there were over 14,000 individuals on the waiting list for liver transplantation. Approximately 7000 liver transplantation candidates will wait for >1 year for a transplant, and many patients will die waiting for an organ. Living donor liver transplantation (LDLT) is one approach that has been used to expand organ availability. Adult-to-adult LDLT has been performed in the United States for over twenty years, and over 4500 patients have received a living donor liver transplant [1].

This topic will review evaluation of the living liver donor candidate, surgical technique for the recipient operation, and outcomes of LDLT. Other issues regarding liver transplantation, such as pretransplantation evaluation of the recipient candidate and selection of organs from deceased donors are discussed separately:

●(See "Liver transplantation in adults: Patient selection and pretransplantation evaluation".)

●(See "Liver transplantation in adults: Deceased donor evaluation and selection".)

Medical care of the liver transplant recipient is discussed separately:

●(See "Liver transplantation in adults: Long-term management of transplant recipients".)

●(See "Liver transplantation in adults: Initial and maintenance immunosuppression".)

●(See "Infectious complications in liver transplantation".)

Perioperative anesthesia management for patients undergoing liver transplantation is discussed separately. (See "Liver transplantation: Anesthetic management".)

An overview of hepatic resection and specific resection techniques are discussed separately. (See "Overview of hepatic resection" and "Open hepatic resection techniques".)

EVALUATION OF THE LIVING LIVER DONOR CANDIDATE — Evaluating and selecting an adult liver donor is a comprehensive process that includes a medical and psychosocial assessment in addition to an assessment by an Independent Living Donor Advocate (ILDA). The decision to accept a liver donor is determined by a multidisciplinary team (eg, transplant surgery, transplant hepatology, mental health clinician, ILDA) and is informed by establishing that:

●The donor is medically fit to undergo donor hepatectomy

●There are no active psychosocial issues that would preclude donation

●The donor liver is suitable based on criteria such as ABO compatibility, liver size, and liver anatomy for the designated recipient

Each liver transplant center has developed specific protocols for donor evaluation and selection based on their experience and the population of donor candidates that they serve. Based on the comprehensive evaluation, a donor candidate may be accepted or declined. The Organ Procurement and Transplantation Network (OPTN) has defined a number of absolute contraindications to liver donation, while there is variability among centers concerning relative contraindications for liver donation. (See 'Contraindications to liver donation' below.) The OPTN guidance can be found here [2].

Blood typing and crossmatch — For adults who wish to be a liver donor, the evaluation of a living liver donor candidate begins with an assessment of the donor and recipient blood groups and crossmatch compatibility, which are the criteria for biologic compatibility of the donor and recipient [3,4]. ABO typing is performed on two separate occasions.

Medical evaluation — After a living donor candidate is screened for blood type and crossmatch compatibility with the designated recipient, a comprehensive medical evaluation of the donor is performed with the following goals (table 1):

●Ensure that the donor is in good health and has normal liver function and structure

●Ensure that the donor is not a risk to the recipient with respect to disease transmission

●Ensure that the donor liver is suitable for the intended recipient based on liver size and anatomy

Less than half of the candidates who complete the evaluation process will be accepted for liver donation. In a study including 1011 donor candidates in the Adult-to-Adult Living Donor Liver Transplantation Cohort, 405 donor candidates (40 percent) were accepted for donation [5]. Donor characteristics that were associated with acceptance included younger age, lower body mass index, and biologic or spousal relationship to the recipient.

History and physical examination — The medical evaluation consists of a history and physical examination and an assessment for pre-existing conditions such as viral hepatitis, nonalcoholic fatty liver disease, cardiovascular disease, malignancy, and bleeding disorders. The evaluation also includes confirming that donors have had age- and sex-appropriate cancer screening. Preventive care in adults is discussed separately. (See "Overview of preventive care in adults", section on 'Cancer screening'.)

Laboratory and screening tests — Laboratory testing is performed primarily to assess liver function, to screen for infections (eg, viral hepatitis), and to screen for diseases affecting the liver (eg, hereditary hemochromatosis). A chest radiograph is also routinely obtained. The pre-anesthesia evaluation for noncardiac surgery is discussed separately. (See "Preoperative evaluation for anesthesia for noncardiac surgery", section on 'Preoperative testing'.)

An electrocardiogram is performed for all donors. If there are abnormalities or if the donor has risk factors for coronary artery disease (eg, family history of cardiac disease), further cardiac testing such as echocardiogram is typically performed along with cardiology consultation. (See "Overview of established risk factors for cardiovascular disease".)

The evaluation of cardiac risk prior to noncardiac surgery is discussed separately. (See "Evaluation of cardiac risk prior to noncardiac surgery".)

The use of liver biopsy is center-specific and is not needed for most donor candidates because computed tomography (CT) or magnetic resonance imaging (MRI) can identify hepatic steatosis that would result in excluding the donor candidate [6,7]. Liver biopsy has been performed at some centers for potential donors with elevated liver biochemical tests and/or mild hepatic steatosis on imaging [6,8]. (See 'Advanced imaging' below.)

Advanced imaging — Advanced imaging of the donor serves to determine if the donor liver is suitable for the designated recipient and includes the following studies, alone or in combination, according to the transplant center’s protocol:

●Triple phase CT of the liver with liver volumetrics and 3D reconstruction – This CT is performed to delineate the arterial and venous anatomy of the donor liver. Additionally, volumetrics and 3D reconstructions are completed to assist the surgical team in determining if the liver is an appropriate size match and which donor lobe is preferred based on anatomic fit. Donation is contraindicated when the expected donor remnant liver is <30 percent of native liver volume. (See 'Surgical technique' below.)

In addition, advanced imaging of the donor liver can identify hepatic steatosis that would typically eliminate the potential donor as a candidate. (See 'Laboratory and screening tests' above.)

Contrast-enhanced MRI of the liver is another option for evaluation of hepatic steatosis, liver size, and vascular anatomy.

●Magnetic resonance cholangiopancreatography (MRCP) – MRCP is performed to assess anatomy of the biliary tree to help plan the surgical approach and determine if right or left liver lobe donation is preferred. In addition, most centers perform intra-operative cholangiography to delineate biliary anatomy prior to transection of the biliary ducts.

Psychosocial evaluation — The OPTN mandates performance of a psychosocial evaluation by a clinician with expertise in mental health (eg, psychiatrist, psychologist, Master's-prepared social worker) prior to donation, including documentation of the following [9]:

●Screening for any psychosocial issues, including mental health issues, that might complicate the living donor's recovery and could be identified as risks for poor psychosocial outcome. The donation process can be a psychologically stressful event for the donor, and review of the donor's social supports and coping skills is an important aspect of this process.

●Screening for behaviors that may increase risk for disease transmission as defined by the United States Public Health Service Guideline [10].

●A review of the living donor's history of smoking, alcohol, and drug use, including past or present substance abuse disorder.

●Establishing that the living donor understands the medical and psychosocial risks for both the living donor and the recipient. Most transplant centers require that donors and their caregivers attend an education session detailing the risks and benefits of live liver donation.

●An assessment of whether the decision to donate is free of inducement, coercion, and other undue pressure by exploring the reasons for donating and the nature of the donor's relationship, if any, to the transplant candidate. Some centers evaluate unrelated, altruistic donors.

●An assessment of the living donor's ability to make an informed decision and the ability to cope with major surgery and related stress. This includes evaluating whether the donor has a realistic plan for donation and recovery, which includes social, emotional, and financial support.

●An assessment of the living donor's ability to provide informed consent, to contemplate the risks of donation and to decline participation, if desired.

●A review of the living donor's occupation, employment status, health insurance status, living arrangements, and social support. Establishing adequate support for donors during their postoperative recovery includes identifying caregivers for the liver donor and for the transplant recipient. The donor cannot serve as primary caregiver for the transplant recipient.

●Establishing that that the living donor understands the potential financial implications of living donation.

Some elements of the psychosocial evaluation (eg, documenting history of smoking or alcohol use) are also performed by the clinician performing the medical evaluation.

Independent Living Donor Advocate (ILDA) — The OPTN policy requires that living donor recovery hospitals must designate and provide each donor candidate with an ILDA (ie, one person or a team with a key contact) who is not involved with the recipient evaluation and is independent of the decision to transplant the potential recipient. The ILDA must have adequate qualification and training requirements regarding knowledge of living organ donation, transplantation, medical ethics, informed consent, and the potential impact of family or other external pressure on the living donor's decision about whether to donate. To fulfill the OPTN requirements, the ILDA must do the following [11] (see "Kidney transplantation in adults: Evaluation of the living kidney donor candidate", section on 'Donor evaluation'):

●Function independently from the transplant candidate's team.

●Advocate for the rights of the living donor.

●Review whether the living donor has received information on each of the following areas: informed consent, the evaluation process, the surgical procedure, medical and psychosocial risks, and follow-up requirements.

●Assist the donor in obtaining additional information from other health care professionals as needed.

CONTRAINDICATIONS TO LIVER DONATION — Exclusion criteria for live liver donation are informed by the Organ Procurement and Transplantation Network (OPTN) and each transplant center's policy. While variability exists among centers, common contraindications to living donation include [9,12,13]:

●Age <18 years.

●Age >60 years – The upper age limit for donors varies depending on the specific program requirements and donor availability. A study comparing outcomes by donor age (≥50 versus <50 years, range 20 to 63 years) found no significant difference in complications based upon donor age [14]. In another study including 378 liver donors, no significant difference in outcomes based on donor age (50 to 60 years versus <50 years) was reported [15].

●Inability to provide informed consent (eg, lack of decision-making capacity) (see "Informed procedural consent").

●Body mass index (BMI) ≥30 to 35 kg/m² – Most centers use a BMI threshold of ≥30 to 35 kg/m² to exclude potential donors because of the risk of hepatic steatosis and surgical complications [16-19].

●Active malignancy or incompletely treated malignancy.

●Evidence of active symptomatic infection (see "Evaluation for infection before solid organ transplantation").

●HIV infection – Unless the requirements for variance are met according to the OPTN Policy 15.7 (Open Variance for the Recovery and Transplantation of Organs from HIV Positive Donors).

●Hepatitis C virus ribonucleic acid positivity.

●Hepatitis B virus surface antigen positivity.

●History of hypercoagulable disorder (see "Overview of the causes of venous thrombosis", section on 'Inherited thrombophilia').

●Active psychiatric conditions requiring treatment before donation, including evidence of suicidality.

●The following alpha-1 antitrypsin phenotypes: ZZ, Z-null, null-null, and S-null (see "Clinical manifestations, diagnosis, and natural history of alpha-1 antitrypsin deficiency", section on 'Background').

●Expected donor remnant volume <30 percent of native liver volume.

●Prior living liver donation.

●High suspicion of donor coercion.

●High suspicion of illegal financial exchange between the donor and the recipient.

ANESTHESIA MANAGEMENT — Perioperative anesthesia management for patients undergoing liver transplantation is discussed separately. (See "Liver transplantation: Anesthetic management" and "Anesthesia for the patient with liver disease", section on 'Anesthesia for hepatic resection'.)

For living liver donors, initiating an enhanced recovery after surgery (ERAS) protocol during the pre-operative period may facilitate pain management, and ERAS is discussed separately. (See "Anesthetic management for enhanced recovery after major noncardiac surgery (ERAS)".)

SURGICAL TECHNIQUE

General principles — In addition to medical and psychosocial evaluation, the surgical team evaluates the donor and reviews the results of laboratory testing and imaging. The decision to accept a liver donor is informed by the donor's liver size and appearance and the recipient's weight:

●Donor liver size – The donor must have sufficient liver size to allow for donation of adequate volume of liver to the recipient while maintaining an adequate size of the future liver remnant (FLR). Resecting <70 percent of donor liver volume is generally acceptable; thus the FLR will consist of ≥30 percent of original liver volume [20].

●Graft weight to recipient weight ratio – Determining a minimum allograft size that will provide the recipient with adequate liver function is based on the recipient's weight. The ratio of allograft weight to recipient weight is used to determine the minimum allograft size [21]. A graft weight to recipient weight (GW:RW) ratio of ≥0.8 percent has been associated with safety and adequate liver function for the recipient, although donor livers with lower GW:RW ratios have been used successfully in selected cases. (See 'Recipient outcomes' below.)

If these criteria cannot be met by the donor/recipient pair, the donor is declined to ensure the safety of both the donor and the recipient.

Donor hepatectomy — The left or right lobe of the liver can be used for transplantation depending upon anatomic considerations, the volume of the donor liver, and the size of the recipient. (See 'General principles' above.)

An overview of hepatic resection and specific resection techniques (eg, left hemihepatectomy, right hemihepatectomy) are discussed separately. (See "Overview of hepatic resection" and "Open hepatic resection techniques".)

Recipient operation

Recipient hepatectomy — The first portion of the recipient operation is the recipient hepatectomy which can often be the most challenging part of the transplant due to portal hypertension, liver size, and adhesions from previous surgeries or episodes of spontaneous bacterial peritonitis. Portal venous bypass has been commonly used to ensure that there is adequate drainage of the portal venous system during hepatectomy and during implantation of the allograft prior to reperfusion.

Another important aspect of the recipient operation is maintaining the length of the recipient's portal structures by dividing the hepatic artery, portal vein, and bile duct as close to the liver as possible and ideally above their respective bifurcations.

Preparing the liver allograft for implantation — The approach to preparing the liver allograft for implantation varies among liver transplantation centers and according to surgical team preference; however, common techniques include:

●Reconstruction of the hepatic veins – Cadaveric donor vein is typically used to reconstruct the hepatic veins to optimize venous outflow. All middle hepatic vein branches >5 mm in diameter are reconstructed in order to maximize venous outflow of the graft. This is more commonly performed with a right lobe donor graft than with a left lobe graft. A venous patch is also often used to widen and lengthen the right or left hepatic vein.

●Preparation for bile duct anastomosis – For transplant centers that typically connect the donor bile ducts to the recipient common bile duct, multiple donor ducts may need to be brought together into one common duct before implanting the allograft. However, for centers that typically perform Roux-en-Y hepaticojejunostomy reconstruction, combining donor bile ducts may not be necessary (figure 1). For some donor livers with multiple ducts, a combination of these two techniques may also be used.

Implantation — The process of implanting of the donor allograft can be divided into the following steps:

●Venous outflow – The first step in implantation of the graft is reconstruction of the venous outflow. This can be accomplished with one or two maneuvers, depending on the size and anatomy of the graft. The first maneuver is reconstructing the main outflow (right hepatic vein or left/middle hepatic vein confluence), typically in an end-to-side fashion to the recipient vena cava. To maximize venous outflow, some right lobe grafts require a second maneuver that is usually performed after reperfusion. This maneuver involves the construction of a venous jump graft created on the back table to drain the graft's large middle hepatic vein branches to the recipient hepatic vein.

●Portal vein inflow – The second step in implantation is the creation of the portal vein anastomosis. This is typically performed with an end-to-end anastomosis. Once the portal vein anastomosis has been completed, the allograft is re-perfused.

●Arterial inflow – Following reperfusion, the arterial anastomosis is created, usually in an end-to-end fashion.

●Biliary reconstruction – The last anastomosis that is performed is the biliary anastomosis, which can be done as a Roux-en-Y hepaticojejunostomy, or as an end-to-end anastomosis to the recipient common bile duct, or a combination of both methods.

The specific approach for biliary reconstruction is based on surgeon preference, the size of the bile ducts, and the number of donor ducts. For example, in a situation where there is a size mismatch between the donor and recipient duct or ducts, a hepaticojejunostomy may be preferred.

●Inflow modulation – The last major step of allograft implantation is assessing portal and arterial vascular supply to the allograft. Portal and arterial flows are measured, and if hepatic arterial flow is low, the measurements are repeated after test clamping the splenic artery. If hepatic arterial flow improves with this maneuver, the splenic artery can be ligated to provide long-term improvement. This approach leverages the hepatic arterial buffer response to decrease portal inflow and subsequently upregulate arterial inflow.

RECIPIENT OUTCOMES

Survival — Multiple case series have demonstrated favorable results with adult LDLT [22-29]. One multicenter report summarized outcomes of 385 LDLT performed at nine centers (the Adult-to-Adult Living Donor Liver Transplantation Cohort [A2ALL] consortium) [30]. 90-day and one-year graft survival rates were 87 and 81 percent, respectively. Graft failure within 90 days occurred in 51 transplant recipients (13 percent), primarily because of vascular thrombosis, primary non-function, and sepsis. Older recipient age and length of cold ischemia time were predictors of graft failure. In a follow-up study of 67 non-A2ALL transplant centers including 1664 transplants, outcomes were not significantly different in the non-A2ALL centers compared with the A2ALL study sites, suggesting that the results of the A2ALL consortium are generalizable within the United States [31].

Data comparing outcomes of LDLT with deceased donor transplantation are mixed, although some studies have suggested a survival benefit for LDLT [1,29]. In a single center study including 245 patients who received LDLT and 592 patients who received deceased donor transplants, LDLT was associated with higher rates of patient survival at three years compared with deceased donor (86 versus 80 percent) [29]. However, these outcomes may not have been directly comparable since most recipients who received a live donor graft had less severe liver disease (ie, lower the Model for End-stage Liver Disease [MELD] score) than patients who received a deceased donor graft. (See "Model for End-stage Liver Disease (MELD)".)

Long-term survival rates were examined in a report from the A2ALL consortium [32]. The study included 963 patients who received LDLT and 464 patients with deceased donor transplants, and after adjusting for confounders such as MELD score, the 10-year survival rates were not significantly different for LDLT compared with deceased donor transplant.

Studies have suggested that LDLT was associated with a survival benefit for adults with end-stage liver disease and a MELD-Sodium (MELD-Na) score as low as 11. In a study using the Scientific Registry of Transplant Recipients (SRTR) that included 119,275 transplant candidates, patients with a MELD-Na score ranging from 11 to 13 who underwent LDLT had lower risk of mortality compared with patients on the waiting list after adjusting for age, sex, and primary diagnosis (adjusted hazard ratio [HR] 0.64, 95% CI 0.47–0.88) [33]. A survival benefit with LDLT was also demonstrated for transplant recipients who had MELD-Na ≥14. These findings differ from previous analyses of the SRTR that showed survival benefit thresholds of MELD >15 to 17 [34] and MELD-Na ≥21 [35] for deceased donor liver transplantation. Decisions regarding LDLT for patients with a lower MELD-Na score should be individualized and informed by the risks to the donor and the recipient. (See "Liver transplantation in adults: Patient selection and pretransplantation evaluation".)

Adverse events — Data have suggested a higher overall complication rate for recipients of LDLT than deceased donor recipients [1,36,37]. Specific recipient complications include:

●Small-for-size syndrome (SFSS; also referred to as early allograft dysfunction) – SFSS is related to a partial liver graft that is too small to meet the metabolic demand of the recipient. SFSS is manifested by elevated liver biochemistries by post-operative day 7 (total bilirubin >10 mg/dL or INR >1.6) in the absence of technical complications [21,38,39]. SFSS has been associated with a graft weight to recipient body weight ratio of less than 0.8 percent [39]. In an analysis of two observational cohorts including a total of 631 LDLT recipients, early allograft dysfunction developed in 16 to 19 percent of recipients. In addition, early allograft dysfunction was associated with higher rates of graft failure at 90 days (24 versus 5 percent). Risk factors for early allograft dysfunction included graft type (left lobe graft), size (lower graft weight), severity of recipient disease (MELD score), and higher portal reperfusion pressure [39].

●Vascular complications – Vascular complications such as hepatic artery thrombosis or portal vein thrombosis have been reported more frequently for living donor grafts than for deceased donor grafts. In a study from the A2ALL consortium including 384 LDLT recipients and 216 deceased donor recipients, LDLT was associated with higher overall rates of hepatic artery thrombosis (7 versus 2 percent) and portal vein thrombosis (3 versus 0 percent) compared with deceased donor recipients [40].

●Biliary complications – Outcome data from A2ALL consortium and other transplant centers have reported biliary complication rates ranging from 5 to 40 percent [29,36,37]. Bile leak was the most commonly reported complication and often occurs from the cut surface of the liver.

●Other complications – For recipients of LDLT, having a biologically-related liver donor has been associated with lower risk of acute rejection. (See "Liver transplantation in adults: Clinical manifestations and diagnosis of acute T-cell mediated (cellular) rejection of the liver allograft", section on 'Epidemiology'.)

DONOR OUTCOMES

General recovery and liver regeneration — While liver donors are at risk for complications of donor hepatectomy, most donors do very well and have an uneventful recovery. The typical length of stay in the hospital after donor hepatectomy is usually four to seven days. Most donors are absent from work for a minimum of two months (or longer if their occupation involves manual labor).

Most liver regeneration occurs within the first two weeks after donation, and studies on postoperative imaging have shown that the donor liver remnant returns to a size ranging from 84 to 92 percent of its original volume by six months [28,41,42]. Additionally, data have suggested that most laboratory abnormalities (eg, liver biochemical and function tests) have returned to baseline by three months after donation [28].

Adverse events — Data from the Adult-to-Adult Living Donor Liver Transplantation Cohort consortium on liver donor outcomes have reported an overall complication rate of 24 percent [1]. Most events were Clavien-Dindo grade 1 (minor) or grade 2 (table 2), while approximately 1 percent of donors developed complications that were classified as grade 3 or higher [29].

Commonly-reported short-term complications have included bile leaks, surgical site infections, and urinary tract infections, while long-term complications included incisional hernias. However, most postsurgical complications resolved by one year after donation [1]. Risk factors for complications were blood transfusion requirement, intra-operative hypotension (ie, systolic blood pressure <100 mmHg), higher body weight, older donor age, and male sex [1].

Reported rates of donor mortality and of donor liver failure requiring liver transplantation have been 0.4 percent and 0.04 percent, respectively [43-45].

Other outcomes — Most donors have reported that they felt positively about their donation, while some donors (<10 percent) had experienced psychosocial distress following donation [46-49]. In a study of 271 living donors that assessed changes in their interpersonal relationships after donation, most donors reported an improved relationship with the recipient [47].

SPECIAL POPULATIONS

Pediatric living donor liver transplantation — The scarcity of appropriate-sized deceased donor organs for infants and children awaiting liver transplantation served as the impetus for advances in segmental liver transplantation. Surgical techniques developed for graft reduction and liver splitting were applied to living donors to achieve successful pediatric LDLT using the left lateral segment or left lobe of the liver [50]. With increased experience, LDLT has become a successful method of transplantation in children [51-55]. (See "Acute liver failure in children: Management, complications, and outcomes", section on 'Liver transplant'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Liver transplantation".)

SUMMARY AND RECOMMENDATIONS

●Evaluation of the living liver donor candidate – Evaluating and selecting a liver donor is a comprehensive process that includes a medical and psychosocial assessment in addition to designating an Independent Living Donor Advocate (ILDA) (table 1). The decision to accept a liver donor is determined by a multidisciplinary team and is informed by establishing that (see 'Evaluation of the living liver donor candidate' above):

•The donor is medically fit to undergo donor hepatectomy

•There are no active psychosocial issues that would preclude donation

•The donor liver is suitable based on criteria such as ABO compatibility, liver size, and liver anatomy for the designated recipient

The Organ Procurement Transplantation Network (OPTN) policy requires that living donor recovery hospitals must designate and provide each donor candidate with an ILDA who is not involved with the recipient evaluation and is independent of the decision to transplant the potential recipient. (See 'Independent Living Donor Advocate (ILDA)' above.)

●Contraindications to liver donation – The OPTN has defined a number of absolute contraindications to liver donation (eg, active malignancy, donor coercion, inability to provide informed consent), while there is variability among centers concerning relative contraindications for liver donation. (See 'Contraindications to liver donation' above.)

●Surgical technique – The decision to accept a liver donor is also informed by the donor's liver size and appearance and the recipient's weight (see 'Surgical technique' above):

•Donor liver size – Resecting <70 percent of donor liver volume is generally acceptable; thus the future liver remnant will consist of ≥30 percent of original liver volume. The donor must have sufficient liver size to allow for donation of adequate volume of liver to the recipient while maintaining an adequate size of the future liver remnant.

•Graft weight to recipient weight ratio – The ratio of graft weight to recipient weight is used to determine the minimum allograft size. A graft weight to recipient weight (GW:RW) ratio of ≥0.8 percent has been associated with safety and adequate liver function for the recipient.

●Donor outcomes – For individuals who undergo donor hepatectomy, most liver regeneration occurs within the first two weeks after donation, and studies on postoperative imaging have shown that the donor liver remnant returns to most of its original volume by six months. (See 'General recovery and liver regeneration' above.)

For individuals who undergo donor hepatectomy, commonly-reported short-term complications have included bile leaks, surgical site infections, and urinary tract infections, while long-term complications included incisional hernias. However, most postsurgical complications have resolved within one year after donation. (See 'Adverse events' above.)