Liver Donor Complications

Living Liver DonorsLiver Donor Deaths & Mortality

Due to a lack of a standardized classification system, and the biases inherent to single-center studies, the reported rates of liver donor morbidity (complications) have been inconsistent. A strong bias exists against reporting complications (161) as exemplified in a recent study from Massachusetts General Hospital. Our understanding of catastrophic complications arising from live liver donation has been…limited by selection and ascertainment biases, small sample size, and the lack of a generalizable denominator for accurate risk estimation (215). 

Approximately, one of two deaths and three of four complications were not reported in the morbidity and mortality conference when compared to data collected using the American College of Surgeons—National Surgical Quality Improvement Program (162)

Note: Use caution when using study results from different countries to gauge the safety of live liver donation.

It is noteworthy that the large Asian centers (Japan, China and Korea) with the lowest recipient morbidity (complication rate) and best survival also had the smallest incidence of severe donor complications. This could be explained by demographic factors: e.g. small and non-obese recipients, better donor–recipient compatibility in the more homogeneous populations, or a different spectrum of liver diseases. A simpler possible explanation could be the experience and skill acquired by hepatobiliary surgeons in treating the liver diseases that are a dominant health concern in that part of the world. (141)

Living liver transplants were originally from adult to child, requiring the use of the smaller left lobe. Adult-to-adult living liver transplants require the removal of the larger right lobe. The risk to the living donor is much higher with a right lobe donation. (126, 140) The information reported on this site is in regards to adult-to-adult living liver donation.

In 2012, A2ALL (see below for explanation) compared their results to those of other researchers, including from other countries, and concluded “that 40% can be considered a fairly definitive assessment of the risk of complications in the first year following live donor right lobectomy” (258). This is independent of surgical experience or transplant center expertise. In other words, even the most meticulous living liver donor procedure will result in a 40% complication rate, presently and in the future.

A 5-center survey in Asia reporting on 1508 living liver transplants between January 1990 and December 2001 [766 adults, 742 children]:

The complication rate was higher in right lobe (28%) than in left lateral segment (9.3%) or left lobe (7.5%) donors.

– Cholestasis (7.3%) – interruption in bile secretion.
– Bile leakage (6.1%) – the liver secretes bile, which can leak into the abdomen.
– Biliary stricture (1.1%) – abnormal narrowing of biliary duct.
– Portal vein thrombosis (.5%) – blood clot of the vein that drains blood from the spleen and GI tract into the liver
– Intra-abdominal bleeding (.5%)
– Pulmonary embolism (.5%) – blood clot of the lung.

There was no hospital mortality, but there was one late liver donor death 3 years after operation. (126)

– A 2006 OPTN report lists three prior living liver donors on the wait list in need of their own transplant from 4/1/1994 thru 5/31/1996. All three where white males between the ages of 25 and 55 at listing, and all three were listed within 30 days of donation.

[An OPTN data request was made on November 11, 2011 for more comprehensive information. A follow-up was made in February 2012.]

– A conference of more than 90 experts who met in Vancouver in May 2007 and reviewed data from around the world found that 35% of liver donors are likely to have complications, including pneumonia, renal failure and repeat surgery. The time frames for follow-up varied among the research examined, but most complications arose shortly after surgery. Data from a national study that reviewed a sample of liver donors from 1998 to 2003 found a similar complication rate of 38%, with a median follow-up time of six months. (55)

From the A2ALL study (118), the largest US study of adult-to-adult living liver transplants to date (data from 9 centers. As of 11/12/2011, 75 live liver transplant programs are listed on OPTN.; 2 inactive)

– 62% of donors experienced no complications
– 21% had 1 complication, and 17% had 2 or more. (total of 37.7% LD complication rate)

Grade 1 (minor) complications = 27%
Grade 2 (potentially life threatening) = 26%
Grade 3 (life threatening) = 2%
Grade 4 (leading to death) = 0.8%

Common complications:

– biliary leaks (bile ducts) beyond postoperative day 7 = 36, 9%
– bacterial infections = 49, 12%
– incisional hernia = 22, 6%
– pleural effusion (fluid around the lungs) requiring intervention = 21, 5%
– neuropraxia (nerve damage) = 16, 4%
– re-exploration = 12, 3%
– wound infections = 12, 3%
– intra-abdominal abscess = 9, 2%
– 2 donors developed portal vein thrombosis, and 1 had inferior vena caval thrombosis.

Fifty-one (13%) donors required hospital readmission, and 14 (4%) required 2 to 5 readmissions.

A subset of A2ALL regarding living liver transplants in treatment of Acute Liver Failure (ALF) found 50% of living liver donors suffering complications as a result of the procedure. (142) There is a concern that an expedited process in the atmosphere of medical urgency might increase the risk of coercion in the candidate’s decision on whether to donate (156).

The latest A2ALL data, from a 2012 publication, is available in a blog post here.

Other Studies on Risk of Complications:

A study reviewed at The International Liver Transplantation Society 13th Annual International Congress (2007) found post-operative complications in 63% of liver donors.(158) Two US studies that same year reported that more than one in three liver donors experience at least one medical complication, during surgery or in the months or more after. (55)

Meanwhile, pooled data of 12 studies from 1995-2001 (6 North American, 4 Asia, 2 Europe) reporting complications specific to right-lobe donations for adults reported 54 events in 174 donors, resulting in a crude complication rate of 31%. (124)

Of 123 adult-to adult living liver transplants in Europe from 1996-2000: Minor complications occurred in 14%, but 22 patients (17.8%) experienced 25 major complications. (123)

Complications requiring readmission were reported by 22%. Out of 27 living liver donors: Eight were administered an autologous blood transfusion (one’s own blood); one donor (3.7%) required a nonautologous blood transfusion in addition to their autologous blood. In response to an open-ended question, 40% of donors reported at least one event that they deemed an immediate complication. (127) 

As reported in November, 2011: a single-center, 10 year study revealed a 61% live liver donor complication rate with 25% re-hospitalizations. (194)

Other Reported Complications:

– Bile leak
– prolonged ileus [intestinal blockage]
– minor wound problems
– neuropraxia [nerve damage]
– transient pressure sores
– pleural effusions [excess fluid in the lung cavity]
– edema [swelling]
– atelectasis [lung collapse].  (124)
– Delay in return to normal bowel function
– pain
– brachial plexus injury [nerves supplying shoulder, arm and hand]
– blood clot
– incisional infection
– pleural effusion [fluid in lung cavity]
– sore throat
– foot paresthesias [tingling, burning, prickling, etc]
– persistent short-term memory loss
– chronic fatigue
– “fluid between lung and liver,”
– bile leak. (127)

Requiring readmission:

– biloma [bubble/pool of bile in the abdomen]
– fever
– pancreatitis [inflammation or infection of the pancreas]
– loculated pleural effusion [pocket of fluid in the lung cavity]
– emesis (vomiting)
– chronic abdominal pain.  (127)

Persistent post-surgical pain was reported by 31% of live liver donors at the six-month follow-up and by 27% of donors at the twelve-month follow-up, according to a single center study published in 2014.

Important FYI:

– A ploy too-often utilized in regards to living kidney donation is to separate living kidney donors from other patients who have undergone an nephrectomy (kidney removal) as a way of minimizing risk. Fortunately, a researcher compared the results of living liver donors and others who have had a liver lobe removed due to disease and found the two cohorts have similar complication rates and outcomes (165) so that excuse is not valid.

Last Updated: November 30, 2015