Future of U.S. living donor liver transplant: Donor and recipient criteria, transplant indications, transplant oncology, liver paired exchange and non-directed donor graft allocation.

In the U.S., living donor liver transplant (LDLT), from both directed and non-directed living donors, has expanded over the past several years. LDLT is viewed as an important opportunity to expand the overall donor pool for liver transplantation, shorten waiting times for a life-prolonging liver transplant surgery, and reduce liver transplant waitlist mortality. The liver transplant community's focus on LDLT expansion in the U.S. is fostering discussions around future opportunities which include, safe expansion of donor and recipient candidate eligibility criteria, broadening indications for LDLT including applications in transplant oncology, developing national initiatives around liver paired exchange, and maintaining vigilance to living donor and recipient candidate risk/benefit equipoise. Potential opportunities for expanding living liver donor and recipient candidate criteria include utilizing donors with more than minimal hepatic steatosis, evaluating older donors, performing LDLT in older recipients to facilitate timely transplantation, and providing candidates who would benefit from liver transplant, but may otherwise have limited access (i.e., lower MELD scores), an avenue to receive a life-prolonging organ. Expansion opportunities for LDLT are particularly robust in the transplant oncology realm, including leveraging LDLT for patients with advanced hepatocellular carcinoma beyond Milan, intrahepatic cholangiocarcinoma, and nonresectable colorectal cancer liver metastases. With ongoing investment in the deliberate growth of LDLT surgical expertise, experience and technical advances in the U.S., the liver transplant community's future vision to increase transplant access to more patients with end-stage liver disease and selected oncology patients may be successfully realized.

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