Safety of living liver donation: Experience and learning curve at a new living donor liver transplant program in the United States.

Abstract

Living donor liver transplantation remains underutilized in the United States, largely because of concerns about donor safety and the technical complexity of donor hepatectomy. Contemporary United States data on program development, learning curves, and donor outcomes are limited. We conducted a retrospective review of consecutive adult living donor hepatectomies performed at a newly established living donor liver transplantation program (February 2018-October 2025). We analyzed donor demographics, operative parameters, and postoperative outcomes. Learning curves for operative duration and estimated blood loss were evaluated using cumulative sum analysis. Posthepatectomy liver failure was defined according to the International Study Group of Liver Surgery criteria. Multivariable logistic regression identified factors associated with morbidity and posthepatectomy liver failure. Ninety donors (99% right hepatectomy) were included. There were no donor deaths, Clavien-Dindo grade IV complications, or biliary complications. Overall morbidity was 28.9% (n = 26), predominantly minor (Clavien-Dindo grades I-II, n = 22). Cumulative sum analysis identified inflection points at case 21 for estimated blood loss and case 34 for operative duration, delineating learning and proficiency phases of the living donor liver transplantation program. Posthepatectomy liver failure occurred in 20 donors (22%), primarily grade A (n = 18). On multivariable analysis, smaller future liver remnant and earlier program experience were independently associated with posthepatectomy liver failure; no predictors of overall complications were identified. Adult living donor hepatectomy can be safely implemented in a newly established living donor liver transplantation program within a structured framework. Surgical proficiency and donor outcomes improve with experience, supporting the feasibility and safety of living donor liver transplantation expansion in contemporary United States practice to increase access to transplantation.