Living donor outcomes in an emerging living donor liver transplantation program: A single-center experience from Malaysia

Abstract

BACKGROUND

Living donor liver transplantation (LDLT) has become an essential strategy to address the shortage of deceased donor organs in Malaysia. Universiti Malaya Medical Centre (UMMC), the second public institution in the country to establish a liver transplantation program, initiated its adult LDLT program in 2017 and became the first center in the country to successfully perform a living-related adult right lobe LDLT. However, data on donor outcomes from emerging LDLT programs remain limited.

AIM

To evaluate donor outcomes and perioperative results of an emerging LDLT program in Malaysia.

METHODS

This retrospective cohort study included all living donor hepatectomies performed at UMMC from January 2017 to June 2025. Data on donor selection, perioperative management, morbidity, and mortality were analyzed.

RESULTS

A total of 30 living donor hepatectomies were performed using right lobe, left lobe, and left lateral segment grafts. No donor mortality was observed. Complications included superficial wound infection (n = 4, 13.3%), anesthetic complications (n = 2, 6.7%), pulmonary atelectasis (n = 2, 6.7%), bile leak (n = 1, 3.3%), and gastrointestinal bleeding (n = 1, 3.3%). The median intraoperative blood loss was 500 mL (interquartile range: 400-800 mL), with a transfusion rate of 6.7%. The median length of hospital stay was 10 days. All donors achieved full functional recovery during follow-up.

CONCLUSION

As an emerging liver transplantation program, UMMC demonstrated favorable donor safety outcomes consistent with published reports from established LDLT centers. Continued refinement of surgical techniques, multidisciplinary perioperative care, and public awareness initiatives will be essential for the sustainable expansion of liver transplantation in Malaysia.

Key Words: Living donor liver transplantation; Donor outcomes; Hepatectomy; Perioperative complications; Malaysia

Core Tip: Universiti Malaya Medical Centre established Malaysia’s first structured adult living donor liver transplantation program in a public institution (2017) and has performed 30 living donor hepatectomies using right lobe, left lobe, and left lateral segment grafts. Donor safety is maintained through rigorous three-phase donor evaluation, multidisciplinary selection meetings, standardized open hepatectomy with routine intraoperative cholangiography, and protocol-driven perioperative care. Zero donor mortality, low-incident self-limiting complications, favorable intraoperative blood loss and length of hospital stay, and complete functional recovery indicate living donor liver transplantation can be safe in a low-volume, resource-constrained center when supported by robust clinical governance and evolving institutional expertise.

INTRODUCTION

Liver transplantation remains the definitive treatment for end-stage liver disease[1-5]. In Malaysia, the first liver transplantation was performed in 1994 as a pediatric living donor liver transplantation (LDLT) in a private institution for a child with biliary atresia. It was not until 2002 that the first public-sector liver transplantation was performed at Hospital Selayang, which was also a pediatric LDLT[3]. Although both deceased donor liver transplantation and LDLT programs are currently available, the annual number of liver transplantations remains substantially lower than that in neighboring countries. This is largely attributable to the scarcity of deceased donor organs; limited transplant infrastructure; and socioeconomic, cultural, public awareness, and healthcare system challenges encountered in Malaysia’s multicultural society[3-6].

In response to these challenges, Universiti Malaya Medical Centre (UMMC), the second public institution in Malaysia to establish a liver transplantation program, initiated its adult LDLT program in 2017 under the leadership of the late Associate Professor Yoong Boon Koon. In the same year, UMMC became the first center in the country to successfully perform a living-related adult right lobe LDLT. The program subsequently expanded to include pediatric LDLT in 2019, establishing a comprehensive LDLT service. During the early development of the program, donor selection emerged as a major challenge. Our previous study demonstrated that obesity and nonalcoholic fatty liver disease were the leading causes of donor nonutilization, posing significant obstacles to the development of a sustainable adult LDLT program in Malaysia[4].

Despite these challenges, the program continued to evolve through meticulous donor selection, multidisciplinary evaluation, and progressive refinement of surgical techniques and perioperative management, with donor safety remaining the highest priority. However, donor outcomes from emerging LDLT centers, particularly in developing countries, remain sparsely reported. Therefore, this study aimed to evaluate the clinical outcomes of living liver donors from our early experience and to describe the donor selection strategies, operative techniques, and perioperative management practices adopted to ensure donor safety.

MATERIALS AND METHODS

Study design and setting

A retrospective cohort study was conducted at the UMMC Liver Transplantation Unit, a tertiary center with a multidisciplinary transplant team comprising the hepatopancreatobiliary team, the plastic surgery and reconstructive team, hepatologists, anesthesiologists, radiologists, psychiatrists, an interventional radiologist, and transplant coordinators. All living donor hepatectomies performed between January 2017 and June 2025 were reviewed. This study was approved by the Medical Research Ethics Committee, Universiti Malaya.

Donor evaluation and selection

Potential living donors underwent a structured three-phase evaluation protocol adapted from the Liver Transplantation Programme of Queen Mary Hospital, Hong Kong, with minor modifications (Table 1). Screening included comprehensive medical, psychosocial, and laboratory assessments. Donors underwent detailed medical history-taking, physical examination, and psychiatric evaluation to ensure physical fitness, mental well-being, and donor safety. Contrast-enhanced multiphasic computed tomography and magnetic resonance cholangiopancreatography were performed to assess hepatic volumetry, vascular anatomy, and biliary tree anatomy (Table 1)[4-7].

Table 1 Evaluation protocol for potential donors in the living donor liver transplantation program at Universiti Malaya Medical Centre[4].

Phase	Evaluation
1	Clinical evaluation: Detailed history (including alcohol consumption) and physical examination. Anthropometric measurements: Height, weight and BMI. Laboratory tests: Blood group, complete blood count, biochemical profile, coagulation profile, FLP, FBS, TFT, ANA, ASMA, caeruloplasmin, tumor markers [AFP, CEA, PSA (male > 50 years), CA 15-3 (female > 40 years)], viral serology (HBsAg, anti-HBs, anti-HBc IgG, anti-HCV, HIV Ag/Ab, VZV IgG, CMV IgG), VDRL test, urine analysis, UPT (for females), FOBT Fibroscan®: CAP and TE
2	Multiphasic CT of the liver: Including volumetry measurements of right and left lobes and liver attenuation, with or without CT of the thorax, abdomen, and pelvis. Cardiac assessment: ECG, echocardiography, with or without EST. Pulmonary assessment: CXR, pulmonary function test. Mammography: Females > 40 years of age
3	Psychological assessment, with or without liver biopsy. Informed consent

Adapted from Rajaram et al[4].

BMI: Body mass index; FLP: Fasting lipid profile; FBS: Fasting blood glucose; TFT: Thyroid function test; ANA: Antinuclear antibody; ASMA: Anti-smooth muscle antibody; AFP: Alpha-fetoprotein; CEA: Carcinoembryonic antigen; PSA: Prostate-specific antigen; HBsAg: Hepatitis B surface antigen; anti-HBs: Hepatitis B surface antibody; IgG: Immunoglobulin G; anti-HCV: Hepatitis C antibody; HIV Ag/Ab: Human immunodeficiency virus antigen/antibody; VZV: Varicella-zoster virus; CMV: Cytomegalovirus; VDRL: Venereal disease research laboratory; UPT: Urine pregnancy test; FOBT: Fecal occult blood test; CAP: Controlled attenuation parameter; TE: Transient elastography; CT: Computed tomography; ECG: Electrocardiogram; CXR: Chest X-ray; EST: Exercise stress test; anti-HBc: Total hepatitis B core antibody; CA: Cancer antigen.

Upon completion of donor and recipient evaluations, every donor-recipient pair was reviewed at a multidisciplinary liver transplant meeting comprising hepatologists, transplant surgeons, anesthesiologists, radiologists, psychiatrists, and transplant coordinators. Donor suitability was assessed from medical, surgical, psychosocial, ethical, and logistical perspectives before proceeding with transplantation. Throughout the study period, all donors were living-related donors. Strict adherence to these selection criteria aimed to maximize donor safety while ensuring optimal recipient outcomes.

Selected living donors underwent right lobe, left lobe, or left lateral segment hepatectomy. All procedures were performed via open laparotomy. Parenchymal transection was performed using the Cavitron Ultrasonic Surgical Aspirator. Routine intraoperative cholangiography was utilized to delineate the biliary anatomy[4-6]. Notably, the routine Pringle maneuver was not performed. Critical operative steps included meticulous identification, dissection, and ligation of the vascular and biliary structures, with intraoperative cholangiography incorporated to ensure accurate bile duct mapping and safe bile duct transection.

Postoperatively, donors were managed in the post-anesthesia care unit initially, before being transferred to the general ward once clinically stable. Early mobilization was encouraged on postoperative day 1, with progressive advancement of oral intake as tolerated. Daily clinical assessments and laboratory monitoring were performed. Donors subsequently underwent scheduled follow-up to evaluate recovery, liver function, and psychosocial well-being.

Statistical analysis

The extracted data included donor demographics, operative details (estimated blood loss, transfusion requirements, and operative time), postoperative complications (graded according to the Clavien-Dindo classification), length of hospital stay, and recovery milestones. Descriptive statistics were calculated for all study endpoints using Microsoft Excel (Microsoft Corporation, Redmond, WA, United States). Results are presented as median (interquartile range) or n (%).

RESULTS

Between 2017 and 2019, during the establishment of the adult LDLT program, 55 potential living donors were evaluated for 33 adult transplant candidates. Of these, 41 (74.5%) were excluded during donor evaluation, predominantly because of obesity, hepatic steatosis, or a combination of both, as previously reported[4]. During the overall study period (January 2017 to June 2025), a total of 30 living donor hepatectomies were performed and are included in the present analysis. The demographic characteristics of these donors are summarized in Table 2.

Table 2 Baseline characteristics of living donors.

Baseline characteristic	n = 30, n (%)
Type of graft
Left lateral sectionectomy	21 (70.0)
Left hepatectomy	4 (13.3)
Right hepatectomy	5 (16.7)
Age in years
10-19	2 (6.7)
20-29	8 (26.7)
30-39	13 (43.3)
40-49	6 (20.0)
50-59	1 (3.3)
Sex
Male	10 (33.3)
Female	20 (66.7)
Ethnicity
Malay	14 (46.7)
Chinese	13 (43.3)
Indian	1 (3.3)
Other	2 (6.7)
BMI (Asia-Pacific), kg/m2
< 18.5	1 (3.3)
18.5-22.9	15 (50.0)
23.0-24.9	6 (20.0)
25.0-29.9	8 (26.7)
Relationship between donor and recipient
Mother	14 (46.7)
Father	7 (23.3)
Child	2 (6.7)
Siblings	3 (10.0)
Second-degree relatives	4 (13.3)

BMI: Body mass index.

Left lateral sectionectomy was the most commonly performed procedure (21/30, 70.0%), followed by right hemihepatectomy (5/30, 16.7%) and left hemihepatectomy (4/30, 13.3%). Most donors were aged 30-39 years (43.3%), followed by those aged 20-29 years (26.7%) and 40-49 years (20.0%). Female donors predominated, accounting for 66.7% of the cohort. The ethnic distribution reflected Malaysia’s multicultural population, with Malays (46.7%) and Chinese (43.3%) comprising the majority of donors. According to the Asia-Pacific body mass index (BMI) classification, half of the donors (50.0%) had a normal BMI (18.5-22.9 kg/m²), whereas 20.0% were overweight (23.0-24.9 kg/m²) and 26.7% had a BMI between 25.0 kg/m² and 29.9 kg/m². Only one donor (3.3%) was underweight. The majority of donors were first-degree relatives of the recipients. Mothers were the most common donors (46.7%), followed by fathers (23.3%), siblings (10.0%), and children (6.7%), whereas second-degree relatives accounted for 13.3% of donations.

Perioperative outcomes

Donor recovery was excellent overall. Only minor postoperative complications (Clavien-Dindo grades I-II) were observed, and all resolved without long-term sequelae, underscoring the safety of donor hepatectomy in our series. No intraoperative re-exploration or perioperative mortality was recorded. The median postoperative length of hospital stay was 10 days. The median intraoperative blood loss was 500 mL (interquartile range: 400-800 mL), and the transfusion rate was 6.7%. Two donors required intraoperative transfusion. One donor (3.3%) remained hospitalized until postoperative day 16 owing to transient mild liver decompensation with ascites and a positive rectal swab for carbapenem-resistant Enterobacterales, but recovered with supportive treatment. Four donors (13.3%) developed superficial surgical site infections, all of which resolved within 2 weeks with wound care.

Two donors (6.7%) developed pulmonary atelectasis and recovered with pulmonary rehabilitation, incentive spirometry, and chest physiotherapy. Two anesthesia-related complications (6.7%) were observed. One donor developed transient right vocal cord palsy following endotracheal intubation, which resolved spontaneously within 3 months without intervention. Another donor sustained left brachial plexus neuropraxia related to intraoperative positioning and recovered fully during follow-up. One donor (3.3%) developed upper gastrointestinal bleeding secondary to an esophageal ulcer, which was managed endoscopically.

One donor (3.3%) developed a bile leak after hepatectomy and underwent early endoscopic retrograde cholangiopancreatography with biliary stent placement. Subsequent cholangiography revealed no major bile leak. The stent was removed after 3 months, and the donor remained well thereafter. One donor (3.3%) sustained an intraoperative bile duct injury at the confluence of the left hepatic duct and common bile duct, which was repaired primarily with 6-0 polydioxanone suture. The donor had an uneventful recovery without bile leak or biliary stricture. Three donors (10%) experienced transient postoperative liver dysfunction. One had an underlying glucose-6-phosphate dehydrogenase deficiency with mild transaminitis, which normalized by 6 months. Another donor had an elevated gamma-glutamyl transferase level of 200 U/L, which normalized by 9 months. The third donor had a persistent mild elevation in gamma-glutamyl transferase (initially 130 U/L and 110 U/L at the 2-year follow-up) without clinical consequences.

There were no instances of biliary stricture, intra-abdominal hemorrhage, or unplanned re-exploration. No donor mortality occurred, and all donors achieved full functional recovery. Long-term follow-up revealed normalization of liver function and absence of chronic sequelae in all donors. A summary and graphical representation of donor complications are presented in Figure 1.

Figure 1 Perioperative outcomes of living liver donors. Values are presented as n (%). LOS: Length of hospital stay.

DISCUSSION

Our early experience suggests that favorable donor safety outcomes can be achieved in an emerging liver transplant center through meticulous multidisciplinary care and adherence to internationally accepted standards. No donor mortality was observed among the 30 living donors, and the overall morbidity was low, with most complications being minor, self-limiting, and within the range reported in the literature (25%-40%)[1,7,8]. Although direct comparisons should be interpreted cautiously because of differences in program maturity and patient selection, our findings fall within the range of outcomes reported by established LDLT centers.

Several factors likely contributed to these favorable outcomes. First, our donor selection process was deliberately stringent, with rigorous preoperative evaluation excluding donors with significant hepatic steatosis, obesity, inadequate future liver remnant, and other unfavorable characteristics, thereby optimizing donor safety before surgery[4]. Second, although our LDLT program was in its early developmental phase, donor hepatectomies were performed under the leadership of an experienced hepatopancreatobiliary surgeon with dedicated liver transplantation training and supported by a multidisciplinary transplant team. Meticulous hilar dissection, blood-sparing parenchymal transection techniques, routine intraoperative cholangiography, and vigilant anesthetic management further contributed to minimizing intraoperative blood loss and donor morbidity[1,2,6-8]. Consequently, the median estimated blood loss of 500 mL compared favorably with that reported in the early experiences of established LDLT centers in Korea, Hong Kong, and the University of California, San Francisco[9-12]. Collectively, these findings suggest that favorable donor outcomes can be achieved in an emerging LDLT program through rigorous donor selection, experienced surgical leadership, meticulous operative technique, standardized multidisciplinary perioperative care, and continuous technical refinement.

Our findings also showed that although the adult LDLT program was established before the pediatric LDLT program at our center, the majority of donor hepatectomies in the present series were performed for pediatric recipients. This reflects the differing donor requirements for adult and pediatric LDLT. The predominance of left lateral sectionectomy mirrored the expansion of the pediatric LDLT program, whereas adult donor hepatectomy remained limited by more stringent donor selection criteria. As reported previously, donor unsuitability represented a major obstacle to adult LDLT, with obesity and nonalcoholic fatty liver disease being the leading causes of donor exclusion, together with inadequate future liver remnant, medical comorbidities, and unfavorable liver anatomy[4,6]. Adult LDLT generally requires a larger graft, most commonly the right lobe, thereby necessitating more stringent donor selection to ensure donor safety. In contrast, pediatric LDLT generally requires only a left lateral section graft, enabling younger and healthier parents to serve as suitable donors while preserving an adequate future liver remnant. These differences largely explain why, despite the adult program being established earlier, a greater proportion of donor hepatectomies in our series were performed for pediatric recipients.

Despite these encouraging outcomes, Malaysia continues to face significant barriers to expanding liver transplantation. These include limited national organ donation infrastructure, persistently low deceased donor rates, insufficient public awareness regarding organ donation, and cultural and religious considerations that influence donor willingness[13-15]. Nevertheless, our findings suggest that LDLT can be performed safely in a lower-volume developing center when supported by rigorous donor evaluation, meticulous operative technique, dedicated multidisciplinary expertise, strong institutional commitment, and continued international collaboration. Continued investment in surgical training, transplant infrastructure, and psychosocial support pathways will be essential to sustain and expand liver transplantation services in Malaysia. Furthermore, strengthening national transplant frameworks, increasing public awareness of organ donation, and establishing long-term donor follow-up registries will be critical to ensuring continued donor safety and sustainable program growth.

This study has several limitations. First, its single-center retrospective design may limit the generalizability of the findings. Second, the relatively small sample size of 30 donor hepatectomies limits the statistical power of the study and precludes robust subgroup analyses. Therefore, our findings should be interpreted with appropriate caution and considered representative of the early experience of an emerging LDLT program rather than definitive evidence of superiority or equivalence to high-volume centers. In addition, donor-reported health-related quality of life, psychosocial well-being, and long-term functional recovery were not formally assessed. Future prospective studies should incorporate validated donor-reported outcome measures, including quality-of-life assessments, psychosocial metrics, and cognitive and physical recovery profiles, to complement surgical and biochemical outcomes[16]. Furthermore, multicenter collaboration, national data-sharing initiatives, and the establishment of a national liver transplant registry will be essential to increase sample size, strengthen benchmarking, refine donor selection pathways, optimize postoperative care, and support evidence-based policy development to expand access to liver transplantation in Malaysia.

CONCLUSION

In conclusion, our early experience demonstrates that living donor hepatectomy can be performed safely in an emerging liver transplant center, with zero donor mortality and low morbidity. Careful donor selection, meticulous surgical technique, multidisciplinary perioperative management, and continued international collaboration were fundamental to achieving these favorable outcomes. Our findings provide valuable benchmarks for emerging LDLT programs in developing countries and suggest that favorable donor outcomes are achievable even in resource-constrained settings. Continued investment in training, infrastructure, public awareness, and national collaboration will be essential to expanding liver transplantation services in Malaysia while maintaining donor safety as the highest priority.

ACKNOWLEDGEMENTS

The authors express their sincere gratitude to the late Prof. Yoong Boon Koon for his invaluable contributions to the establishment and development of the liver transplantation program at Universiti Malaya Medical Centre.