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Over Thirty Years of Living Liver Donation in North America: Mortality Associated with Donation
*Elizabeth A. King⁸, Roberto Hernandez Alejandro³, *Juliet Emamaullee⁶, *David Al-Adra⁴, *Matthew Byrne³, *Nazia Selzner⁷, *Blaire Anderson⁵, Elizabeth Pomfret², Kim M. Olthoff^1
1Surgery, University of Pennsylvania, Philadelphia, PA; ²Surgery, University of Colorado, Denver, CO; ³Surgery, University of Rochester, Rochester, NY; ⁴Surgery, University of Wisconsin, Madison, WI; ⁵Surgery, University of Alberta, Edmonton, AB, Canada; ⁶Surgery, University of Southern California, Los Angeles, CA; ⁷Ajmera Transplant Institute, University of Toronto, Toronto, ON, Canada; ⁸Surgery, Johns Hopkins University, Baltimore, MD

Objectives: Greater than 11,000 living donor hepatectomies have been performed in the United States and Canada over the last 3 decades. The true incidence of donor mortality is unknown. The OPTN requires all centers to report any known donor deaths 2 years from donation. It is critical to define the actual short and long-term risk of donation to inform counseling of potential donors. This study through the North American Living Liver Donor Innovation Group (NALLDIG) seeks to determine the true risk of donation.
Methods: National registry data from the OPTN database were used to identify all living liver donors that donated in the United States from 1989 through 2023 and determine those which had died at any time following donation as verified by OPTN resources. Summary data on the total number donors and deaths were collected directly from Canadian centers. Centers in the United States with donor deaths within 5 years of donation were sent a survey to obtain more detail. The risk of death and cumulative incidence were determined.
Results: A total of 9,400 living liver donations were performed in the US. There were 79 donor deaths (0.8%) at 35 centers. There were an additional 1,550 living liver donations performed in Canada with 4 donor deaths (0.3%) at 2 centers. In the US, median time from donation to death was 8.8 years (range 0 days to 24.5 years). Six deaths occurred perioperatively or within 30 days of donation (0.06%), 2 deaths in the first 90 days, 17 within five years, and an additional 53 beyond 5 years (Table 1). Overall, Incidence of death has decreased over time (Fig. 1). In Canada, all 4 donor deaths occurred beyond 5 years of donation. Early perioperative cause of death (COD) included cardiovascular (2), respiratory arrest (2), infection (1), and one unknown. Known later COD within 5 years included trauma (2), cancer (2), and suicide (2), with remaining COD still under investigation. Donor deaths occurred among donors for all graft types. Three living donors required liver transplant within the first 9 days of donation, all remain alive at latest follow-up.
Conclusions: Perioperative death and death within the first 90 days following hepatectomy for liver donation is a rare event in North America, with an estimated incidence of 0.06% (approximately 1 in 1750 donors). Causes of perioperative death include cardiovascular event from bleeding, intra-abdominal infection, and respiratory arrest. Later causes do not appear to be associated with hepatic surgery and include trauma, cancer, and suicide. Continued efforts to collect data and identify outcomes after liver donation is important as living liver donation rates increase in North America.
Clinical Characteristics of Living Liver Donors in the US