Live liver donation is routinely practiced in Asia and in Middle Eastern countries accounting for 80–90% of liver transplant activity. In contrast, annual data for 2015 in the US showed that the vast majority of the 7,127 adult liver transplants used organs from deceased donors (n=6,768; 95%) (Kim et al., 2017). The risk of donor death is higher in live donor liver transplantation than in live renal donation and is estimated at 0.2% (1 in 500) (National Institute for Health and Care Excellence [NICE] [IPG535], 2015). However, with the marked increase in the incidence of hepatocellular carcinoma and patients with non-alcoholic steatohepatitis (NASH), liver transplant programmes even in North America have established live liver donation programmes to bridge the organ shortage. This is especially true for patients who present with primary liver tumours (HCC) beyond the Milan criteria. A comparison of living versus deceased donor liver transplantation for hepatocellular carcinoma (HCC) showed similar tumour recurrence rates after 5-year follow up: rates were 14 out of 110 (12.7%) in deceased donor recipients, compared with 4 out of 31 (12.7%) in living donor recipients. Furthermore, the waiting time for living donor liver transplantation was significantly shorter than for deceased donor transplantation (2.6 ± 2.4 months versus 7.9 ± 9 months; P=0.001) (Bhangui et al., 2011).

A meta-analysis of 12 studies compared living and deceased liver donors for treatment of HCC. It demonstrated improved disease-free survival in those receiving grafts from living donors, although overall survival was no different. Combined HRs were 1.59 (95% CI, 1.02–2.49) for disease-free survival; and 0.97 (95% CI, 0.73–1.27) for overall survival (Grant et al., 2013).

An earlier meta-analysis of seven studies showed no statistically significant difference in overall survival rates of living versus deceased donor liver transplantation for HCC: the pooled relative risks (RR) were 0.99 (95% CI, 0.90–1.09, P=0.87) at 1 year; 0.97 (95% CI, 0.83–1.13, P=0.68) at 3 years; and 0.96 (95% CI, 0.81–1.13, P=0.61) at 5 years (Hu et al., 2012).

Guidelines for liver transplantation from living donors have recently been published (National Institute for Health and Care Excellence (NICE), November 2015; Manas et al., 2016).