Living liver donor safety: Intraoperative considerations in living liver donation-Guidelines from the ILTS-iLDLT group consensus conference 2025

Prashant Bhangui¹, Abdul Rahman Hakeem², Tommaso Di Maira³, Ashwin Rammohan⁴, Blayne Amir Sayed⁵, Yuji Soejima⁶, Alexandra Shingina⁷, Yee Lee Cheah⁸, Stuart McCluskey⁹, Michael Spiro¹⁰, Swaytha Ganesh¹¹, Rajesh Rajalingam⁴, Subash Gupta¹², James Findlay¹³, Amar Gupta¹⁴, Alfred Kow Wei Chieh¹⁵, Seisuko Sakamoto¹⁶, Qiang Xia¹⁷, Ki-Hun Kim¹⁸, Wojciech G Polak¹⁹, Gonzalo Sapisochin²⁰, Arvinder Singh Soin¹, James Pomposelli²¹, Mary Vyas²², Chantal Wiggins²², Valeria Mas²³, Timucin Taner²⁴, Dieter Broering²⁵, Chao-Leng Chen²⁶, Norah Terrault²⁷, Patrizia Burra²⁸, Gideon Hirschfield²⁹, Nancy Ascher³⁰, Jan Lerut³¹, Mohamed Rela⁴, Julie Heimbach²⁴, Nazia Selzner³², Deniz Balci³³, Kim Olthoff³⁴

Affiliations

¹ Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi, NCR, India.
² Institute of Liver Studies, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK.
³ Department of Digestive Diseases, Hepatology and Liver Transplantation Unit, Hospital Universitari i Politècnic La Fe, Valencia, Spain.
⁴ Institute of Liver Disease and Transplantation, Dr. Rela Institute and Medical Center, Bharath Institute of Higher Education and Research, Chennai, India.
⁵ Liver Transplantation Program, The Hospital for Sick Children and Toronto General Hospital, Toronto, Canada.
⁶ Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan.
⁷ Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA.
⁸ Division of Transplantation, Division of Surgery, Houston Methodist Hospital, Houston, Texas, UK.
⁹ Department of Anesthesiology and Pain Medicine, University of Toronto and Toronto General Hospital, University Health Network, Toronto, Canada.
¹⁰ Department of Anaesthesia and Intensive Care Medicine, The Royal Free Hospital, London, UK.
¹¹ Department of Gastroenterology and Liver Transplantation, Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
¹² HPB Surgery and Liver Transplant, Center for Liver and Biliary Surgery, New Delhi, India.
¹³ Department of Anesthesiology and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA.
¹⁴ Liver and Pancreas Disease Center, Baylor University Medical Center, Dallas, Texas, USA.
¹⁵ Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, National University Hospital, Singapore, Republic of Singapore.
¹⁶ Organ Transplantation Center, National Center for Child Health and Development, Tokyo, China.
¹⁷ Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
¹⁸ Division of HB Surgery and Liver Transplant, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
¹⁹ Division of Hepatopancreatobiliary and Transplant Surgery, Department of Surgery, Erasmus MC Transplant Institute, University Medical Center Rotterdam, The Netherlands.
²⁰ Hospital Universitario Vall d´Hebron and Vall d´Hebron Institute of Research, Barcelona, Spain.
²¹ Division of Abdominal Transplant and Hepatobiliary Surgery, Tufts University School of Medicine, Boston, Massachusetts, USA.
²² PSC Partners Seeking a Cure, Toronto, Canada.
²³ Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA.
²⁴ Division of Transplant Surgery, Mayo Clinic, Rochester, Minnesota, USA.
²⁵ Organ Transplant Center of Excellence, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.
²⁶ Liver Transplantation Center, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.
²⁷ Department of Surgery, Keck Medical Center of the University of California, San Francisco (UCSF), San Francisco, California, USA.
²⁸ Department of Gastroenterology, Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy.
²⁹ Division of Gastroenterology and Hepatology, The Autoimmune and Rare Liver Disease Programme, Toronto General Hospital, University Health Network, Toronto, Canada.
³⁰ Department of Surgery, University of California, San Francisco, San Francisco, CA, USA.
³¹ Institute for Experimental and Clinical Research (IREC) Université Catholique de Louvain (UCL), Brussels, Belgium.
³² Ajmera Transplant Center, University of Toronto, Toronto, Canada.
³³ Department of Surgery and Transplantation, Bahcesehir University School of Medicine, Medical Park Goztepe Hospital, Istanbul, Turkey.
³⁴ Division of Transplant Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA.

PMID: 41490582
DOI: 10.1097/LVT.0000000000000800

Living liver donor safety: Intraoperative considerations in living liver donation-Guidelines from the ILTS-iLDLT group consensus conference 2025

Prashant Bhangui et al. Liver Transpl. 2025.

. 2025 Dec 29.

doi: 10.1097/LVT.0000000000000800. Online ahead of print.

Authors

Affiliations

¹ Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi, NCR, India.
² Institute of Liver Studies, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK.
³ Department of Digestive Diseases, Hepatology and Liver Transplantation Unit, Hospital Universitari i Politècnic La Fe, Valencia, Spain.
⁴ Institute of Liver Disease and Transplantation, Dr. Rela Institute and Medical Center, Bharath Institute of Higher Education and Research, Chennai, India.
⁵ Liver Transplantation Program, The Hospital for Sick Children and Toronto General Hospital, Toronto, Canada.
⁶ Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan.
⁷ Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA.
⁸ Division of Transplantation, Division of Surgery, Houston Methodist Hospital, Houston, Texas, UK.
⁹ Department of Anesthesiology and Pain Medicine, University of Toronto and Toronto General Hospital, University Health Network, Toronto, Canada.
¹⁰ Department of Anaesthesia and Intensive Care Medicine, The Royal Free Hospital, London, UK.
¹¹ Department of Gastroenterology and Liver Transplantation, Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
¹² HPB Surgery and Liver Transplant, Center for Liver and Biliary Surgery, New Delhi, India.
¹³ Department of Anesthesiology and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA.
¹⁴ Liver and Pancreas Disease Center, Baylor University Medical Center, Dallas, Texas, USA.
¹⁵ Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, National University Hospital, Singapore, Republic of Singapore.
¹⁶ Organ Transplantation Center, National Center for Child Health and Development, Tokyo, China.
¹⁷ Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
¹⁸ Division of HB Surgery and Liver Transplant, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
¹⁹ Division of Hepatopancreatobiliary and Transplant Surgery, Department of Surgery, Erasmus MC Transplant Institute, University Medical Center Rotterdam, The Netherlands.
²⁰ Hospital Universitario Vall d´Hebron and Vall d´Hebron Institute of Research, Barcelona, Spain.
²¹ Division of Abdominal Transplant and Hepatobiliary Surgery, Tufts University School of Medicine, Boston, Massachusetts, USA.
²² PSC Partners Seeking a Cure, Toronto, Canada.
²³ Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA.
²⁴ Division of Transplant Surgery, Mayo Clinic, Rochester, Minnesota, USA.
²⁵ Organ Transplant Center of Excellence, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.
²⁶ Liver Transplantation Center, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.
²⁷ Department of Surgery, Keck Medical Center of the University of California, San Francisco (UCSF), San Francisco, California, USA.
²⁸ Department of Gastroenterology, Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy.
²⁹ Division of Gastroenterology and Hepatology, The Autoimmune and Rare Liver Disease Programme, Toronto General Hospital, University Health Network, Toronto, Canada.
³⁰ Department of Surgery, University of California, San Francisco, San Francisco, CA, USA.
³¹ Institute for Experimental and Clinical Research (IREC) Université Catholique de Louvain (UCL), Brussels, Belgium.
³² Ajmera Transplant Center, University of Toronto, Toronto, Canada.
³³ Department of Surgery and Transplantation, Bahcesehir University School of Medicine, Medical Park Goztepe Hospital, Istanbul, Turkey.
³⁴ Division of Transplant Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA.

PMID: 41490582
DOI: 10.1097/LVT.0000000000000800

Abstract

The success of living donor liver transplantation (LDLT) has bridged the growing gap between organ demand and availability in patients with liver failure or liver cancer. Safety of the living liver donor (LLD) is paramount, and astute intraoperative management plays a critical role in ensuring optimal outcomes for them. Given that intraoperative surgical and anesthesia practices vary widely across centers, the International Liver Transplantation Society (ILTS) and the International Living Donor Liver Transplantation Group (iLDLT Group) convened a global consensus conference in Toronto in March 2025 to develop guidelines for intraoperative management of the LLD. This manuscript details the recommendations on intraoperative considerations for the safety of LLD developed by Working Group II of the Consensus Scientific Committee, using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system for assessment of recommendations, and the Danish model of consensus. Working Group II focused on intraoperative monitoring, fluid and ventilation strategies, surgical techniques for vascular and biliary division, surgeon and center-specific experience, and intraoperative crises planning. These guidelines aim to support both established and emerging LDLT teams to ensure high-quality and safe intraoperative care for the LLD.

Keywords: consensus; donor safety; hepatectomy; minimally invasive; perioperative care; recommendation.

PubMed Disclaimer

References

1. Staubli S, Grover AS, Turner BRH, Raptis DA, Spiro M, Tinguely P, et al. Launch of the International Living Donor Liver Transplantation Outcomes Registry. Lancet Gastroenterol Hepatol. 2023;8:698–699.
1. Magyar CTJ, Choi WJ, Li Z, Cattral MS, Selzner N, Ghanekar A, et al. The aim of donor safety: Surgical approaches and current results. Updates Surg. 2025;77:1755–1766.
1. Standards for Basic Anesthetic Monitoring in AMA, American Society of Anesthesiologists. Standards for Basic Anesthetic Monitoring. 2020. Accessed July 15, 2025. https://www.asahq.org/standards-and-practice-parameters/standards-for-ba...
1. Chaves R, Barbas C, Queiroz V, Serpa Neto A, Deliberato RO, Pereira AJ, et al. Assessment of fluid responsiveness using pulse pressure variation, stroke volume variation, plethysmographic variability index, central venous pressure, and inferior vena cava variation in patients undergoing mechanical ventilation: A systematic review and meta-analysis. Crit Care. 2024;28:289.
1. Liu T, Shen Q, Zhou X, Shen X, Lai L, Hou X, et al. Application of controlled low central venous pressure during hepatectomy: A systematic review and meta-analysis. J Clin Anesth. 2021;75:110467.

LinkOut - more resources

Full Text Sources
- Ovid Technologies, Inc.
- Wolters Kluwer
Miscellaneous
- NCI CPTAC Assay Portal

Save citation to file

Email citation

Add to Collections

Add to My Bibliography

Your saved search

Create a file for external citation management software

Your RSS Feed

Living liver donor safety: Intraoperative considerations in living liver donation-Guidelines from the ILTS-iLDLT group consensus conference 2025

Affiliations

Living liver donor safety: Intraoperative considerations in living liver donation-Guidelines from the ILTS-iLDLT group consensus conference 2025

Authors

Affiliations

Abstract

References

LinkOut - more resources

Full Text Sources

Miscellaneous