Live donor/split liver grafts for adult recipients: when should we use them?

1. Split liver transplantation for a child and an adult recipient is standard today. Living donor liver transplantation for small children should only be necessary in exceptional situations in a country with a well-organized organ donation program. 2. True split liver transplantation for two adults is still not very common. In the United States between April 2000 and May 2001, 89 surgical teams transplanted only 15 left lobes and 13 right lobes. Especially left lobes from deceased donors have a poor outcome; in Europe the ELTR shows a 1-year graft survival of 47%. 3. While in Asia left lobes, right lateral segments, and dual left lateral segments are more frequently used, living donor liver transplantation for adults in Europe and the United States is predominantly performed with right lobes.78 This carries a significant morbidity and mortality risk for the donor. Outcome compared to deceased donor liver transplantation (DDLTx) is similar with a trend towards more short-term and long-term biliary complications. 4. Living donor and split liver transplantation should be used mainly in an elective situation. Candidates are tumor patients, patients with cholestatic liver disease, and elective patients with bile disease. 5. Urgent liver transplantation is not a good option for living donor and split liver transplantation. Hepatic assist devices may change the picture in the future. 6. Living donor liver transplantation for metabolic disorders like Alpha-1-Antitrypsin deficiency, Hyperoxaluria, and others cannot be recommended at present since the genetically related donor and the patient may carry an unknown risk.