Living Donor Liver Transplantation for Acute Liver Failure With Fixed Pupils: Are We Fixed?

Living donor liver transplantation (LDLT) is fraught with the social and ethical dilemma of excising a part of the liver from a healthy first-degree relative. When LDLT is to be done for an acute liver failure (ALF), identification of a suitable donor is a race against time. Herein, we describe a unique challenge faced by the transplant team of whether to proceed with donor hepatectomy from a son, when the recipient (HBV-related ALF) developed non-reactive fully dilated pupils on the table, prior to beginning the surgery. The patient ultimately underwent a LDLT despite fixed dilated pupils by virtue of further workup, which suggested that cerebral blood flow was maintained despite clinical evidence of brainstem herniation.