Preoperative living liver donor safety: Recommendations from the ILTS–iLDLT consensus conference

Recommendations on preoperative living donor liver transplantation (LDLT) safety were published in Liver Transplantation by Selzner et al. on behalf of the International Liver Transplantation Society (ILTS) and the International Living Donor Liver Transplantation (iLDLT) Group, following a consensus conference convened in March 2025 in Toronto, Canada. A total of 93 experts from 16 countries applied the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system and the Danish consensus model to generate 28 recommendations. 

Key data: Recommendations addressed donor acceptability (upper age limit of 60 years; elevated body mass index [BMI] alone should not exclude an otherwise suitable donor), hepatic macrovesicular steatosis thresholds (<10% ideal; 10–30% requires individualized assessment; >30% and/or steatohepatitis precludes upfront donation), medical contraindications (significant cardiac comorbidities; active or incompletely treated malignancy; bleeding and clotting disorders; uncontrolled hypertension; active hepatitis C viral infection), surgical workup (future liver remnant [FLR]/total liver volume [TLV] ratio ≥30%), and psychosocial evaluation (early assessment; active, uncontrolled psychiatric illness and problematic substance use are contraindications; motivation for donation should be altruistic). 

Key learning: Careful donor selection, supported by a thorough multidisciplinary preoperative assessment of medical, surgical, and psychosocial factors, is essential for ensuring the safety of living liver donors.