The United States faces a significant gap in leveraging living donors for liver transplants, a strategy that has proven successful for kidney transplants but remains underutilized for livers due to a lack of robust infrastructure and standardized processes. Despite the U.S. having a substantial pool of potential living liver donors, the country lags behind international counterparts in performing these life-saving procedures.
Kidneys and livers together constitute over 90 percent of the demand on the U.S. organ waiting list. While living kidney donation has seen considerable growth, with approximately 24 percent of kidney transplants utilizing living donors in 2025 according to preliminary data, only about 6 percent of the roughly 12,000 liver transplants performed in the U.S. last year involved living donors. In contrast, countries like India rely heavily on living donors for liver transplants, with 81 percent of their procedures coming from living donors in 2022.
The Potential of Living Liver Donation
The liver, unique in its ability to regenerate, is a strong candidate for living donation. For individuals with end-stage liver failure, transplantation is the only treatment option, unlike kidney failure patients who can rely on dialysis. Approximately one in five liver transplant candidates die while awaiting an organ. Living liver donors undergo rigorous screening to ensure the quality of the donated organ, and research suggests these organs lead to equal or better survival rates compared to those from deceased donors. Furthermore, living donor transplants can be scheduled, allowing for optimized organ preservation and reduced transport times, which are critical for liver viability.
A notable example of successful living donor liver transplantation occurred earlier this year at the University Health Transplant Institute in San Antonio, where seven pairs of living donors and recipients were matched in what was then the largest such chain in the country. These chains often begin with a non-directed donor willing to give to a stranger, facilitating transplants for others who may have an incompatible donor.
Barriers to Widespread Adoption
Despite this potential, several systemic issues hinder the expansion of living donor liver transplants in the U.S. A survey of liver transplant programs revealed that centers not performing these procedures often cited institutional barriers, including a lack of financial support and insufficient training for surgeons in these complex operations. Unlike kidney donation, which benefits from standardized processes facilitated by organizations like the National Kidney Registry, living liver donation lacks a central matching organization and formalized protocols for donor screening and organ allocation. This variability between centers complicates collaboration and resource sharing.
The complexity of liver transplant surgeries, especially paired exchanges, requires significant resources, including multiple surgeons for each operation. The logistical challenges are further compounded by the organ's limited cold ischemia time—the period between procurement and transplantation during which the organ is kept cool without blood flow. Unlike kidneys, which can tolerate longer transport, livers must be transplanted relatively quickly, limiting long-distance travel. A pilot program for a nationwide liver paired donation by United Network for Organ Sharing (UNOS) Labs in 2023, funded by a private benefactor, shut down within a year due to funding issues and the logistical challenges of moving donors rather than organs. Experts suggest a focus on moving organs and exploring regional hub models could be more viable.
Supporting Donors and Improving Infrastructure
Beyond infrastructure, supporting living donors is crucial. Donors often incur costs for travel, lodging, and time off work for surgery and recovery. While some non-profits offer assistance, eligibility is often tied to the recipient's income. Universal protections and financial support for living donors are seen as essential to prevent them from facing financial hardship. Organizations like the National Living Donor Assistance Center (NLDAC) provide subsidies, but coverage is limited.
Advancements in organ preservation technology, such as using external pumps to circulate oxygenated fluids, are showing promise in extending organ viability and could reduce the need for donors to travel extensively. However, this technology is not expected to diminish the importance of living donors, particularly for patients with specific clinical needs not captured by standard waiting list scores.
Efforts are underway to address these challenges. The American Liver Foundation has launched a non-directed living liver donation network to connect potential donors with transplant centers. Ultimately, improving living donor liver transplantation requires a dual approach: enhancing medical infrastructure, standardizing processes, and providing robust support for donors, alongside continued innovation in organ preservation. Such comprehensive improvements could unlock the full potential of living donation and save countless lives.