Management of Steatosis in Living Donors: Where Do We Stand?

With the progressive rise in rates of liver transplantation, stagnant donor pool, and social factors, living donor liver transplantation (LDLT) forms the majority of liver transplantations performed in Asian countries. As the global prevalence of metabolic-associated fatty liver disease (MAFLD) is increasing, around 17-25% of all the prospective donors turn out to be steatotic at the time of evaluation and, as such, rejected for donor hepatectomy, thereby considerably reducing the living donor pool. Steatotic grafts are a risk factor to both the recipient (primary nonfunction, delayed graft function, and mortality) and the donor (poor regeneration, higher blood loss, and prolonged hospital stay). Weight reduction and dietary optimization have been known to be associated with improvement in steatosis, and multiple interventions have been used in the past to reduce steatosis in these donors and be able to convert these donors from marginal steatotic donors to normal or low-risk donors and utilize these grafts. Most of these studies indicated the efficacy of these optimization protocols. They suggested similar outcomes in these previously steatotic donors compared to donors without steatosis at baseline, but these optimization protocols lack uniformity. This review article aims to highlight the rising prevalence of steatosis in living liver donors, assess the literature on pre-operative management options for steatosis donors, and study the efficacy, safety, and feasibility of these management options.