Quantifying long-term outcomes and risks for living liver donors: a review of the current global experience

Living donor liver transplantation is a critical treatment for end-stage liver disease, with numerous advantages over deceased donor liver transplant. However, living liver donors face potential long-term physical, psychological, and social challenges. This review summarizes the long-term impact of donation and highlights the ethical need for lifelong follow-up. While major complications occur in 2-8% of donors, evidence on outcomes beyond one year remains limited. Biliary complications remain the most frequent serious morbidity, and are generally managed endoscopically, rarely requiring hepaticojejunostomy. Incisional hernias occur in up to 20% of donors, and diaphragmatic hernias are uncommon but potentially life-threatening. After the first postoperative year, many donors report persistent incisional numbness, and 27% experience chronic pain. Cosmetic concerns affect body image and mental health, though minimally invasive techniques improve these outcomes. Nearly 80% of donors return to work within 3 months, and physical quality of life usually returns to baseline within 6-12 months. However, one-quarter report ongoing activity limitations. Financial burden persists for 22-40% of donors, even two years post-donation. Psychologically, the majority of donors express no donation-related regret, although depression and anxiety affect approximately 8% of donors. Perioperative mortality is extremely low, with further improvements over time, and long-term survival parallels matched controls; however, donors have a higher risk of suicide and certain cancers. Current evidence supports extending donor monitoring beyond one year, with particular emphasis on psychiatric screening and targeted health surveillance. A global registry of long-term donor outcomes would strengthen risk stratification and optimize donor care.