Living Liver Donors With Obesity and Metabolic Risk: Review and Guidance on Donor Triage and Care

With the increasing prevalence of obesity in the United States, potential living liver donors (LLDs) are similarly impacted. Historically, LLDs with obesity are deemed too high risk for donation due to concern for hepatic steatosis (HS) or post-surgical complications. Evolving data show that obesity is not the absolute indicator of HS and metabolic risk. Instead, distribution of fat in the visceral area as well as body composition drive the risk for metabolic dysfunction associated steatotic liver disease (MASLD). Prior practice patterns of denial of obese LLDs with metabolic risk require a change in mindset from the liver transplant community with a thoughtful, individualized risk assessment of all LLDs. By losing weight utilizing various dietary and procedural strategies, these "gray zone" LLDs improve their metabolic risk profile and can move into a low risk "green zone", thus expanding the donor pool. Little data exist whether "gray zone" LLDs who succeed in weight loss have long-term consequences to their own health if they regain their weight or the clinical impact on their LDLT recipients. Ethical and financial questions remain as to the LDLT centers' direct responsibility to maintaining donor health. Future studies evaluating interventions and outcomes are needed.