Living Donor Liver Transplant: What Donors Need to Know About Risks, Recovery and Eligibility

Donating part of your liver is major surgery with a small but real risk. In a worldwide survey of 11,553 living liver donors, 0.2% died and about 24% had some complication, most of them minor and short-lived. The liver you keep regrows to roughly 80% of its original size within three months, and most healthy adult donors are back at work in under three months.
— Dr Chetan Kalal, DM Hepatology, Gleneagles Hospital Mumbai

Picture a composite of the person who sits across from me most weeks at Gleneagles: a 29-year-old engineer from Thane whose father has decompensated cirrhosis. He has already decided to donate. What he wants from me is not permission — it is the truth about what it will cost him. Will he die? Will he be able to work? What happens to the liver he gives away, and the part he keeps?

Those are the right questions, and this article answers them with numbers rather than reassurance. In my earlier post on the liver transplant waiting list in India, I promised a companion guide for the donor. This is it: who may donate, what the evaluation involves, right lobe versus left, the verified risks, how the liver regrows, what recovery looks like, and your absolute right to say no at any point. Read it before your evaluation, then bring your questions to the transplant team. Nothing here replaces that conversation.

Can I donate part of my liver? Who is allowed to donate in India

Yes, if you are a healthy adult, your blood group is compatible, your liver is large enough and fat-free enough to share, and the law recognises your relationship with the recipient. In India, the majority of liver transplants are performed with a living donor, as Narasimhan noted in a 2016 review of the field. That is unlike Europe or the United States, and it means the donor conversation is the central conversation in Indian transplantation.

The legal frame is the Transplantation of Human Organs and Tissues Act. A “near relative” — spouse, parent, child, sibling, grandparent or grandchild — may donate after the hospital’s committee confirms the relationship and that no money has changed hands. A cousin, a friend or an in-law may still donate, but only after the state Authorisation Committee is satisfied that the motive is affection, not payment. Where blood groups do not match within a family, the Act also permits swap donation between two families. Expect the paperwork to take time and the questions to be blunt. That is the law doing its job.

Medically, the blood group comes first. ABO-compatible donation is the standard; ABO-incompatible transplantation is possible at experienced centres with additional preparation of the recipient, and I discuss that on my liver transplant specialist page. Age limits vary by centre. So do weight limits, because a fatty donor liver is a poor graft and a greater risk to the donor. In a Delhi series of 768 prospective donors assessed by MRI, 22% had significant liver fat, most of them with a BMI between 25 and 30. Many were asked to lose weight and come back. A refusal at this stage is not a verdict on you; it is the team protecting you.

What does the donor evaluation involve?

The evaluation is deliberately slow and built in stages, simplest tests first. Stage one is blood: group and cross-match, liver and kidney function, counts and clotting, hepatitis B, hepatitis C and HIV markers, and metabolic screening. Many potential donors are ruled out here, quietly and cheaply.

Stage two is imaging. A CT scan with contrast maps the arteries, portal vein and hepatic veins, and measures the volume of each lobe. An MRI or MRCP maps the bile ducts and quantifies liver fat. From these, the surgical team calculates two numbers that decide everything: how much liver the recipient needs, and how much liver you would be left with. The second is the remnant liver volume, and it is the rule that protects you. If giving the recipient a large enough graft would leave you with too small a remnant, the answer is no, however much you want to help. Every programme has its own threshold; ask your team what theirs is and why.

Stage three is fitness for a long anaesthetic: heart, lungs, and a frank review of anything that raises your risk. Stage four is the part donors underestimate — the psychosocial assessment. An independent clinician, not part of the recipient’s team, meets you alone to confirm that the decision is yours, that you understand the risks, and that nobody is leaning on you. If there is pressure at home, this is the one room where you can say so, and the team will take the decision off your shoulders.

Only then does the legal committee sit. The process runs over weeks, not days; for a patient with acute liver failure it is compressed into days without skipping a safety step.

Right lobe or left lobe: what happens in the operation

The surgeon removes either the right lobe or the left lobe of your liver, with its own artery, vein and bile duct, and transplants it into the recipient. Which lobe depends on the recipient’s size and your anatomy. An adult recipient usually needs the larger right lobe; a child, or a small adult, can often be served by the left lobe or its lateral segment. The right lobe is the more demanding operation for the donor. In the largest benchmark study of donor surgery — 5,202 donor hepatectomies at 12 high-volume centres — major complications were twice as frequent after right-lobe removal as after left. I explain the recipient side of the procedure on my liver transplant surgery page.

Keyhole donor surgery deserves a word. In the 2025 multicentre study of 10,025 donor hepatectomies, 1,479 were laparoscopic and 236 robotic, with severe-complication rates no different from open surgery. A smaller scar is a real benefit. It is not a reason to choose a centre that has done few of them.

What are the real liver donor risks?

Death is the risk every donor asks about first, so here is the figure. In a worldwide survey of 71 transplant programmes in 21 countries covering 11,553 donor operations, 23 donors died — 0.2% — most within 60 days of surgery, and all but four from the donation itself. Five donors (0.04%) needed a liver transplant themselves. The same survey found that 1.1% of donors had a “near-miss” event in which their life was briefly in danger, and 1.2% had the operation abandoned once it had begun. Those last two were commoner at low-volume programmes.

The more recent data are better. Across 10,025 donor operations at 16 high-volume centres between 2013 and 2022 — a group that includes three Indian centres — there were no donor deaths at all. Complications severe enough to need a second operation occurred in 1.17%, and intensive-care-level complications in 0.12%. I would not promise any donor a zero risk of death. I would tell them that at an experienced centre it is now very close to it.

Complications short of death are common; expect the possibility rather than be surprised by it. In the 5,202-donor benchmark study, 12% of donors had at least one complication and 3.8% had a major one, mostly bile leaks or bleeding. The American A2ALL cohort, which counted every problem rather than only the serious ones, found that 40% of 740 donors had some complication — overwhelmingly minor — and that 95% had resolved within a year. Hernias at the scar (7%) and psychological difficulties (3%) were the ones that surfaced after the first year. Bile leak is the single most frequent serious problem, usually settled with a drain or an endoscopic procedure rather than another operation.

One number in the benchmark study matters more than any other for an Indian family choosing where to go. Centres that had performed 100 or more donor hepatectomies had an overall complication rate of 10.2%; centres below that threshold had 35.9%. Major complications were 3% against 12.1%. Volume is the strongest risk factor you control. I have been part of more than 1,000 liver transplants, around 300 of them complex cases, with 92% patient survival — I say that not to advertise but because experience is measurable, and you are entitled to ask any centre for its numbers.

How does the liver regrow, and how long is recovery?

The liver regenerates — genuinely, not as a figure of speech. In the A2ALL regeneration study of 350 donors, the remaining liver grew by an average of 676 grams in three months and had reached 80% of its original volume by then. Donors with the smallest remnants grew the most, but also had higher bilirubin and clotting abnormalities in the first month — which is why the remnant threshold in your evaluation is not negotiable. The liver never returns to exactly its old shape, and it does not need to.

Recovery in hospital is measured in days. The mean stay in the 5,202-donor benchmark series was 11.7 days, with wide variation between centres and countries; many Indian programmes discharge earlier. Expect incision pain, fatigue, poor appetite and disturbed sleep in the first two weeks. Expect to be walking on the first or second day, because that is how we prevent clots and chest infections.

Recovery at home is measured in weeks and months, and honesty serves you better here than optimism. In the 2026 review by Rammohan and colleagues from Chennai, nearly 80% of donors were back at work within three months, and physical quality of life returned to baseline within six to twelve months. A desk job comes back sooner than manual work; your team will give you a date based on what you do. Heavy lifting waits for the abdominal wall to heal. Alcohol has no place in a regenerating liver.

Two things persist in a minority. The same review found that about 27% of donors reported chronic pain or numbness at the scar after the first year, and roughly a quarter reported some ongoing limitation of activity. Incisional hernia occurred in up to 20% of donors in some series. None of these is a reason not to donate. All of them are reasons to know what you are signing.

Long-term outcomes, and your right to say no

Long-term survival of living liver donors parallels that of matched healthy controls; the Chennai review is explicit on this point, while noting that evidence beyond the first year is thinner than it should be. Depression or anxiety affects roughly 8% of donors, more often when the recipient does badly. Financial strain — lost wages, travel, the cost of a carer — persisted for 22 to 40% of donors in Western studies two years on, and I suspect the Indian figure is no better. Plan for it. The large majority of donors, in every study that has asked, express no regret.

Lifelong follow-up is the price of a good outcome, and the Chennai authors argue, rightly, that it should extend beyond the first year with attention to mental health. At minimum, a liver check at one, three, six and twelve months, then yearly. Keep a healthy weight; a regenerated liver can turn fatty just as an original one can.

Now the part families do not always want to hear. A donor can withdraw at any stage — after the blood tests, after the scans, after the committee has approved, on the night before surgery. No transplant team worth its name will ask you to justify it, and the recipient does not need to know the reason. Ask your team early how they would handle a withdrawal; a good one will have an answer ready. Giving part of your liver is among the most generous things a person can do. It is only generous if it is free.

If you are weighing it now, write down your questions and bring them to your transplant team. The evaluation exists to find reasons not to proceed, and the right outcome is whichever one keeps you safe.

References

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3. Rössler F, Sapisochin G, Song G, et al. Defining benchmarks for major liver surgery: a multicenter analysis of 5202 living liver donors. Ann Surg. 2016;264(3):492–500. PMID 27433909. doi:10.1097/SLA.0000000000001849
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6. Olthoff KM, Emond JC, Shearon TH, et al. Liver regeneration after living donor transplantation: adult-to-adult living donor liver transplantation cohort study. Liver Transpl. 2015;21(1):79–88. PMID 25065488. doi:10.1002/lt.23966
7. Rammohan A, Patel MS, Cherukuru R, et al. Quantifying long-term outcomes and risks for living liver donors: a review of the current global experience. Ann Hepatol. 2026;31(2):102233. PMID 42229752. doi:10.1016/j.aohep.2026.102233
8. Gupta S, Rastogi R, Singh R, et al. Correlative study of hepatic venous diameter/liver volume index and extent of hepatic steatosis in living related liver donors: a retrospective observational study. Clin Transplant Res. 2026;40(2):287–293. PMID 41937480. doi:10.4285/ctr.25.0097