Transplant

In right lobe (RL) living donor liver transplantation (LDLT), portal vein (PV) variations are of immense clinical significance. In this study, we describe in detail our PV reconstruction techniques in RL grafts with variant PV anatomy and evaluate the impact of accompanying biliary variations on the recipient outcomes. In a total of 386 RL LDLTs performed between July 2004 and July 2012, the clinical data on 52 (13%) transplants using RL grafts with variant PV anatomy were retrospectively analyzed. Portal vein anatomy was classified as type 2 in 20 patients, type 3 in 24 patients, and type 4 in eight patients. The PV reconstruction techniques utilized included back-wall plasty (n = 21), back-wall plasty with saphenous vein graft interposition (n = 6), saphenous vein graft interposition (n = 5), cryopreserved iliac vein Y-graft interposition (n = 6), and quiltplasty (n = 3). There was no donor mortality. In a median follow-up of 29 months, none of the recipients had vascular complications. Anomalous PV anatomy was associated with a high (54%) incidence of biliary variations; however, these variations did not result in increased biliary complication rate. Overall, the 1-and 3-year patient survival rates of recipients were 91% and 81%, respectively. Vascular and biliary variations in RL grafts render LDLT technically more challenging. By employing appropriate reconstruction techniques, it is possible to successfully use RL grafts with PV variations without endangering recipient and donor safety.

Hepatocyte transplantation is a conceptually attractive alternative to whole organ grafting for some inborn metabolic errors and for fulminant liver failure. However, studies of the immunogenicity of transplanted allogeneic hepatocytes have yielded contradictory results. In these experiments, the effect of purification and cryopreservation of the hepatocytes on the ability of these cells to engraft in the mouse allogeneic recipients without immunosuppression was studied. BALB/ cByJ mouse crude (unpurified), modified (purified or cryopreserved), or dead (irradiated) hepatocyte preparations labeled with fluorescein dye CFSE were infused either into the portal vein or into the spleen parenchyma of the recipient CBA mice. A histological examination revealed normal appearance of engrafted modified hepatocytes with no signs of acute rejection up to 21 days posttransplant. Many of the intrasplenically implanted hepatocytes migrated into the hepatic sinusoids. The modified hepatocytes showed intact ultrastructural appearance 7 days after transplantation. The numbers of inoculated crude hepatocytes rapidly declined with signs of dense infiltration of mononuclear cells in the graft indicating destructive response. The fluorescence of dead hepatocytes was undetectable. These results suggest that reduced immunogenicity may be responsible for the longer survival time of inoculated, purified or cryopreserved hepatocytes with no adverse morphological effects.

Porcine and human pancreatic islets were microencapsulated in an alginate-polylysine biomembrane and put in a chamber of a new vascular prosthesis composed of an inner tubing of Dacron mesh and an outer tubing of expanded polytetrafluorethylene material. The vascular prosthesis was anastomized between the iliac artery and the contralateral vein of diabetic dogs. The recipients did not receive any immunosuppressive therapy. Function of porcine and human islets was monitored by measuring serum glucose levels and human C-peptide concentrations. After transplantation, serum glucose levels were maintained at values lower than 200 mg/dl, and C-peptide concentrations were between 0.8 and 3.2 nglml. Injected insulin requirements decreased by 50 %-6O %. Four to 8 weeks after transplantation, histologic examination showed well-preserved and functioning islets in the majority of intact microcapsules. Fibrin and inflammatory cells were not observed in the chamber. These data suggest long-term survival and function of microencapsulated pancreatic islets in the vascular prosthesis.

BackgroundGraft-versus-host disease (GVHD), a common complication of hematopoietic stem cell transplant, is generally regarded to develop through cell-mediated immune response following activation of helper T cells. Since production of antibodies is also mediated by helper T cells, the role of humoral immunity in GVHD is questioned and has not yet been explored in clinical practice. We conducted a pilot study

The influence of human leukocyte antigen (HLA) on acute liver allograft rejection was investigated in 48 adult patients. The diagnosis of rejection was always based on the full triad of histological findings, clinical signs, and the required antirejection treatment. Sixty-two percent of the patients closely observed for 6 months postoperatively revealed acute rejection within the first 3 weeks, mostly on days 7-11. HLA compatibility was not observed to have any significant influence on the incidence of acute rejection. However, different histological and clinical features were revealed in conjunction with DR compatibility. Patients without DR compatibility showed a type of rejection with fever and increase of bilirubin, frequently associated with cholestasis and cholangitis, which sometimes persisted for weeks. Patients with 1 DR compatibility showed a predominant increase of transaminases, which was never associated with cholangitis. The conjunction of different DR compatibilities and various clinical signs may indicate possible pathways from immunological assault to the clinical appearance of acute rejection. A knowledge of a patient's individual compatibility and an expectation of certain rejection patterns may lead to earlier and more reliable diagnosis and treatment.

A survey of the public attitudes towards organ donation in a Turkish community and of the changes that have taken place in the last 12 years Abstract In 1990 we carried out a survey on public attitudes toward organ donation in a Turkish community. We repeated this study 12 years later in order to evaluate the changes that had taken place in the meantime. Using the same questionnaire and method, we repeated the study in a different part of the city with similar socio-economic characteristics as in the former area, which had in the meantime ceased to be our research and training area. The 983 participants were chosen by a random stratified method. Of those interviewed, 57.0% were willing to donate, while 18.3% refused and 24.7% were uncertain. A total of 52.6% consented to donation. Twelve years later, some public attitudes toward organ donation had changed. Refusal to donate for religious reasons had diminished (16.1% versus 26.2%); uncertainty whether to donate had risen (24.7% versus 15.8%). Attitudes towards organ donation were clearly related to educational level, age and sex.

We tested if Quilty (endocardial infiltration of lymphocytes) in routinely processed endomyocardial biopsy is associated with poor outcome after heart transplantation (HTx). Biopsies (n = 9829) harvested within the first post-transplant year from 938 patients (778 men, mean age 49 years) were evaluated for Quilty and acute cellular rejection (according to the International Society for Heart and Lung Transplantation, ISHLT, classification). Transplant vasculopathy was evaluated by coronary angiography, and severe stenosis was found in 19% of patients. Survival was tested by Kaplan-Meier and Cox regression analyses for all-cause mortality and major cardiac events (lethal acute cellular rejection, graft loss or myocardial infarction). We found 1840 (19%) Quilty-positive biopsies in 487 Quilty-positive patients (52%). Quilty was more prevalent in women (p = 0.038) and younger men (p = 0.001), and was correlated with ISHLT grade 1R (OR 1.45, 95% CI 1.36-1.55; p b 0.001) and ISHLT grade 2R (OR 2.48, 95% CI 2.21-3.41; p b 0.001). Quilty in any biopsy was associated with a higher all-cause mortality (log rank p = 0.045) due to a higher risk for major cardiac event (p = 0.0001). Multivariate regression analysis showed Quilty (RR 1.69, 95%CI 1.05-2.73) and transplant vasculopathy (RR 2.78, 95%CI 1.68-4.61) as risk factors for major cardiac events and treated hyperlipidemia as lowering the risk for major cardiac events (RR 0.47, 95%CI 0.28-0.77). Quilty is associated with graft loss and poor outcome post HTx. Index biopsy during the first post-transplant year is a useful tool to identify patients at risk and is recommended during routine post-transplant management.

The direct interaction between antigen specific CD8 CD28 T suppressor cells (T ) with dendritic cells (DC) results in the q y S tolerization of DC by inducing the upregulation of immunologlobulin like transcript 3 (ILT3) and ILT4. We show here that such tolerogenic DC anergize alloreactive CD4 CD45RO CD25 T cells converting them into regulatory T cells (T ), which in q q q R turn, continue the cascade of suppression by tolerizing other DC. Interleukin 10 (IL-10) and interferon-a (IFN-a) also induce ILT3 and ILT4 upregulation in DC, rendering them tolerogenic. This implies a common mechanism of DC-mediated suppression. This finding and the observation that in organ allograft recipients quiescence is associated with the presence in the circulation of donor-specific T and T emphasize the importance of the cross talk between tolerogenic DC and T cells in suppression of the S R immune response. ᮊ

Terminal heart disease affects not only the patient, but also members of the patient's family, and especially the spouse. The aim of this prospective study of 26 couples was to collect information about the impact of heart transplantation on the partner relationship. Data were collected from patients and spouses when the patients were placed on the waiting list for transplantation, 1 year postoperatively, and 5 years postoperatively. The Family Assessment Measure (FAM HI), a self-report instrument that provides quantitative indices of family functioning on seven interacting dimensions, was used. In the course of the transplant process, both patients and spouses reported a significant deterioration in the partner relationship in general. While patients perceived only one clear-cut point of conflictcommunication about emotionsas crucial, the spouses reported a significant worsening in role performance, communication, emotional involvement, and values and norms. These changes were discernible 1 year after transplantation and persisted for at least 5 years. We conclude that heart transplantation has a significant negative impact on the partner relationship 1-5 years after transplantation. Consequently, more attention should be paid to all aspects of the partner relationship in a holistic approach to the treatment of heart transplant recipients and their partners.

The worldwide shortage of liver grafts causes medical, social and ethical problems. Although this situation requires intensive efforts to develop alternative grafts using regenerative biotechnology, they are still far away from the practical application. Now, we have the strategy to develop regenerative chimeric liver grafts containing human hepatocytes and the scaffold of xenogeneic animals such as transgenic pigs. Using our established rodent model that the chimeric livers with rat hepatocytes and mouse scaffold are transplanted to rat recipients, we evaluated their long-term function after transplantation and outcomes in graft and recipient survivals under immunosuppressive treatments. We produced chimeric livers in urokinase-type plasminogen activator/severe combined immunodeficiency (uPA/SCID) mouse by cell transplantation with hepatocyte isolated from luciferase transgenic Lewis (LEW) rat (MHC haplotype: RT1 l ), and transplanted them to wild-type LEW rats (RT1 l ) and Nagase analbuminemia rats (NAR) (RT1 a ) in the auxiliary fashion, followed by daily tacrolimus administration. We evaluated the intensity of luminescence derived from the transplanted chimeric liver as a marker of its viability and examined serum rat albumin level in NAR recipients using ELISA. Furthermore, we evaluated blood circulation in chimeric livers using Doppler ultrasonography. In vivo bioluminescent imaging showed that tacrolimus monotherapy improved graft survivals for four weeks after transplantation, suggesting the controllability of the rejection toward transplanted chimeric livers. In NAR recipients, chimeric livers produced rat albumin after transplantation, and we could detect it even 170 days after transplantation. Doppler ultrasonography indicated the arterial inflow and venous outflow in chimeric livers even six months after transplantation.

Purpose: Intraportally transplanted islets provoke an instant blood-mediated inflammatory reaction (IBMIR), resulting in acute islet destruction. In a simplified in vitro model, we compared the mechanisms of IBMIR induced by human (allogeneic, A) and pig (xenogeneic, X) islets. Methods/Materials: 2,500IEQ were incubated with fresh non-anticoagulated human blood in petri dishes in an incubator-shaker (37°C, 100rpm). Clotting times were recorded. Levels of complement activation products (iC3b for common pathway and Bb for alternative pathway) and C-peptide were compared to dishes with blood alone at 5, 30 and 60min. At 60min, clots were fixed for immunofluorescent staining. The effect of 1.6mg/mL low molecular weight dextran sulfate was investigated. Results: Exposure of human and pig islets to human blood induced equally rapid clotting (A: 3:13+1:31min vs. X: 3:54+1:42, P=0.35; compared to blood alone: 46:25+16:23min, P<0.0001). In X, average porcine C-peptide levels increased from 118 to 627ng/mL between 5 and 60min, indicating islet cell lysis. In A, human C-peptide only increased from 41 to 64ng/mL (P<0.05). IgM and IgG binding were observed on pig but not on human islets. In X, supernatants released by clots at 30min contained 50% more iC3b, and 77% more Bb than controls. These increases were only 7% and 38% in A (P<0.05). Dextran sulfate completely prevented clotting and reduced iC3b and Bb to control levels. However, in X, it did not prevent antibody binding and porcine C-peptide release. Conclusion: Xenogeneic IBMIR was more aggressive than allogeneic IBMIR in an in vitro model of islets exposed to human blood. Dextran sulfate prevented complement activation through the alternative pathway, but did not prevent antibody binding to pig islets and C-peptide release, suggesting an important role for the classical pathway of complement activation.

The goal of steroid minimization trials has been to minimize or eliminate steroid-related side-effects while simultaneously not increasing the rate of acute rejection (AR) and chronic graft loss. Early trials of late steroid withdrawal ( ‡3 months post-transplant) were associated with significantly increased AR rates and late graft loss. More recent trials of rapid discontinuation of prednisone (RDP) (£7 days post-transplant) have been associated with little or no increase in AR rates and no difference in graft survival (versus maintenance prednisone). Of note, induction therapy appears to be important for success; however, it is not clear if any single maintenance protocol is superior. Intermediate-term follow-up (5-7 years) is now available for some randomized and nonrandomized trials; graft survival and renal function remain excellent. Most of these trials have been done in low immunologic risk recipients, but there are reports of success of RDP in children, black recipients, sensitized recipients, recipients with potentially recurring disease, and kidney-pancreas recipients. Of critical importance, steroid-related side-effects have been minimized. Steroid minimization protocols can clearly be recommended for low-risk patients; additional trials are necessary for those at higher risk. Additional research is also necessary on integrating calcineurin inhibitor minimization with steroid minimization.

For reducing the corticosteroid (CS)-related side-effects, especially cardiovascular events, CS-sparing protocols have become increasingly common in pancreas transplantation (PT). Lympho-depleting induction antibodies, such as rabbit anti-thymocyte globulin (rATG) or alemtuzumab, have been widely used in successful trials. The results of various CS-sparing protocols combining calcineurin inhibitors (CNI) and mycophenolate or sirolimus, have been mixed for rejection and survival rates. Most of the studies were uncontrolled trials of low-risk patients, therefore the grade of evidence is limited. Large-scale prospective studies with long-term follow up are necessary to assess risks and benefits of CS-sparing regimens in PT before recommending such strategies as standard practice. Islet allo-transplantation for patients with brittle type 1 diabetes mellitus, less invasive and safer procedure than PT, has been attempted since late 1980s, but diabetogenic immunosuppressants at maintenance, mainly CS and high-dose CNI, prevented satisfactory results (10% insulin-independence at 1-year post-transplant). Since 2000, CS-free and CNI-reducing protocols, including more potent induction [daclizumab, OKT3c1(ala-ala) anti-CD3 antibody, rATG] and maintenance (sirolimus, mycophenolate) agents, have significantly improved short-term outcomes whereas long-term are still inadequate (from 80% to 20% insulin-independence from 1-to 5-year posttransplant). Main limitations are allo-and autoimmunity, immunosuppressionrelated islet and systemic toxicity and transplant site unsuitability, which tolerogenic protocols and biotechnological solutions may solve.

Context and Aim: Low therapeutical adherence (TA) to immunosuppressive drugs is one of the main factors that determine the survival of heart transplant recipients (HTx). The aim of this study is to measure the TA improvement by means of a comprehensive care programme in a multidisciplinary environment, together with the support of Mobile Health Technology (mHealth). Materials and methods: A prospective pilot study was carried out. Patients who had received a HTx in the past 18 months and had a mobile device were included. TA was assessed by the SMAQ validated test at the beginning and end of the two-months follow-up. Personalized interventions on-line via the mHeart platform were performed. The mHeart platform is an APP and a website directed to facilitate communication, treatment adherence and patient empowerment. An independent statistician analysed the data (IBM-SPSS V22.0). Results and discussion: Of the 35 eligible recipients, 32 (91.4%) were included in the study; 23 (71.9%) were men of an average age of 52.4 years [42.9-63.7] taking a median of 12 [8.5-14] different daily drugs. The follow-up time was 2.03 months [1.3-2.5]. The effectiveness of the pharmaceutical interventions implemented through the mHeart tool was high: 83% of the nonadherent recipients in the first visit became adherent at the end of the study according to the SMAQ test. Medication adherence global rate in the first visit was 61%, increasing to 87% at the last visit according to the SMAQ test (p = 0.039). The final TA figure was over 85%, the target medication adherence figure in solid organ transplants to avoid negative results due to non-adherence. Conclusions: Personalized interventions together with the support of the mHeart tool, permits effective supervision of nonadherent patients, resulting in the improvement in TA. The final TA figure was over 85%, the target figure in SOT to avoid negative results due to non-adherence.

The global challenge for solid organ transplantation programs is to distribute organs to the highly sensitized recipients. The purpose of this work is to describe and test the functionality of the EpHLA software, a program that automates the analysis of acceptable and unacceptable HLA epitopes on the basis of the HLAMatchmaker algorithm. HLAMatchmaker considers small configurations of polymorphic residues referred to as eplets as essential components of HLA-epitopes. Currently, the analyses require the creation of temporary files and the manual cut and paste of laboratory tests results between electronic spreadsheets, which is time-consuming and prone to administrative errors. Results: The EpHLA software was developed in Object Pascal programming language and uses the HLAMatchmaker algorithm to generate histocompatibility reports. The automated generation of reports requires the integration of files containing the results of laboratory tests (HLA typing, anti-HLA antibody signature) and public data banks (NMDP, IMGT). The integration and the access to this data were accomplished by means of the framework called eDAFramework. The eDAFramework was developed in Object Pascal and PHP and it provides data access functionalities for software developed in these languages. The tool functionality was successfully tested in comparison to actual, manually derived reports of patients from a renal transplantation program with related donors. Conclusions: We successfully developed software, which enables the automated definition of the epitope specificities of HLA antibodies. This new tool will benefit the management of recipient/donor pairs selection for highly sensitized patients.

Delayed graft function (DGF) in renal transplantation using non-heart-beating donors (NHBDs) usually exceeds 80%. There is debate whether DGF in this subgroup is associated with poor long-term outcome. Between 1 January1988 and 3 1 January 2000, 130 of 158 (82.3%) NHBD graft recipients with functioning grafts transplanted within our regional NHBD programme developed DGF. Overall graft survival and graft survival censored for recipient death was 1 I3/ 130 (86.9%) versus 113/121 (93.4%) at year I, 55/84 (65.5%) versus 55/64 (85.9%) at year 5 and 18/40 (45.0%) versus 18/28 (64.3%) at year 10 after transplantation. Seventeen grafts (I 3 . I YO) were lost due to rejection or graft nephropathy. Nine of these kidneys failed during the 1st year. Twenty-seven patients (20.8%) died with functioning grafts, eight within the 1st year after transplantation. In those patients who survived, DGF was associated with excellent longterm outcome in this study. The number of grafts lost due to recipient death exceeded those lost due to rejection or graft nephropathy.

Deceased donor organ programme is still in infancy in India. Assessing deceased donation potential and identifying barriers to its utilization are required to meet needs of patients with organ failure. Over a 6-month period, we identified and followed all presumed brainstem dead patients secondary to brain damage. All patients requiring mechanical ventilation with no signs of respiratory activity and dilated, fixed and nonreacting pupils were presumed to be brainstem dead. All events from suspicion of brainstem death (BSD) to declaration of BSD, approach for organ donation, recovery and transplants were recorded. Subjects were classified as possible, potential and effective donors, and barriers to donation were identified at each step. We identified 80 presumed brainstem dead patients over the study period. The mean age of this population was 35.9 years, and 67.5% were males. When formally asked for consent for organ donation (n = 49), 41 patients&#39; relatives refused. The convers...

Various factors determine the graft-and patient survival after transplantation. HLA-matching and immunological factors are of importance for the short-and long-term survival. Apart from these obvious determinants, nonimmunological factors play an important role in defining the baseline organ quality as well as the recipients' status. The influence of these parameters on graft-and patient survival is still underestimated and is a topic of debate. On account of the increasing acceptance of marginal-donor organs these events are of increasing importance for graft survival and long-term function. We review nonimmunological causes for deteriorated graft function and graft loss after solid organ transplantation.

The critical pathway of deceased donation provides a systematic approach to the organ donation process, considering both donation after cardiac death than donation after brain death. The pathway provides a tool for assessing the potential of deceased donation and for the prospective identification and referral of possible deceased donors.

Mammalian target of rapamycin (mTOR) inhibition is potentially a less nephrotoxic form of immunosuppression. Compared with calcineurin inhibitors (CNIs), mTOR inhibition has been extensively studied for more than two decades in recipients of kidney transplants . Optimal use of the two mTOR inhibitors, sirolimus (SRL) and everolimus (EVL), needs to be better defined in kidney transplantation. Both of the currently marketed CNIs, cyclosporin A (CsA) and tacrolimus (Tac), display nephrotoxicity that not only acutely results in deterioration of glomerular filtration rate (GFR) but also contributes to long-term anatomical injuries of tubular atrophy and interstitial fibrosis . Given that mTOR inhibitors are less nephrotoxic, especially in the absence of CNIs, much attention has focused on their use as a substitute for CNIs or as a strategy to diminish CNI exposure . mTOR inhibitors also have a unique mechanism of action that may be beneficial to retard progressive atherosclerotic injury and are associated with a decreased incidence of malignancies . Given that cardiovascular disease and malignancy are important clinical concerns following transplantation, mTOR inhibition may be an important long-term therapeutic consideration for renal transplant recipients. Mammalian target of rapamycin inhibitors also possess unique side effects that require understanding . Most of these are dose-related, requiring monitoring of drug levels, with some side effects potentially requiring treatment cessation. This review provides

For evaluation of triple-phase multislice computed tomography (CT) for assessment of hepatocellular carcinoma (HCC) before liver transplantation. All HCC patients who underwent liver transplantation at our institution between 2001 and 2006 and had contrast-enhanced abdominal 4-/16-slice CT [unenhanced, arterial (20 s delay), portal venous (40 s), and venous (80 s) scan] within 100 days before transplantation were enrolled retrospectively. CT data were reviewed by two observers. Results were correlated to histopathologic findings by means of a lesion-by-lesion evaluation. Thirty-two patients with 76 HCC-lesions were included. The lesion-based sensitivity of observer 1 and 2 was 78% (59/76) and 83% (63/76) (false positives, n = 6 and n = 10). The sensitivity of observer 1/2 was 89%/95% for lesions >20 mm (n = 37), 94% for lesions 11-20 mm (n = 18), and 43%/53% for lesions <10 mm (n = 21). The mean detection rates of unenhanced, arterial, portal venous, and venous phase scans were 30%, 74%, 59%, and 40%. All detected lesions were visible on arterial and/or portal venous scans (arterial only, 24%; portal venous only, 9%). Arterial and portal venous phase scans are the strongest contributors to the high detection rate of triple-phase multislice-CT in HCC. However, the detection of small HCC measuring <10 mm and false positive findings remains a challenge.

To assess the significance of antibodies detected by complement-dependent cytotoxicity (CDC), solid phase (SPA) and flow cytometry (FC) assays we compared their predictive value in 354 consecutive cases of deceased-donor kidney transplantation. Pre-transplantation screening of anti-HLA class I and class II antibodies was performed by CDC and SPA. The direct crossmatch between recipients' sera and donors' T and B cells was performed by CDC followed by FC and SPA ("virtual cross-match"). The past history of antibodies displayed by the recipient was not considered a contraindication for transplantation even when it showed DSA. A side-by-side comparison of the correlation between graft loss, history of DSA and cross-match results indicated that sensitivity was 5%, 16% and 17% while specificity was 99%, 93% and 86% in CDC, SPA, FC crossmatches respectively. There was no significant difference between the 3 year survival of primary and secondary kidney allografts. We conclude that screening and cross-matching the sera by CDC provides reliable results and optimizes the patient's chances to receive a transplant. SPA and FC, however, are of great importance for identifying patients which require close monitoring by biopsy and serology for early diagnosis and treatment of acute antibody mediated rejection (AAMR).

This paper proposes a low complex forward adaptive loss compression algorithm that works on the frame by frame basis. Particularly, the algorithm we propose performs frame by frame analysis of the input speech signal, estimates and quantizes the gain within the frames in order to enable the quantization by the forward adaptive piecewise linear optimal compandor. In comparison to the solution designed according to the G.711 standard, our algorithm provides not only higher level of the average signal to quantization noise ratio, but also performs a reduction of the PCM bit rate for about 1 bits/sample. Moreover, the algorithm we propose completely satisfies the G.712 standard, since it provides overreaching the curve defined by the G.712 standard in the whole of variance range. Accordingly, we can reasonably believe that our algorithm will find its practical implementation in the high quality coding of signals, represented with less than 8 bits/sample, which as well as speech signals follow Laplacian distribution and have the time varying variances. K e y w o r d s: forward adaptive technique, loss compression algorithm, piecewise linear optimal compandor

Living donor liver transplantation (LDLT) is a well-established strategy to decrease the mortality in the waiting list and recent studies have demonstrated its value even in patients with low MELD score. However, LDLT is still under a high level of scrutiny because of its technical complexity and ethical challenges as demonstrated by a decline in the number of procedures performed in the last decade in Western Countries. Many aspects make LDLT different from deceased donor liver transplantation, including timing of transplantation, procedure-related complications as well as immunological factors that may affect graft outcomes. Our review suggests that in selected cases, LDLT offers significant advantages over deceased donor liver transplantation and should be used more liberally.