Table 4.

Long-term outcomes in living liver donors: Recommendations for a research and clinical agenda for the future

Area		Recommendations
Research	Duration of follow-up:	Extend analyses of medical and psychosocial outcomes beyond the first decade postdonation.
	Study samples:	Identify and assess suitable comparison groups of individuals with similar health status as living liver donors before donation; consider whether individuals undergoing other types of abdominal surgeries might be enrolled for comparison purposes, including, if feasible, individuals undergoing liver resection for benign disease.
	Study sites:	Examine long-term mortality in national cohorts beyond the United States, including cohorts that represent the different major areas of the world where LDLT is performed. For other long-term medical and psychosocial outcomes, expand the limited range of countries and areas of the world that have provided data to date. Design studies that directly compare long-term medical and psychosocial outcomes across sites in different countries and consider whether meta-analyses could be performed to examine differences across sites, countries, or geographical regions.
	Assessments:	Utilize research methodologies (e.g. qualitative approaches) to uncover any additional areas of donor psychosocial concerns inadequately assessed or overlooked in quantitative investigations. In quantitative investigations of psychosocial outcomes, utilize established, validated measures rather than items with unknown performance characteristics.
	Risk factors and mechanistic factors:	Enroll samples of sufficient size so that analyzes are powered to detect clinically significant differences between donors depending on graft donated or on other risk factors. Calculate and report power to detect effects as part of the study design. Move beyond cross-sectional/retrospective studies to perform prospective data collection with serial measurements to determine trajectories of onset and change in medical and psychosocial outcomes. Expand research comparing medical and psychosocial outcomes in donors as a function of graft type (e.g. left lateral segment vs. left lobe vs. right lobe donation). Perform long-term mechanistic studies in order to better understand pathways leading to and influencing observed clinical abnormalities and psychosocial difficulties. Examine whether medical outcomes in the long term are related to or predict the degree of psychosocial difficulties expressed by living donors, including impact on overall HRQOL. Identify predonation and early postdonation risk factors and potential biomarkers for long-term development or persistence of medical complications, abnormalities in liver regeneration, and abnormalities detected in laboratory testing. Identify predonation and early postdonation risk factors for impaired long-term psychosocial outcomes in the domains of physical, emotional, and interpersonal/socioeconomic well-being. Assess donor perceptions of gaps in predonation education and informed consent based on their experiences in the long term since donation.
Clinical	Predonation	Incorporate information on long-term medical and psychosocial outcomes into predonation educational and informed consent discussions with donors.
	Donation and early postdonation	Develop preventive interventions or alternative surgical techniques to avoid development of common long-term medical complications such as incisional hernias. Provide postdonation education that includes strategies to prevent or manage the most common long-term complications and donor-reported symptoms (e.g. gastrointestinal problems and associated limitations in daily life). Augment efforts to assist donors to identify additional financial resources as needed to address unexpected financial burdens arising from donation or its aftermath.
	Long-term postdonation	Provide routine clinical follow-up care to donors well beyond the first year postdonation and include assessment not only of medical but also psychosocial parameters. Provide heightened clinical surveillance into the long term for individuals with short-term complications and abnormal laboratory findings.

LDLT, living donor liver transplantation; HRQOL, health-related quality of life.