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Domino liver transplantation (DLT) involves 3 consecutive but at the same time overlapping operations necessitating 3 separate teams that work on deceased donor, maple syrup urine disease (MSUD) donor and DLT recipient. Explanted liver from deceased donor has approximately 15% normal enzyme activity and is enough for MSUD patient and the explanted enzyme deficient liver from MSUD patient is compensated by approximately 85% normal extrahepatic enzyme activity in domino recipient
