A New Lifeline: Feasibility and Outcomes of Altruistic Donor Programs in Living-Donor Liver Transplantation, A Single Saudi Center Experience

Introduction

Living-donor liver transplantation (LDLT) has become an essential life-saving procedure for patients with end-stage liver disease, particularly in regions with limited access to deceased-donor liver transplantation [1,2]. In Saudi Arabia and the broader Gulf region, the availability of deceased donors remains constrained by multiple factors, including low rates of organ donation after brain death and logistical challenges related to organ procurement [3]. As a result, many liver transplant programs – including ours at King Fahad Specialist Hospital in Dammam (KFSH-D) – rely heavily on living-donor grafts. However, a persistent challenge in LDLT is the lack of suitable donors for some patients, especially those without family members or close contacts who are both medically suitable and willing to donate. This donor-recipient mismatch underscores the critical need for innovative strategies to expand the living-donor pool [4].

One such approach is the utilization of altruistic or unrelated undirected living liver donors – individuals who voluntarily offer to donate a portion of their liver to a recipient with whom they have no prior relationship. Altruistic donation is conceptually distinct from unrelated directed donation, in which the donor chooses to give to a specific individual (such as a friend or colleague). In contrast, altruistic donors act purely out of compassion and a desire to help a stranger in need, with no personal connection or emotional obligation. This form of donation reflects a profound act of selflessness and humanity and challenges the traditional boundaries of living organ donation [5,6].

The ethical and logistical feasibility of altruistic living liver donation has historically been met with caution, primarily due to concerns about donor motivation, psychological readiness, and long-term outcomes. However, evolving global experience has demonstrated that with robust psychosocial evaluation, thorough informed-consent processes, and comprehensive follow-up, altruistic liver donation can be both ethically sound and clinically successful. Altruistic donors are often among the most committed, well-informed, and resilient individuals in the donor population [7,8].

At KFSH-D, we have recently embarked on an initiative to incorporate altruistic living donors into our LDLT program. This effort represents a groundbreaking step in Saudi Arabia and the region, where the concept of unrelated nondirected living liver donation has not been widely implemented. Our experience suggests that altruistic donation can offer a vital lifeline for patients without related or directed donors – patients who would otherwise deteriorate or die awaiting a deceased-donor liver that may never become available.

The introduction of altruistic living liver donors into our program has not only expanded the donor pool but also allowed us to serve a more diverse and equitable patient population. This paper aims to describe our institutional experience with the altruistic liver donors at KFSH-D, exploring the evaluation process, ethical considerations, perioperative outcomes, and broader implications for liver transplantation in donor-constrained settings. In doing so, we seek to highlight the transformative potential of altruism in saving lives and reshaping the future of LDLT.

Material and Methods

STATISTICAL ANALYSIS:

Data were analyzed using descriptive statistics. Continuous variables are presented as mean±standard deviation or median (range), as appropriate. Categorical variables are expressed as frequencies and percentages. No comparative or inferential statistical testing was performed due to the descriptive nature of the study and the absence of a control group

Results

A total of 32 altruistic living liver donors were included in this study. The median donor age was 35 years, with 31.2% being female. Graft types included left lateral hepatectomy in 21 donors (65.6%), predominantly for pediatric recipients, and right hepatectomy in 11 donors (34.4%). The median donor hospital stay was 4 days, with minor complications in 18.8% of donors and no major complications or mortality (Table 1).

All 32 recipients received grafts from altruistic unrelated donors. Of these, 21 recipients (65.6%) were pediatric, receiving left lateral grafts, while 11 adult recipients (34.4%) received right lobe grafts. The median model of end-stage liver disease (MELD) score at transplant was 20. At the time of last follow-up, 29 recipients (90.6%) were alive. Postoperative complications occurred in 46.9% of recipients, with major complications (Clavien-Dindo grade ≥3a) documented in 15.6%. The median recipient hospital stay was 20 days (Table 2).

All donors underwent rigorous medical and psychosocial screening before donation, as part of a structured, ethically grounded protocol.

The grafts donated were predominantly left lateral segments, reflecting the pediatric-oriented recipient selection. The average length of hospital stay was 3.9 days (range: 3–6 days). All donors were monitored in a high-dependency or step-down surgical unit postoperatively and discharged in stable condition.

Surgical outcomes were excellent; 81% (26/32) of the donors experienced no postoperative complications (Clavien-Dindo grade 0). Among the 6 donors (18.8%) with complications, 4 (12.5%) had grade I complications, including mild pain, nausea, vomiting, or low-grade fever, which resolved with conservative management. Two donors (6.3%) experienced grade II complications, including transient elevations in liver enzymes and urinary tract infections requiring oral antibiotics. No donor experienced a major complication (Clavien-Dindo grade ≥III), and there were no reoperations, readmissions, or ICU-level interventions. All donors were alive, in good health, and had returned to normal activity at last follow-up.

Discussion

This study presents one of the first comprehensive studies of experiences with altruistic living liver donors in Saudi Arabia and the Gulf region. Our findings demonstrate that altruistic donation, when performed within a robust ethical and clinical framework, is both safe for donors and effective in addressing the persistent shortage of transplantable liver grafts, particularly in pediatric and urgent adult cases.

The incorporation of unrelated, nondirected donors into our program has significantly expanded the living-donor pool and provided critical access to transplantation for patients who otherwise would not have had a timely opportunity. Notably, the selection and allocation of recipients for altruistic donors in our program were determined by an independent multidisciplinary committee, a structural safeguard designed to eliminate conflicts of interest and ensure equitable, need-based distribution. This committee, comprising a transplant hepatologist, social worker, donor advocate, and transplant coordinator, prioritized cases based on medical urgency, absence of suitable related donors, and recipient vulnerability – particularly pediatric patients and those with acute liver failure or metabolic liver diseases.

Altruistic living liver donors are often driven by a profound internal motivation to help others without expecting personal gain. Unlike related donors, whose decisions may be influenced by familial obligation or emotional bonds, altruistic donors typically act from a deep sense of compassion, empathy, and moral responsibility [8,9]. In our experience, many of these individuals demonstrated a clear and consistent desire to “make a difference” in someone’s life, particularly when they learned about the long waiting times and limited access to deceased-donor organs in the region [10–12].

In Saudi society, altruism, generosity, and community service are deeply rooted in Islamic teachings and social norms. This cultural framework creates a fertile ground for altruistic donation, as individuals are often socially and religiously encouraged to engage in acts of selflessness for the benefit of others [13,14]. In this sense, altruistic donation becomes not only a personal sacrifice but a collective moral act – an expression of solidarity within society. This cultural and ethical richness highlights the potential for structured altruistic donor programs to thrive in communities where doing good for others is considered both a moral imperative and a path to spiritual fulfillment [6,7,12,13].

In addition, our program has recently introduced robotic donor hepatectomy as part of our surgical innovation pathway. The robotic platform offers several potential advantages, including reduced postoperative pain, shorter hospital stay, and improved cosmetic outcomes compared with conventional open approaches. These benefits directly translate into enhanced donor safety and recovery, which is particularly important in the context of altruistic donation [15,16]. Altruistic donors, who step forward without personal ties to their recipients, may be especially encouraged by the prospect of a less invasive procedure with faster convalescence and fewer long-term sequelae. We believe that the integration of robotic donor surgery will not only improve clinical outcomes but also serve as a catalyst to increase the willingness of altruistic individuals to volunteer for donation, thereby expanding the donor pool even further.

Our results confirm the clinical safety and feasibility of altruistic living liver donation. Over 80% of donors experienced no complications, and the remaining 18.8% experienced only minor (Clavien-Dindo grade I–II) issues, all managed conservatively without the need for reoperation or readmission. The absence of major surgical complications (Clavien-Dindo grade ≥III) is particularly notable and compares favorably with published outcomes for related living liver donors globally. These findings support the notion that altruistic donors, despite lacking a familial emotional bond with the recipient, are no more prone to adverse outcomes than traditional related donors. In fact, as shown in other international series, altruistic donors often undergo donation with high levels of motivation, emotional preparedness, and psychosocial resilience due to the depth and intensity of the screening process [7,10].

The relatively short average hospital stay (3.9 days) further supports the safety and efficiency of this model. In our program, there was a predominance of left lateral hepatectomy in altruistic donations, reflecting a strategic preference for pediatric recipients, which may have also contributed to the low morbidity rate. While this may limit direct comparison to adult right lobe donors, it aligns with our institutional goal of minimizing donor risk while maximizing life-saving impact for vulnerable patients.

The outcomes observed among recipients of altruistic living-donor liver grafts in our cohort were encouraging and consistent with established benchmarks for both adult and pediatric transplantation. Of the 32 recipients, two-thirds were pediatric patients who received left lateral segment grafts, while the remaining third were adults who underwent right lobe transplantation.. The overall patient survival rate was 90.6% at the end of follow-up, underscoring the efficacy of altruistic donation in life-saving interventions, even among recipients with high urgency and limited alternatives.

Complication rates among recipients were within acceptable limits. Nearly half (46.9%) experienced some form of postoperative complication, with major complications (Clavien-Dindo grade ≥3a) occurring in 21.9% of cases. These rates are consistent with previously published outcomes for LDLT and reflect the complexity of the procedure, particularly in high-risk or pediatric recipients [17–20]. Importantly, the integration of altruistic donors did not compromise surgical outcomes, supporting the viability of including unrelated donors in standard transplant practice. The median hospital stay of 20 days was typical for this population and reflects both the acuity of illness and the multidisciplinary care required post-transplant. These data validate the use of altruistic liver transplantation as a safe and effective strategy to expand access in donor-constrained settings.

The ethical framework of altruistic liver donation is intensely discussed worldwide. Critics have historically raised concerns regarding donor autonomy, psychological coercion, and long-term regret [10]. However, these risks can be mitigated through a structured psychosocial evaluation, independent donor advocacy, and clear informed-consent protocols – components that are integral to our institutional workflow [5,9]. In our experience, donors who passed the psychosocial screening demonstrated a deep understanding of the procedure and its risks, and most expressed a sustained desire to help others irrespective of personal gain. The motivation among altruistic donors in our cohort was strikingly consistent: compassion, social responsibility, and a sense of moral purpose.

Our findings also highlight the potential for altruistic donation to integrate with paired exchange transplant models, further enhancing flexibility and reach. By allowing an altruistic donor to initiate a domino-like chain of transplants, this approach can benefit multiple recipients and overcome common compatibility barriers. This concept, well-established in kidney transplantation, is gaining traction in liver transplantation and represents a promising frontier in donor pool optimization [21,22]. The program has also served as a catalyst for public awareness about living donation, helping normalize the concept of nondirected altruism within a culturally sensitive framework.

Nonetheless, several challenges remain. The scalability of altruistic liver donation depends on public trust, regulatory clarity, and continued advocacy [11,12,23]. There is also a need for long-term follow-up data on donor health, psychological well-being, and quality-of-life, which were beyond the scope of this retrospective study. Future prospective studies with longitudinal donor tracking will be essential to fully understand the long-term impact of altruistic donation and to refine donor support services accordingly.

Altruistic living liver donation raises unique ethical concerns related to donor autonomy, potential coercion, psychological vulnerability, and the risk of undue influence. Recognizing these challenges, our program was deliberately structured around a rigorous ethical governance model designed to prioritize donor safety, voluntariness, and transparency at every stage of the process.

A central safeguard in our program is the use of an independent multidisciplinary donor allocation and approval committee, functioning separately from the recipient clinical teams. This committee includes a transplant hepatologist, transplant coordinator, social worker, and an independent donor advocate, ensuring that donor evaluation and recipient allocation decisions are insulated from conflicts of interest. Donors are assessed independently of recipient urgency, and approval is granted only after unanimous consensus that the decision to donate is voluntary, well-informed, and free from external pressure.

Comprehensive psychosocial and psychiatric assessments are mandatory components of donor evaluation. These assessments focus on donor motivation, expectations, understanding of surgical risks, capacity for informed consent, and psychological resilience.

Recipient selection is guided by ethical principles of fairness, medical urgency, and compatibility. In our cohort, there was a deliberate tendency to prioritize pediatric recipients and high-urgency cases, particularly those lacking suitable related or directed donors. Importantly, donors are not involved in recipient selection, and recipient identities are not disclosed, preserving the nondirected nature of altruistic donation and minimizing emotional or psychological entanglement.

Institutional oversight is further reinforced through formal approval by the hospital ethics committee for every altruistic donation. This layered governance structure—combining independent donor advocacy, multidisciplinary review, and ethics committee oversight—aligns with international recommendations for nondirected living organ donation and serves as a critical mechanism to mitigate ethical risks.

By embedding altruistic donation within this robust governance framework, our program demonstrates that unrelated nondirected living liver donation can be conducted ethically, transparently, and safely. Such structured oversight is essential not only to protect donors, but also to foster public trust and enable responsible expansion of altruistic donor programs in regions with limited access to deceased-donor transplantation.

Donors were followed clinically after discharge with routine outpatient visits. At last follow-up, all donors were alive, had returned to baseline daily activity, and reported no major physical limitations. Formal quality-of-life or psychological scoring instruments were not routinely applied, which represents a limitation of the current study.

These findings confirm the safety of altruistic living liver donation when implemented within a robust ethical and clinical governance framework. The absence of serious complications and the streamlined recovery across all donors underscore the viability of altruistic donation as a strategy to address donor shortages, particularly in pediatric and high-urgency transplant settings.

This study is limited by its retrospective, single-center design and relatively small sample size, which restrict generalizability and preclude comparative statistical analysis. The absence of a control group of related living donors limits direct outcome comparisons. Although all donors underwent structured psychosocial evaluation and demonstrated excellent clinical recovery, standardized quality-of-life and validated psychological assessment tools were not routinely applied. Follow-up duration varied, and longer longitudinal studies are needed to fully assess long-term physical and psychosocial outcomes.

Conclusions

The introduction of altruistic unrelated living liver donors has proven to be a safe, ethical, and highly effective strategy for expanding the donor pool. With excellent donor outcomes, no major complications, and a robust selection process guided by an independent multidisciplinary committee, this approach has enabled life-saving transplants for recipients with no other donor options – particularly pediatric patients and those with acute liver failure. Our experience demonstrates that, when supported by a structured psychosocial evaluation, ethical oversight, and careful recipient allocation, altruistic liver donation can be a sustainable and transformative addition to living-donor liver transplantation programs in regions with limited access to deceased-donor organs. This model provides a framework for centers aiming to overcome donor shortages and enhance equitable transplantation access.