A proactive approach to expanding liver transplant access in the Midwest

For hepatologists and other physicians who treat patients with advanced liver disease, the gap between the number of patients who need transplant and the number of available organs is a familiar challenge. That gap has widened in recent years as wait times lengthen, and some patients experience disease progression before an organ becomes available.

At the WashU Medicine and Barnes-Jewish Transplant Center, in St. Louis, Missouri, the transplant care team recognized this need and took steps to expand treatment options. The Center, where WashU Medicine surgeons performed the state’s first successful liver transplant in 1985 and have completed more than 3,000 since, formally established in 2025 an adult-to-adult living donor liver transplant program, designed to provide another path to transplant for patients who might otherwise remain on the waiting list. Deceased donor transplantation remains the foundation of liver transplant programs, but living donation can expand the donor pool and allow select patients to access transplant sooner, restore functional status, and return to a healthier quality of life.

Responding to a changing donor environment

The number of patients registered on the liver transplant waiting list continues to grow, driven in part by metabolic dysfunction-associated steatohepatitis (MASH). According to data from the U.S. Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients, MASH accounted for 20.4% of liver transplant wait list registrations in 2023—more than double the share a decade earlier. At the same time, the supply of deceased donor organs has not kept pace.

“We’re doing our best to address this deficit and get people the lifesaving transplants they need, including through living donation,” says Lindsay Meurer, MD, a WashU Medicine gastroenterologist and hepatologist at the WashU Medicine and Barnes-Jewish Transplant Center.

In the living donor model, a healthy donor undergoes hepatectomy to provide a segment of liver for transplantation. Because the liver has significant regenerative capacity, both donor and recipient grafts typically reach near-normal volume within months.

For transplant teams and referring physicians, the potential benefit is straightforward: Living donation can reduce time on the waiting list and allow transplantation before further hepatic decompensation occurs.

Patients who may benefit

The Model for End-Stage Liver Disease (MELD)-based allocation system appropriately prioritizes the sickest patients. However, clinicians encounter individuals whose disease burden is significant despite relatively modest MELD scores.

“In the context of the deceased donor liver transplantation, patients will wait for some time before an appropriate liver becomes available,” Dr. Meurer says. “Unfortunately, during that period of waiting, there’s a risk of progression of their liver disease. The opportunity to offer a living donor option is exciting because it improves survival by allowing for transplant in a timely manner.”

Living donor transplantation may also create opportunities for select oncology patients whose transplant candidacy is not well served by MELD-based allocation alone.

Patients with hepatocellular carcinoma often maintain relatively low MELD scores despite having disease that is potentially curable with transplant. Similarly, carefully selected patients with colorectal liver metastases may become transplant candidates.

For these patients, the ability to identify a living donor can allow transplantation on a more predictable timeline after appropriate oncologic therapy.

Building the infrastructure for adult living donation

Although the WashU Medicine and Barnes-Jewish Transplant Center has extensive experience with liver transplantation—the Center performs the highest volume of all organ transplants in Missouri and is the only adult-to-adult living donor liver program in St. Louis—adult living donor transplantation requires additional infrastructure and planning.

Historically, the Center has performed living donor transplants primarily in pediatric settings, where an adult donor provides a smaller liver segment for a child recipient. Adult-to-adult donation presents different surgical considerations because the graft size required for the recipient is larger.

To support the new program, the transplant team implemented advanced imaging and surgical planning using new imaging technologies that allow detailed mapping of hepatic vasculature and bile duct anatomy, which is critical when determining the optimal segment for donation.

The team continues to utilize refined donor selection protocols with rigorous medical, surgical, and psychosocial evaluations to ensure donor safety and appropriate candidacy.

Potential donors are also supported by a separate clinical team and transplant coordinator to ensure autonomy and confidentiality throughout evaluation.

This preparation allows the team to responsibly offer adult living donor transplantation while maintaining a strong emphasis on donor safety.

Indications for referral

For gastroenterologists, hepatologists, and other specialists caring for patients with advanced liver disease, the addition of a living donor transplant pathway expands the range of options available in the region.

The most common conditions leading to liver transplant include:

• Cirrhosis
• Hepatocellular carcinoma
• Cholangiocarcinoma
• Alpha-1-antitrypsin deficiency
• Primary biliary cirrhosis (PBC)
• Primary sclerosing cholangitis (PSC)
• Wilson’s disease
• Acute liver failure
• Metabolic steatohepatitis (MASH)
• Other diseases effecting the liver: Budd-Chiari syndrome, cystic fibrosis, amyloidosis, and polycystic liver disease

To learn more or refer a patient, contact the WashU Medicine and Barnes-Jewish Transplant Center.