However, considering the needs of and risks to the live donor, DDLT is preferable to LDLT. A central

principle in medicine is primum non nocere, that is, ‘first, do no harm’. The healthy live donor must undergo major surgery for no direct, physical benefit. Donor morbidity is not infrequent; the donor mortality rate has been estimated at around 0.1–0.3%.1 Moreover, graft volume is usually smaller in LDLT than in DDLT, which is unfavorable for recipients of LDLT. Direct comparison of the results between screening assay LDLT and DDLT is therefore not productive, although LDLT has achieved results comparable to those of DDLT. LDLT is best situated as an alternative option to DDLT. In other words, LDLT and DDLT can be implemented together to facilitate effective LT. With an understanding of the actual circumstances of use, LDLT offers several advantages

over DDLT. The first major advantage of LDLT is the reduction in waiting time mortality. This benefit is especially useful in patients with hepatocellular carcinoma (HCC). Second, LDLT can shorten the cold ischemic time (CIT). Prolonged CIT is a known risk factor for acute cellular rejection (ACR) and graft loss in DDLT.2,3 Third, various preoperative interventions, including nutritional treatment, EGFR inhibitor can be planned for both the donor and recipient, since LDLT is performed under elective circumstances. We discuss herein the advantages and disadvantages of living donation compared with deceased donation in LT. Most HCC occurs against a background of cirrhosis. LT is thus an attractive treatment option for patients with HCC, offering the possibility of curing both the tumor and the underlying cirrhosis. Nevertheless, patient survival after DDLT for HCC was initially so poor due to the high tumor recurrence rate that HCC was considered a contraindication for LT. After the adoption of the Milan criteria (MC),4 favorable survival outcomes could be obtained after LT for HCC with survival rates comparable to those in patients receiving transplants for nonmalignant

diseases. With the accumulation of experience with DDLT for HCC, however, problems such as a high dropout rate from tuclazepam the waiting list due to tumor progression (15% at 6 months, 25% at 12 months),5 a shortage of deceased donors, and excessive restrictiveness of the MC have emerged. In some regions for some blood types in the United States, even patients within the MC may have a 9- to 12-month wait for DDLT.6 The lack of an effect on the donor pool of organs for patients with non-malignant liver disease is a crucial advantage of LDLT, since the living donor graft is a dedicated gift directed exclusively to the recipient. LDLT can thus shorten the waiting time and lower the dropout rate. Studies using hypothetical decision analytical models have demonstrated theoretical survival benefits for LDLT over DDLT.