Background and Aims: Organ shortage has been the ongoing obstacle to expand liver transplantation world-wide including Saudi Arabia. Living donor liver transplantation (LDLT) was hoped to improve this shortage. The aim of the present study was to analyse the impact of variant anatomy and insufficient liver volume on living donation. Methods: From July 2007 to May 2012, a total of 147 deceased donor liver transplants and 139 LDLT were performed at our institution. 600 potential living donors were worked up according to a step-wise evaluation protocol. Those with BMI >28 were not worked up. The age of the worked up donors ranged from 18 to 50 years (mean=28). They were all first and second degree relatives of the patients. Results: Only 139(23%) donors were accepted for donation and 461(77%) were rejected. Some were excluded either at initial screening due to incompatible blood group, positive hepatitis serology, elevated liver enzymes. Others were rejected because of significant steatosis, socioeconomic reasons or for reasons related to recipients status. 78(13%) potential donors were rejected because of variations in biliary anatomy and 16(2%) others were rejected because of portal and hepatic vein anatomical varitions. 106(18%) potential donors were rejected due to insufficient remnant volume (<30%) as determined by CT volumetry, while 21(3.5%) were rejected because of graft to body weight ratio less than 0.8%. Conclusion: There is no doubt that LDLT has helped in alleviating the severe shortage of deceased organs in Saudi Arabia. However suitable living donors are not easy to find especially with prevalent hepatic steatosis. Over 35% of the potential donors were rejected because of either anatomical variations or inadequate liver volumes. Our initial evaluation is effective in eliminating a large number of unsuitable donors. The donor evaluation process indeed remains to be a large burden on the resources of our program.

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