Domino Liver Transplantation

What Is Domino Liver Transplantation?

Domino liver transplantation usually involves a patient with a rare metabolic liver disease, such as hereditary transthyretin amyloidosis, who needs a new liver^[1].

That patient receives a donor liver. Their original liver, which is structurally normal and works well but carries the genetic defect, is then transplanted into a second recipient. The second recipient does not have the underlying genetic disease at the time of surgery but can develop signs of the metabolic condition many years later.

When Domino Liver Transplant Is Considered

Domino liver transplantation is performed only in selected centers and specific situations^[1].

• When a patient with a suitable metabolic disease (for example, hereditary transthyretin amyloidosis) is being transplanted.
• When the removed liver is otherwise structurally normal and has good function.
• When there is another candidate on the waiting list who may benefit from receiving this “domino” liver rather than waiting longer.
• When the second recipient understands and accepts the long-term risk of developing the donor’s metabolic disease.

Domino grafts are sometimes considered for older recipients or those with limited life expectancy from other conditions, where the delayed onset of the metabolic disease may never become clinically significant.

Donor & Recipient Selection

Careful selection is essential for both the index patient (whose liver is used) and the domino recipient.

Index (metabolic) patient:

• Has a liver-based metabolic disease where replacing the liver corrects or improves the condition.
• Has a liver that is not cirrhotic and has acceptable vascular and biliary anatomy.
• Is otherwise suitable for liver transplant.

Domino recipient:

• Typically older or with comorbidities that limit long-term lifespan.
• Accepts the possibility of developing a metabolic disease years after transplant.
• Understands that close follow-up will be needed to monitor for late complications.

Multidisciplinary review (hepatology, surgery, genetics, neurology, ethics) is standard in programs that perform domino transplants.

Benefits & Potential Risks

The main benefit of domino liver transplantation is that it increases the number of usable grafts, potentially shortening wait time and reducing mortality on the waiting list^[1].

Potential benefits:

• Expanded donor pool using otherwise discarded organs.
• Access to transplantation for patients who might otherwise wait much longer.
• Good short- and medium-term graft function in appropriately selected cases.

Potential risks for the domino recipient:

• Development of the donor’s metabolic disease (for example, amyloid neuropathy or cardiomyopathy) after a latency of years.
• Need for long-term surveillance and specialist follow-up.
• Ethical concerns if informed consent is incomplete or if risk is underestimated.

Special Situations & Ethical Considerations

Domino liver transplantation raises important ethical questions about risk-sharing, informed consent, and fairness^[2].

• Age and life expectancy: older recipients may accept the delayed risk more readily than young recipients.
• Severity of the donor’s metabolic disease: conditions with later onset or slower progression may be more acceptable.
• Pediatrics: use of domino grafts in children is controversial because of their long expected lifespan.
• Transparency: patients must clearly understand that the liver itself carries a genetic or metabolic abnormality.

Many centers use ethics committees and detailed consent processes to ensure that patients and families make fully informed decisions.

Counseling Patients About Domino Offers

When discussing a domino liver offer, the transplant team focuses on clear, balanced information^[2].

• Explain what makes this liver different from a standard graft.
• Review expected benefits (earlier transplant, improved survival vs. staying on the list).
• Describe the specific metabolic disease risk, how it might appear, and over what time frame.
• Discuss alternative options if the patient declines the domino graft.
• Allow time for questions, reflection, and discussion with family and caregivers.

Ultimately, choosing a domino liver is a personal decision. The transplant team’s role is to provide expert guidance, but the patient (and family) decide whether the balance of risk and benefit feels acceptable.