Travel for Translantation; Framework and Experience of Living Donor Liver Transplantation against Organ Trafficking

Travel for Translantation; Framework and Experience of Living Donor Liver Transplantation against Organ Trafficking | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Travel for Translantation; Framework and Experience of Living Donor Liver Transplantation against Organ Trafficking Tonguç Utku YILMAZ, Ali OZER, Ömer Faruk OZTURK, Meltem Can GÜNER, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9120224/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background: Organ shortage, high medical costs, long waiting periods, and the absence of liver transplantation led individuals to seek other alternatives, including travel for transplantation. Although associated with several difficulties, travel for transplantation is a legal solution to this impossibility. This study aimed to present patients who travel to our center for living donor liver transplantation (LDLT). Methods: This retrospective descriptive study was conducted in the Acibadem Atakent Organ Transplantation Unit from November 2016 to November 2024 among patients who had traveled abroad. The framework, preoperative evaluation, and legal documents required for preventing organ trafficking were comprehensively explained. Data of patients’ country origins, demographic data, clinical findings, and infectious status were collected from hospital records. Mortality rates, postoperative complications, treatment options of biliary complications, and follow-up results were also gathered. Results: Overall, 243 patients traveled abroad from 38 different countries. Patients from the Middle East and Africa constituted 72% of all patients. Pediatric cases comprised 38% of all cases. The leading indication for pediatric liver transplantation was biliary atresia. The main indication for adult liver transplantation was non-alcoholic steatohepatitis. Mean model for end-stage liver disease score was 19. The overall survival rate was 86% among all patients. Biliary complications were observed in 49 (20%) patients, all of whom were successfully treated. Conclusions: A well-structured framework for LDLT is effective in preventing organ trafficking. Following the guidelines of the Declaration of Istanbul and World Health Organization enhances the quality of healthcare in LDLT of patients who travel abroad. Living Donor Liver Transplantation Travel for Transplantation Organ Trafficking Complication International Figures Figure 1 Figure 2 INTRODUCTION The global prevalence of end-stage liver disease (ESLD) is approximately 4.5% of the general population, and liver transplantation is frequently the best life-saving procedure available. A recent study on patients on liver waiting list versus liver transplant per million populations has reported that the demand remains high, and several patients died while on the waiting list[ 1 ]. The number of liver transplantation is inconsistent, particularly in African countries. The demand for transplantation is high in the USA, Mongolia, and Croatia, whereas it is very low in Belgium and Canada[ 1 ]. In certain countries, liver transplantation may be limited or unavailable. Asian countries with lower prices for transplantation are particularly attractive to neighboring nations; however, countries with well-established organ-sharing systems should be prioritized[ 2 , 3 ]. Travel for transplantation refers to the movement of organs, donors, recipients, or transplant professionals across jurisdictional borders for the purpose of transplantation[ 4 ]. Proper travel for organ transplantation varies from transplant tourism, which is considered unethical. To prevent organ trafficking and transplant commercialization, transplant centers and countries should adhere to the principles outlined in the Declaration of Istanbul (DOI)[ 5 ]. For these reasons, living donor liver transplantation (LDLT) centers should develop a specialized framework for foreign patients that addresses issues, including battling organ trafficking, performing comprehensive preoperative evaluations, and upholding ethical standards[ 6 ]. We aimed to present our framework for patients traveling for LDLT and share our experiences with LDLT for non-Turkish patients. MATERIALS AND METHODS This retrospective study was conducted in Acibadem Atakent (ACU) Hospital Organ Transplantation Center. The Acibadem Ethical Committee approved the study protocol (ATADEK-2024/14). Consent forms were obtained from the participants. This study was conducted following the ethical guidelines of the World Medical Association Declaration of Helsinki 2013. All foreign patients who underwent LDLT from November 2016 to November 2024 were included in this study. ACU Hospital, one of the hospitals of the private health organization Acibadem Health Group, is located in Istanbul, Turkey. Liver transplantation was established in 2012. The liver transplant program started with a limited number of cases, all of which were domestic. After 2016, the international liver transplant program was started. The Turkish Social Security system has paid all costs associated with liver transplantation among Turkish citizens. The ACU Hospital international patient service supports the patients for accommodation, translation, legal document preparation etc.. Moreover, the Acibadem Health Group encompasses 25 hospitals, 15 health centers, and 56 health points across different countries. Health points are centers wherein a nonmedical staff works to communicate with local doctors, patients, and Acibadem doctors. Patients seeking treatment travel to the health points for consultations. In countries without health points, patients are referred to our international patient office by e-mail. International patients are frequently consulted via e-mail or video conference with the assistance of local health offices or local doctors. Communication between local health offices and local doctors continues even after transplantation for postoperative follow-up. After confirming the indication for liver transplantation, patients are invited to our center with their donors for further evaluation. Financial costs are shouldered individually or by the social security system or charity foundations of their specific countries. In Turkey, the Turkish Ministry of Health (TMH) regulates and supervises all types of solid organ transplantations, which are performed following the guidelines of the Organ Transplantation Regulations[ 7 ]. Patients’ data are entered into the computer-based TMH Organ Transplantation Monitoring System. Data on the demographic characteristics, kinship relationship of donors, etiology of diseases, and comorbidities were collected. The countries where patients came from were divided according to geographic locations, such as the Middle East and North Africa, Europe and Balkans, and Asia. All patients were searched using comprehensive tests. Suspicions of any infections were preoperatively managed. In patients with hepatocellular carcinoma (HCC), abdominal magnetic resonance imaging (MRI) and positron emission tomography–computed tomography (PET–CT) were performed. Patients who had distant HCC metastasis were not accepted for transplantation. Those who had HCC with macrovascular invasion, alpha fetoprotein (AFP) levels > 400 ng/mL, and > 5-cm lesions underwent bridging therapy with either transarterial chemoembolization or transarterial radioembolization. Transplantation was continued when the tumor thrombus disappeared, AFP levels decreased to 15 ng/mL/month, and ≥ 30% reduction in tumor size. These guidelines are similar both for international and national patients. Postoperative complications were graded using the Clavien–Dindo Classification[ 8 ]Data on preoperative and postoperative hospital stays were collected. Comparisons were performed according to country regions and surviving and nonsurviving cases. Regulations for Liver Transplantation in International Patients [ 7 ] According to guidelines, only LDLT can be performed for International patients[ 7 ]. LDLT can be performed among relatives up to the fourth degree of consanguinity. Spouses should be married for at least 2 years or the liver disease should start following the marriage. Donors and recipients who are not relatives, are friends, or at least recognize each other are regarded as unrelated. Altruistic donations are not accepted in Turkey. When no kinship relationship exists between donors and recipients, they should administer to the TMH Ethical Committee (TMH subunit) to show the absence of financial relationship. No payment is required for the ethical committee application. The ethical committee comprises the following: Deputy provincial police chief or director of the department of combating migrant smuggling and border gates, Medical doctor, Psychiatrist, Lawyer, and Social worker. The Ministry of Health appoints and pays all committee members. The Commission investigates the accuracy of the information and documents submitted and decides on the ethical suitability of the transplant when it is convinced that there is no unethical or illegal situation between the recipient and the donor according to their professions. The documents for the ethical committee are presented in SDC, Table 1 . Routine ethical committee meetings are performed every 15 days; however, this committee can immediately unite in urgent conditions. Decisions are taken according to majority vote. Table 1 Preoperative workup for living donors Steps Items First Step Informing the donor regarding the surgery and postoperative period. Psychiatry consultations. Introducing the donor to the donor right protector. Quitting oral contraceptive drugs for females Second Step General blood tests : ABO-Rh typing, complete blood test, coagulation tests, liver function tests, kidney function tests, lipid profile, serological tests (hepatitis B, hepatitis C, hepatitis A, human immunodeficiency virus, syphilis, cytomegalovirus [CMV], Epstein–Barr virus [EBV], toxoplasma, rubella, and varicella) Chest X-ray, electrocardiography Urinalysis Occult blood and parasite in the stool B-HCG for females Third Step Advanced blood test: tumor markers (Ca 19 − 9, carcinoembryonic antigen [CEA], alpha fetoprotein [AFP], and prostate-specific antigen [PSA]), thyroid function tests, copper, vitamin B12, folic acid, ceruplasmin, rheumotoid factor, protein C activity, protein S activity, anti-thrombin III, transferrin, and iron Fourth Step Heart consultation when the donor is older than 35 years old Pulmonologist consultation when any symptom is noted Fifth Step Radiological studies: dynamic liver computed tomography (CT) with volumetry, liver magnetic resonance with cholangiography (MRCP) Sixth Step Ultrasonography-guided liver biopsy To rule out the possibility of forgery, photos of passports of donors and recipients are sent to the local department of combating migrant smuggling and border gates. The migrant smuggling office primarily investigates fake and suspicious documents. All International patients and donors should bring Turkish-translated documents that show kinship relationship. Recipients and donors should bring their family tree or family book or marriage certificate or birth certificate with them. Although local offices (Apostille) certify the authenticity of signatures in the documents, all documents are sent to the Consulate for approval. Consulate offices either approve the documents or certify that the donor and recipient with the mentioned passports have a kinship relationship. The passports of donors and recipients should be translated to Turkish and notarized. Precautions have been taken following incidences of organ trafficking attempts and difficulties in documentation. Despite having a kinship relationship, patients and donors from countries in which suspicious organ trafficking attempts had occurred should be sent to the local ethical committee for thorough evaluation. The suspicious attempts are all controlled by General Directory of Security. As organ trafficking is closely monitored in our country, some temporary changes can be implemented, including the suspension of paired organ transplantation in international patients. In every transplant center, there should be a living donor right advocator who is responsible to the TMH. Donor right advocator gives information to the donor about the rights. Before the onset of donor evaluations, all donors are initially met by a donor right advocator and then a psychiatrist. A donor right protector is a hospital social worker who assesses the existence of influence over donors, information about donors’ financial and accommodation status, and the possibility of coercion and exploitation[ 9 ]. As emphasized in the previous studies, evaluation of donors by social workers are crucial[ 10 , 11 ]. Preoperative Framework for International Patients Psychiatry consultations are performed before donor evaluation. The psychiatrist evaluates donor anxiety, psychological status, decision-making capacity, motivation for donation, ability to cope with stress, and voluntariness of donation (SDC,Tables 2 and 3 ). Before the evaluation, information about the transplantation process, risk of complications, treatment options in the event of complications, and recent success rates are conveyed to the patients. Table 2 Preoperative workup for recipient candidates Groups Items Blood test ABO-Rh typing, complete blood test, coagulation tests, liver function tests, kidney function tests, lipid profile, tumor markers (Ca 19 − 9, CEA, AFP, and PSA), thyroid function tests, copper, vitamin B12, folic acid, ceruplasmin, rheumotoid factor, protein C activity, protein S activity, anti-thrombin III, transferrin, iron, and autoimmune markers (when the patient has autoimmune hepatitis diagnosis or cryptogenic liver cirrhosis) Serological Test Hepatitis B, hepatitis C, hepatitis A, human immunodeficiency virus, syphilis, CMV, EBV, toxoplasma, rubella, and varicella Microbiological test Rectal, nasal, urinary, and blood cultures Radiological test Dynamic abdomino–pelvic CT, When the patient has hepatocellular carcinoma; dynamic contrast MR, positron emission tomography and cranial CT Consultations Dentistry, psychiatry, gastroenterology, cardiology, and other departments when needed Endoscopic evaluations Esophagogastroduodenoscopy, colonoscopy Special test Factors II, V, methylenetetrahydrofolate reductase (MTHR), plasminogen activator inhibitor (PAI) gene mutation when portal vein thrombosis is noted Metabolic tests when metabolic disease is observed in pediatric cases Table 3 Distribution of patients according to their country of origin Middle Asia and North Africa Europe and Balkan Asia Country Number of Patients (% ) Country Number of Patients (%) Country Number of Patients (%) Bahrain 1 (0.4%) Albania 3 (1.2%) Afghanistan 1 (0.4%) Algeria 92 (37.9%) Bulgaria 7 (2.9%) Azerbaijan 4 (1.6%) Djibouti 1 (0.4%) England 1 (0.4%) Indonesia 1 (0.4%) Dubai 1 (0.4%) Montenegro 22 (9. 1%) Georgia 4 (1.6%) Morocco 36 (14.8%) Kosovo 1 (0.4%) Kazakhstan 1 (0.4%) Ivory Coast 1 (0.4%) Macedonia 3 (1.2%) Mongolia 2 (0.8%) Iraq 3 (1.2%) Moldova 2 (0.8%) Uzbekistan 1 (0.4%) Cameroon 1 (0.4%) Romania 4 (1.6%) Pakistan 4 (1.6%) Qatar 1 (0.4%) Serbia 5 (2.1%) Turkmenistan 1 (0.4%) Libya 1 (0.4%) Ukrainian 1 (0.4%) Egypt 1 (0.4%) Mauritania 1 (0.4%) Sudan 1 (0.4%) Saudi Arabia 2 (0.8%) Tunisian 2 (0.8%) Oman 3 (1.2%) Lebanon 5 (2.1%) Palestine 3 (1.2%) Jordan 19 (7. 8%) Total 175 (72.1%) Total 49 (20.1%) Total 19 (7.8%) Table 4 Demographic data of the recipients, blood groups, kinship relationship of donors, MELD scores, presence of HCC, presence of ascites, presence of encephalopathy, mean GWRW hospital stay preoperatively, and surgery types (donor demographics are provided) n (%) Sex Female 99 (40.7) Male 144 (59.3) Patient age (year) Mean ± Ss 30.9 ± 24.4 Median (Min–Max) 37.4 (0–70.5) Height (cm) Mean ± Ss 141.6 ± 44.1 Median (Min–Max) 165 (58 – 195) Weight (kg) ( 18 years old) (n = 149) Mean ± Ss 25.4 ± 4.1 Median (Min–Max) 25 (16–39) Blood groups 0 100 (41.2) A 101 (41.6) B 30 (12,.3) AB 12 (4.9) Comorbidities Exist 82 (34.3) Donor 1st degree 161 (66.3) 2nd degree 34 (14) 3rd degre 18 (7.4) 4th degree 9 (3.7) Unrelated 21 (8.6) Preoperative hospital stay (days) Mean ± Ss 39.4 ± 68.9 Median (Min–Max) 24 (1–64) Positive culture results during admission 36 (16.0) Presence of HCC 19 (7.8) Postoperative hospital stay (days) Mean ± Ss 19.8 ± 11.3 Median (Min–Max) 17 (4–65) MELD score Mean ± Ss 19.5 ± 6.9 Median (Min–Max) 19 (9–32) Presence of ascites 182 (75.2) GWRW ratio Pediatric Median (Min–Max) 2.5 (0.9–5) Adult Median (Min–Max) 1.1 (0.7–1.8) Surgery type Pediatric Adult Monosegment Reduced left lateral lobe Left lateral lobe Left lobe Right lobe Left lobe 10 (4.1%) 50 (20.5%) 32 (13.1%) 2 (0.9%) 134 (55.1%) 15 (6.1%) Presence of encephalopathy 88 (36.5) Donors Age (year) Mean ± Ss Median (Min–Max) 32.9 ± 9.2 32 (18–52) Sex Female Male 112 (46%) 131 (54%) BMI (kg/m 2 ) Mean ± Ss Median (Min–Max) 24.47 ± 3,19 24.4 (17–32) HCC, hepatocellular carcinoma; MELD, model for end-stage liver disease; GWRW, graft-weight-recipient-weight; BMI, body mass index Table 5 Comparisons of countries by regions Regions p Middle East and Africa Europe and Balkan Asia MELD score Mean ± Ss 19.18 ± 6.66 20.42 ± 7.93 19.64 ± 5.44 aa 0.214 Median (Min–Max) 18 (7–42) 21(2–35) 21.5 (8–27) Preoperative hospital stay (days) Mean ± Ss 33.07 ± 29.69 65.64 ± 138.2 26.43 ± 25.6 aa 0.290 Median (Min–Max) 26 (1–238) 22 (1–648) 16 (1–97) BMI (kg/m 2 ) (> 18 years old) Mean ± Ss 25.59 ± 4.26 24.63 ± 3.47 27.05 ± 3.67 aa 0.298 Median (Min – Max) 25 (16.5–38.9) 24.3 (15.2–35) 28.3 (21–32) Blood groups 0 71 (39.7) 22 (44.0) 7 (50.0) d 0.923 A 75 (41.9) 21 (42.0) 5 (35.7) B 22 (12.3) 6 (12.0) 2 (14.3) AB 11 (6.1) 1 (2.0) 0 Positive culture results during admission 34 (19.0) 5 (10.0) 0 d 0.077 HCC 10 (5.6) 6 (12.0) 3 (21.4) d 0.043* Mortality 25 (14.0) 8 (16.0) 0 b 0.291 Etiology Autoimmune hepatitis 10 (5.6) 4 (8.0) 1 (7.1) d 0.543 Biliary atresia 48 (26.8) 4 (8.0) 3 (21.4) d 0.012* Cryptogenic 35 (19.6) 5 (10.0) 0 d 0.066 HBV 11 (6.1) 5 (10.0) 2 (14.3) d 0.542 HCV 14 (7.8) 2 (4.0) 4 (28.6) d 0.033* NASH 19 (10.6) 2 (4.0) 0 d 0.243 PFIC 10 (5.6) 3 (6.0) 0 d 1.000 aa Kruskal–Wallis test b Pearson chi-square test d Fisher–Freman–Halton Test *p < 0.05 PFIC, progressive familial intrahepatic cholestasis; HBV, hepatitis B virus; HCV, hepatitis C virus; NASH, non-alcoholic steatohepatitis; HCC, hepatocellular carcinoma; MELD, model for end-stage liver disease; BMI, body mass index Before discharging the patients and donors, they are informed about postoperative precautions. Special informative documents are provided to the patients. In the outpatient department, we assess the clinical well-being of the patients and evaluate whether they have learned the precautions. Obtained results were statistically analyzed using the Number Cruncher Statistical System (NCSS) 2022 (NCSS LLC, Kaysville, UT, USA). Descriptive analyses for quantitative variables were presented as means, standard deviations, medians, and minimum and maximum values; qualitative variables were expressed as frequencies and percentages. The Kruskal–Wallis test was employed for comparisons between the groups of parameters that did not show normal distribution, and the Mann–Whitney U test was used for evaluations according to the two groups. The Pearson chi-square test, Fisher’s exact test, and Fisher–Freeman–Halton test were employed for comparing qualitative data. The Kaplan–Meier test was performed for overall survival analysis. The difference between survival rates was examined with the Log Rank test. Statistical significance was set at p < 0.05 and confidence interval of 95%. RESULTS A total of 875 patients underwent LDLT in ACU Hospital from November 2016 to November 2024. Only 41 deceased donor liver transplantations (DDLTs) were performed during this period (4.4% of all transplantations). Of the 875 patients, 243 (27.7%) came from abroad for LDLT. The distribution of patients according to their country of origin is shown in Table 1 . The preoperative findings are summarized in Table 2 . Regarding comorbidities, 46 (18.9%), 14 (5.8%), 14 (5.8%), 5 (2.1%), and 1(0.4%) patients had diabetes mellitus, arterial hypertension, coronary artery diseases, chronic kidney diseases, and congenital immune deficiency, respectively. All donor hepatectomies were performed via open surgery. Routine blood cultures taken during the first admission to the transplantation unit were positive in 36 (16%) cases, and these cases were treated before the transplantation. CMV IgM was detected in 14 cases (6%), all of whom were pediatric cases. Seropositivities of viral serologies were 91.3%, 83.3%, 87.3%, 85%, and 77% for CMV IgG, EBV IgG, toxoplasmosis IgG, rubella IgG, and varicella IgG, respectively. All pediatric cases were vaccinated, regardless of missed doses. Although the patients were screened for IgM and IgG in the preoperative period, polymerase chain reaction (PCR) test was preferred in the postoperative period. The distribution of etiologies of patients is depicted in Fig. 1 . Of 243 patients, 19 (7.8%) had HCC. The mean number of HCC was 3.6 ± 3.1, and the mean diameter of the biggest HCC lesion was 4.6 ± 2.6 (2–10) cm. These patients are still being followed without recurrences. Postoperative complications were categorized using the Clavien–Dindo classification. Complications were classified into the following: grade I, 55 (22%); grade II, 10 (4%); grade IIIA, 29 (14%); and grade IIIB, 48 (33%). Sepsis was observed in 21% of 243 cases. Bile complications were noted in 49 cases (20.2%). These complications were managed using either endoscopic retrograde cholangiopancreatography (ERCP) (32 [13.2%]) or percutaneous transhepatic cholangiography (PTC) (19 [7.8%]). Of the patients, 27 (11.1%) were diagnosed with acute cellular rejection and managed using high-dose steroids. The comparisons of country regions are presented in Table 3 . The overall mortality rate of pediatric and adult patients was 14.9% and 12.8%, respectively. The 1-year survival rate of pediatric and adult patients was 87% (n = 82) and 92% (n = 137), respectively. The 3-year survival rate of pediatric and adult patients was 80% (n = 75) and 90% (n = 135), respectively. The 3-year survival analysis results of pediatric and adult patients are depicted in Fig. 2 . When we compared the model for end-stage liver disease (MELD) scores, preoperative hospital stay, preoperative positive culture rates, ascites and encephalopathy prevalence rates, and postoperative complication rates among surviving and nonsurviving cases, only postoperative complications demonstrated a significant difference between the two groups (P = 0.001). Regarding complications, only postoperative bleeding (p = 0.003), pneumonia (p = 0.33), and vascular conditions (p = 0.001) were significant. P values for comparisons of mean MELD scores, preoperative hospital stay, preoperative positive culture rates, and ascites and encephalopathy prevalence rates were 0.175, 0.584, 0.385, 0.074, and 0.76, respectively. Four patients who underwent retransplantation due to primary nonfunction and hepatic artery thrombosis were noted. Patients with primary nonfunction were pediatric cases and retransplanted from other parents. One of them died owing to sepsis. One adult patient had hepatic artery thrombosis, and he underwent retransplantation from cadaveric transplantation. All recipients completed their 6-month follow-up. In the first-year follow-up, 242 (99%) patients sent their recent medical reports. During the follow-up period, 35 (14.4%) patients were invited back to Turkey owing to suspicion of biliary complications and were subsequently managed using ERCP. A total of 16 (6.5%) patients were re-invited owing to abnormal laboratory test results, necessitating further evaluations. No donor mortality was reported among the donors during the study duration in Turkey. Moreover, no donor morbidity with Clavien–Dindo Classification scores of > 3 was noted during the early postoperative period. The mean hospitalization duration following donor hepatectomy was 4.3 (3–6) days. Donors were invited to the hospital at 1 week following discharge for routine control and sent to their countries. Even after they returned to their countries, donors were followed for 1 year. We prepared the hospital records and a letter for the local office and local doctors regarding patient follow-up. During the clinical follow-up of the donors in their countries, 213 (87.6%) and 165 (67.9%) completed their 6-month and 1-year follow-up, respectively. Only 3 (1%) patients developed incision hernia during follow-up. DISCUSSION Liver transplantation is a life-saving procedure for acute liver failure, ESLDs, liver cancers, and metabolic diseases. Patients from countries lacking liver transplant procedures, sufficient cadaveric donors, or adequate healthcare services attempt to seek treatment options abroad. The World Health Assembly in 2004 declared that organ trade is an issue requiring immediate attention. Members were warned about taking precautions against transplant tourism and sale of organs[ 2 ]. Transplant tourism poses risks of surgical complications, poor graft outcomes, increased mortality, and significantly increased infectious complications. Transplant tourism is considered illegal owing to loss of traceability, transparency, and continuity of care, along with its associated ethical issues[ 4 ]. In the DOI, transplant tourism was distinguished from travel for transplantation[ 5 , 6 ]. In travel for transplantation, the government and health professional should follow the recommendations and principles stipulated by the DOI and WHO. Regulations in Turkey align with the WHO and DOI and are regularly updated. Cases of organ trafficking had been attempted in our country in previous years, most of which were associated with fake documents approved by the Consulate offices. To address this concern, some transplant centers opened crime services wherein special police officers are employed to regulate documents. In our center, we verify the documents of international patients for the authorities combating migrant smuggling. In our center, the combating migrant smuggling office identified four cases of forgeries in passports during the routine controls of passports of International patients. The legal process was initiated for these four cases. They were sent to the court, and surgeries were not performed. The police department searched the suspicious intermediaries, and the recipients were sent back to their countries. Regarding transparency and traceability, all legal and medical documents are stored in the hospital and the TMH Organ Transplantation Monitoring System. Furthermore, certain regulations are based on national values, including the significance of family. As the donor candidates are willing to undergo a complex surgery, possible complication risks should also be accepted by the spouses. Therefore, the lack of spouse approval prevents donation of a competent adult. Liver transplant patients from 38 different countries visit Turkey owing to its geographical position. Being just in the middle of Asia and Europe, Turkey demonstrates transportation advantages. As the number of LDLT is low in European countries and Turkey is the second country worldwide with the highest number of LDLT, Turkey draws significant attention for several countries[ 12 ]. Moreover, the low cost of LDLT in Turkey attracts several International patients. In the United Kingdom, Korea, the USA, and Taiwan, an LDLT for noncitizens would cost approximately 878,000 USD, 150,000–250,000 USD, 500,000–800,000, and 84,000 USD, respectively[ 13 , 14 ]. In Turkey, the cost of LDLT is approximately 45,000–65,000 USD[ 13 ]. The price encompasses organ transplantation and postoperative follow-up. In case of long hospital stay due to unexpected complication, additional budget may be offered, which has occurred in 42 (17.2%) patients. Nonetheless, compared with other Asian counterparts and the USA, Turkey is highly affordable. As being very attractive, 27.7% of all LDLTs in our center are international cases. This ratio is 3.1% in South Korea and 5% in the USA[ 15 , 16 ]. In countries with high cadaveric donation rates, international patients can be listed in cadaveric liver transplantation[ 16 ]. However, countries with limited cadaveric donation, LDLT is the only way for international patients. Although this situation appears like a limitation, as observed in our study, 27.7% of the patients are international cases. Data on the survival rates of patients who are traveling abroad are insufficient. A study conducted in South Korea reported 1- and 3- year survival rates of 96% and 92%, respectively. However, in this study, the mean MELD score of the patients was lower and the need for hospitalization before transplantation was shorter than our cases. This finding indicates that our patients are arriving in poorer health and with infections. In Asia, the actual 1-year survival rate is 78.7%–97.8%, whereas that in the USA is 81%[ 17 , 18 ]. The actual survival rates for international patients who had LDLT are 90% and 88% at 1 and 3 years, respectively, consistent with our results[ 19 ]. The survival rate difference depends on the patients’ general condition and difficulty of transplantation. The biliary atresia rate was 86% in the study by Kabiling et al., whereas 30% in the study by Kim et al[ 15 , 19 ]. In our center, the postoperative hospital stay of the recipients and donors was shorter than that reported in the study by Kim et al[ 15 ]. Kim et al. revealed that the mean hospital stays of adult recipients and donors were 39.8 and 12.1 days, respectively[ 15 ]. Under normal conditions, according to the regulations, overseas patients are prohibited to obtain organ from national deceased donor owing to limited health donation[ 7 ]. In 2024, the number of DDLTs was 188, whereas that of LDLT was 1,543[ 1 , 20 ]. The limited number of cadaveric organs is not offered to international patients as the organs are used for national patients. However, in urgent cases following LDLT, such as hepatic artery thrombosis, or primary nonfunction livers, centers can refer to the TMH for cadaveric liver transplantation. As the cadaveric donation is highly limited in Turkey, finding an organ from the national system is challenging. Therefore, generally, centers attempt to find new living donor candidates. In our center, the DDLT rate is < 5%. Pediatric cases account for 38% of the total number of patients. The leading indication for liver transplantation at our center is biliary atresia, representing 22.6% of all patients and 59.1% of pediatric cases. In the study by Kim et al., the rate of biliary atresia among international pediatric cases is 90.6%[ 15 ]. Patients with biliary atresia encounter several challenges, including previous surgeries, low body weight, portal vein pathologies, and recurrent cholangitis, all of which may increase the risk of complications. The study indicates pediatric cases exhibit significantly higher mortality rates 15 . Similarly, Chen et al. reported reduced survival rates among international patients with biliary atresia[ 17 ]. These overseas patients tend to be more severely ill than local patients. Moreover, some pediatric patients lack necessary vaccinations, extending the waiting period for live vaccinations before transplantation. The present study revealed that 6% of our cases tested positive for CMV IgM. Vaccinations and screening programs for viral infections and endemic diseases are crucial for overseas patients. The high mean MELD score and the presence of infection during admission demonstrate that the patients are referred to us late or not optimally treated in their respective countries. In the study by Kim SH et al., the MELD score of international patients was 16, which was lower than our study[ 15 ]. Similarly, among noncitizens and nonresident liver transplant cases in the study by Braun HJ et al., the mean MELD score was 16[ 16 ]. The high MELD score and the existence of infection have caused increased preoperative hospital stay and complication risks. To overcome late admission and achieve optimal patient management, local physicians should be informed about early consultation to transplant centers. The limited access to transplantation in these countries has led to decreased awareness and healthcare. Therefore, we invited four gastroenterologists and twelve general surgeons from various countries to share knowledge and support the development of organ transplantation programs in their home countries. Several indications of liver transplantation have been noted in our cases, with non-alcoholic steatohepatitis (NASH) cirrhosis being the leading indication among adults. This rate aligns with the worldwide trend in NASH rates[ 21 ]. This finding indicates that patients are coming from diverse locations, not just specific regions. In the study by Braun HJ et al., hepatitis C virus was identified as the leading indication for liver transplantation for noncitizen and nonresident patients in the USA[ 16 ]. In the study by Kim SH, hepatitis B virus was the leading indication for overseas patients[ 15 ]. Patients traveling from abroad frequently present with one donor candidate who typically lack prior radiological images. As they do not have an available donor, we had to select graft with graft-weight-recipient-weight between 0.8 and 1.0 or multiple bile openings on graft. Although these cases carry risk of small-for-size syndrome or bile complications, no small-for-size syndrome-related mortalities are noted. The success of organ transplantation extends beyond surgical outcomes; it also encompasses medical follow-up, managing complications, screening for infections, prompt detection of potential malignancies, and monitoring for possible drug side effects. At our center, the bile complication rate is approximately 20% across all patients, including adults and pediatrics. This rate is lower than that reported by several living donor liver centers. In a previous meta-analysis, the biliary complication rates in LDLT ranged 12%–35%[ 22 ]. All our patients who have encountered biliary complications have been treated with repeated ERCP and PTC, underscoring the significance of continuity of care. To effectively manage complications, transplant centers should include experienced gastroenterologists and interventional radiologists. The DOI Custodian Group recommends that to facilitate timely communication regarding patient care, a system of international support and cooperation among health authorities should be established. In addition to managing complications, prevention, awareness, and proper care are essential during the postoperative period. Therefore, comprehensive information should be provided before discharge, and follow-up assessments are conducted[ 23 ]. Collaboration is crucial for the long-term survival of patients[ 24 , 25 ]. To prevent CMV and pneumocystis infections, we prefer prophylactic treatment. For CMV prophylaxis, we prefer administering oral valganciclovir for 3 months following liver transplantation for adult cases and 6 months for pediatric cases. CMV PCR is performed when CMV infection is suspected. For Pneumocystis jirovecii infection prophylaxis, trimethoprim–sulfamethoxazole is administered for 3 months. Patients with hepatitis B were followed up with anti-HbsAg measurements. Hepatitis B immunoglobulin is administered to high-risk patients whose anti-HbsAg levels are < 100 IU/L. A significantly increased risk of infection, with rates estimated at 45%–50%, represents a primary transplant tourism-associated concern[ 26 ]. Studies have reported that transplant tourism is associated with an 85-fold higher risk of infection than domestic transplants[ 26 , 27 ]. The following are the main factors contributing to this increased risk: (1) the prevalence of endemic diseases, (2) variability in the screening of donor infectious diseases, (3) inadequate patient education, and (4) absence of prophylactic measures[ 28 ]. CONCLUSION Consequently, a well-structured LDLT framework can help prevent organ trafficking. Adhering to the guidelines set by the DOI and WHO improves the quality of healthcare for international patients. Abbreviations ACU Acibadem Atakent AFP Alpha fetoprotein BMI Body mass index Ca 19 − 9 Carbohydrate Antigen 19 CEA Carcinoembryonic antigen CMV Cytomegalovirus CT Computed tomography DOI Declaration of Istanbul DDLT Deceased donor liver transplantation EBV Ebstein–Barr virus ERCP Endoscopic retrograde cholangiopancreatography ESLD End-stage liver disease GWRW Graft-weight-recipient-weight HBV Hepatitis B virus HCC Hepatocellular carcinoma HCV Hepatitis C virus LDLT Living donor liver transplantation MELD Model for end-stage liver disease MRI Magnetic resonance imaging MRCP Magnetic resonance with cholangiography MTHR Methylenetetrahydrofolate reductase NASH Non-alcoholic steatohepatitis NCSS Number Cruncher Statistical System PAI Plasminogen activator inhibitor PCR Polymerase chain reaction PET–CT Positron emission tomography–computed tomography PFIC Progressive familial intrahepatic cholestasis PSA Prostate-specific antigen PTC Percutaneous transhepatic cholangiography TMH Turkish Ministry of Health WHO World Health Organization Declarations Ethical approval and consent to participate The Acibadem Ethical Committee approved the study protocol (ATADEK-2024/14), Inform consent forms that were signed before the operation state that the data of the patients’ would be used for future scientific studies. Consent fot publication Not applicable Availability of data and materials Data supporting the findings of this study are available upon request from the corresponding author. Competing interest The authors declare that they have no competing interest Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors Author Contribution T.U.Y. participated in conception of the study, study design, statistical analysis, review of the analysis, article writing, and revision. A.O. participated in conception of the study, study design, drafting the article, Ö.F.Ö. participated in conception of the study, collecting the data, article writing, M.C.G. participated in review of the analysis and article revision, M.Y. participated in review of the analysis, collecting the data, article revision, F.O.Ö participated in statistical analysis, and revision. V.E, participated in review of the analysis and article revision. H.K. participated in conception of the study, study design, review of the analysis, article writing, and revision.. References WHO-ONT Collaboration. INTERNATIONAL REPORT ON ORGAN DONATION AND TRANSPLANTATION ACTIVITIES 2023. https://www.transplant-observatory.org/. Shimazono Y. The state of the international organ trade: a provisional picture based on integration of available information. Bull World Health Organ . 2007;85(12):955. doi:10.2471/BLT.06.039370 Manzano A, Monaghan M, Potrata B, Clayton M. The invisible issue of organ laundering. Transplantation . 2014;98(6):600-603. doi:10.1097/TP.0000000000000333, Akoh JA. Key issues in transplant tourism. World J Transplant . 2012;2(1):9. doi:10.5500/WJT.V2.I1.9 Steering Committee of the Istanbul Summit. Organ trafficking and transplant tourism and commercialism: the Declaration of Istanbul. The Lancet . 2008;372(9632):5-6. doi:10.1016/S0140-6736(08)60967-8 THE DECLARATION OF ISTANBUL ON ORGAN TRAFFICKING AND TRANSPLANT TOURISM (2018 Edition) . Sağlık Bakanlığı. ORGAN NAKLİ HİZMETLERİ YÖNETMELİĞİ . Accessed May 1, 2025. https://www.resmigazete.gov.tr/eskiler/2022/12/20221209-3.htm Dindo D, Demartines N, Clavien PA. Classification of surgical complications: A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg . 2004;240(2):205-213. doi:10.1097/01.SLA.0000133083.54934.AE, Şahin B, Bican Demir A, Kaya E. Independent Living Donor Advocate in Organ Transplantation: An Ethical and Application Guide. Uludağ Üniversitesi Tıp Fakültesi Dergisi . 2025;51(2):331-339. doi:10.32708/uutfd.1653254 Fadhil RAS, Al Abdulghani A, Alabdulla M, et al. Psychosocial Evaluation of Prospective Living Kidney Donors in Qatar: A Profile of Prospective Donors, Process, and Outcomes. Transplant Direct . 2025;11(5):e1785. doi:10.1097/TXD.0000000000001785 Martin DE, Capron AM, Fadhil RAS, et al. Prevention of Trafficking in Organs, Tissues, and Cells. Transplantation . 2025;109(1):88-97. doi:10.1097/TP.0000000000005212 Rela M, Rammohan A. Why are there so many liver transplants from living donors in Asia and so few in Europe and the US? J Hepatol . 2021;75(4):975-980. doi:10.1016/J.JHEP.2021.05.036/ATTACHMENT/E9B078D8-38EF-4FDF-BF85-D068B8689880/MMC1.PDF Liver transplant Cost Worldwide - Transplants | MediGence. Accessed May 2, 2025. https://medigence.com/hospitals/transplants/liver-transplant Kabiling CS, Chen CL, Concejero A, et al. Section 18. Professional Framework For Liver Transplantation For Overseas Patients. Transplantation . 2014;97(Supplement 8S):S75-S79. doi:10.1097/01.TP.0000446282.66675.24 Kim SH, Hwang S, Song GW, et al. Institutional standard framework and experience of living donor liver transplantation for overseas non-Korean patients at Asan Medical Center. Korean Journal of Transplantation . 2021;35(2):93-99. doi:10.4285/KJT.20.0045, Braun HJ, Amara D, Shui AM, et al. International Travel for Liver Transplantation: A Comprehensive Assessment of the Impact on the United States Transplant System. Transplantation . 2022;106(2):E141-E152. doi:10.1097/TP.0000000000003970, Chen CL, Fan ST, Lee SG, Makuuchi M, Tanaka K. Living-donor liver transplantation: 12 Years of experience in Asia. Transplantation . 2003;75(3 SUPPL.). doi:10.1097/01.TP.0000046533.93621.C7, Olthoff KM, Abecassis MM, Emond JC, et al. Outcomes of adult living donor liver transplantation: Comparison of the adult-to-adult living donor liver transplantation cohort study and the national experience. Liver Transplantation . 2011;17(7):789-797. doi:10.1002/LT.22288, Kabiling CS, Chen CL, Concejero A, et al. Section 18. Professional framework for liver transplantation for overseas patients: Traveling for living donor liver transplantation. Transplantation . 2014;97(8):S75-S79. doi:10.1097/TP.0000000000000060 Müller PC, Kabacam G, Vibert E, Germani G, Petrowsky H. Current status of liver transplantation in Europe. International Journal of Surgery . 2020;82:22-29. doi:10.1016/j.ijsu.2020.05.062 Majumdar A, Tsochatzis EA. Changing trends of liver transplantation and mortality from non-alcoholic fatty liver disease. Metabolism . 2020;111. doi:10.1016/j.metabol.2020.154291 Hassouneh R, Beran A, Rosenheck M, et al. Risk factors for biliary strictures and leaks after living-donor liver transplantation: a systematic review and meta-analysis. Journal of Gastrointestinal Surgery . 2024;28(11):1870-1882. doi:10.1016/j.gassur.2024.08.009 Bababekov YJ, Ven Fong Z, Chang DC, Simpson MA, Yeh H, Pomposelli JJ. Is liver transplant education patient-centered? Liver Transplantation . 2017;23(8):1070-1072. doi:10.1002/LT.24801, McGuire BM, Rosenthal P, Brown CC, et al. Long-term management of the liver transplant patient: Recommendations for the primary care doctor: Special feature. American Journal of Transplantation . 2009;9(9):1988-2003. doi:10.1111/J.1600-6143.2009.02733.X, Hoppmann N, Massoud O. Medical care of liver transplant patients. Expert Rev Gastroenterol Hepatol . 2020;14(10). doi:10.1080/17474124.2020.1797483, Babik JM, Chin-Hong P. Transplant Tourism: Understanding the Risks. Curr Infect Dis Rep . 2015;17(4). doi:10.1007/S11908-015-0473-X, Allam N, Al Saghier M, El Sheikh Y, et al. Clinical outcomes for Saudi and Egyptian patients receiving deceased donor liver transplantation in China. American Journal of Transplantation . 2010;10(8):1834-1841. doi:10.1111/j.1600-6143.2010.03088.x Babik JM, Chin-Hong P. Transplant Tourism: Understanding the Risks. Curr Infect Dis Rep . Current Medicine Group LLC 1 . 2015;17(4). doi:10.1007/s11908-015-0473-x Additional Declarations No competing interests reported. Supplementary Files SupplementarymaterialA.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 04 May, 2026 Reviewers agreed at journal 24 Apr, 2026 Reviewers agreed at journal 23 Apr, 2026 Reviewers agreed at journal 20 Apr, 2026 Reviewers agreed at journal 20 Apr, 2026 Reviewers invited by journal 15 Apr, 2026 Editor assigned by journal 13 Apr, 2026 Editor invited by journal 23 Mar, 2026 Submission checks completed at journal 20 Mar, 2026 First submitted to journal 20 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9120224","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":626095671,"identity":"220d9222-f4b1-487d-aab5-e05353f05aea","order_by":0,"name":"Tonguç Utku YILMAZ","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEElEQVRIiWNgGAWjYFACNhAhIQMkGB8AGQkMDAkgEWY8OiBaeECqDFC1sOHVwgDSwibBAFZPQIvB/bY0CcY2Cx7d9uPPKn7UWOTxtycf3cBQYZ3YIN/7AKuWY2zHgFokeMzOJKTd7DkmUSxx5lnaDYYz6YkNbOwG2LWwt0G0HEg4doO3QSKx4UaO2Q3GtsNALdhdhtBy/mFb4V+glvk38r/dYPyHTwvMYTeS2ZhBtmy4kcN2g7EBtxbJY2nJFgnnQFqeMUvLAP1ieOaZ2Y2EY+nGbWxpWLXwHT5meONDWZ2c2fn0hx/f1NTlyR1PfnbjQ421bD/zMaxawCARwwUJDLhjEgL+4JUdBaNgFIyCkQ4AFf1fNe0EQbwAAAAASUVORK5CYII=","orcid":"","institution":"Acıbadem University Atakent Hospital","correspondingAuthor":true,"prefix":"","firstName":"Tonguç","middleName":"Utku","lastName":"YILMAZ","suffix":""},{"id":626095672,"identity":"de3e13b2-442c-49e6-bb70-257f6054b82b","order_by":1,"name":"Ali OZER","email":"","orcid":"","institution":"Acıbadem University Atakent 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Hospital","correspondingAuthor":false,"prefix":"","firstName":"Hamdi","middleName":"","lastName":"KARAKAYALI","suffix":""}],"badges":[],"createdAt":"2026-03-14 06:53:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9120224/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9120224/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107515255,"identity":"094a1170-2930-486d-80dc-4bc0acada0f8","added_by":"auto","created_at":"2026-04-22 08:28:12","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":496784,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of etiologies\u003c/p\u003e","description":"","filename":"Figure1.DistributionofEtiologyresized.png","url":"https://assets-eu.researchsquare.com/files/rs-9120224/v1/12a33220592d8f2d9f5e95a1.png"},{"id":107515351,"identity":"a6962193-74ca-4068-ac33-9d63017cf9fb","added_by":"auto","created_at":"2026-04-22 08:28:17","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":101991,"visible":true,"origin":"","legend":"\u003cp\u003eThree-year survival analysis of pediatric and adult cases\u003c/p\u003e","description":"","filename":"Figure2SurvivalEdited.png","url":"https://assets-eu.researchsquare.com/files/rs-9120224/v1/18afd1f5093b8cbee114b040.png"},{"id":107515442,"identity":"21314fb3-a4ec-4ce9-bcfa-fee07d0f1522","added_by":"auto","created_at":"2026-04-22 08:28:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1610092,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9120224/v1/4bf19835-f020-4759-b8a2-8f5e78e872dd.pdf"},{"id":107515370,"identity":"e2dc3cdb-d742-4497-8d47-7a3ede47873a","added_by":"auto","created_at":"2026-04-22 08:28:28","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":23957,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementarymaterialA.docx","url":"https://assets-eu.researchsquare.com/files/rs-9120224/v1/91904aa04f272bc12324c652.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Travel for Translantation; Framework and Experience of Living Donor Liver Transplantation against Organ Trafficking","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eThe global prevalence of end-stage liver disease (ESLD) is approximately 4.5% of the general population, and liver transplantation is frequently the best life-saving procedure available. A recent study on patients on liver waiting list versus liver transplant per million populations has reported that the demand remains high, and several patients died while on the waiting list[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The number of liver transplantation is inconsistent, particularly in African countries. The demand for transplantation is high in the USA, Mongolia, and Croatia, whereas it is very low in Belgium and Canada[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In certain countries, liver transplantation may be limited or unavailable. Asian countries with lower prices for transplantation are particularly attractive to neighboring nations; however, countries with well-established organ-sharing systems should be prioritized[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTravel for transplantation refers to the movement of organs, donors, recipients, or transplant professionals across jurisdictional borders for the purpose of transplantation[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Proper travel for organ transplantation varies from transplant tourism, which is considered unethical. To prevent organ trafficking and transplant commercialization, transplant centers and countries should adhere to the principles outlined in the Declaration of Istanbul (DOI)[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. For these reasons, living donor liver transplantation (LDLT) centers should develop a specialized framework for foreign patients that addresses issues, including battling organ trafficking, performing comprehensive preoperative evaluations, and upholding ethical standards[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe aimed to present our framework for patients traveling for LDLT and share our experiences with LDLT for non-Turkish patients.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003eThis retrospective study was conducted in Acibadem Atakent (ACU) Hospital Organ Transplantation Center. The Acibadem Ethical Committee approved the study protocol (ATADEK-2024/14). Consent forms were obtained from the participants. This study was conducted following the ethical guidelines of the World Medical Association Declaration of Helsinki 2013. All foreign patients who underwent LDLT from November 2016 to November 2024 were included in this study.\u003c/p\u003e \u003cp\u003eACU Hospital, one of the hospitals of the private health organization Acibadem Health Group, is located in Istanbul, Turkey. Liver transplantation was established in 2012. The liver transplant program started with a limited number of cases, all of which were domestic. After 2016, the international liver transplant program was started. The Turkish Social Security system has paid all costs associated with liver transplantation among Turkish citizens. The ACU Hospital international patient service supports the patients for accommodation, translation, legal document preparation etc.. Moreover, the Acibadem Health Group encompasses 25 hospitals, 15 health centers, and 56 health points across different countries. Health points are centers wherein a nonmedical staff works to communicate with local doctors, patients, and Acibadem doctors. Patients seeking treatment travel to the health points for consultations. In countries without health points, patients are referred to our international patient office by e-mail. International patients are frequently consulted via e-mail or video conference with the assistance of local health offices or local doctors. Communication between local health offices and local doctors continues even after transplantation for postoperative follow-up. After confirming the indication for liver transplantation, patients are invited to our center with their donors for further evaluation. Financial costs are shouldered individually or by the social security system or charity foundations of their specific countries.\u003c/p\u003e \u003cp\u003eIn Turkey, the Turkish Ministry of Health (TMH) regulates and supervises all types of solid organ transplantations, which are performed following the guidelines of the Organ Transplantation Regulations[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Patients\u0026rsquo; data are entered into the computer-based TMH Organ Transplantation Monitoring System.\u003c/p\u003e \u003cp\u003eData on the demographic characteristics, kinship relationship of donors, etiology of diseases, and comorbidities were collected. The countries where patients came from were divided according to geographic locations, such as the Middle East and North Africa, Europe and Balkans, and Asia. All patients were searched using comprehensive tests. Suspicions of any infections were preoperatively managed. In patients with hepatocellular carcinoma (HCC), abdominal magnetic resonance imaging (MRI) and positron emission tomography\u0026ndash;computed tomography (PET\u0026ndash;CT) were performed. Patients who had distant HCC metastasis were not accepted for transplantation. Those who had HCC with macrovascular invasion, alpha fetoprotein (AFP) levels\u0026thinsp;\u0026gt;\u0026thinsp;400 ng/mL, and \u0026gt;\u0026thinsp;5-cm lesions underwent bridging therapy with either transarterial chemoembolization or transarterial radioembolization. Transplantation was continued when the tumor thrombus disappeared, AFP levels decreased to \u0026lt;\u0026thinsp;450 ng/mL or after a 3-month follow-up no increase of \u0026gt;\u0026thinsp;15 ng/mL/month, and \u0026ge;\u0026thinsp;30% reduction in tumor size. These guidelines are similar both for international and national patients. Postoperative complications were graded using the Clavien\u0026ndash;Dindo Classification[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]Data on preoperative and postoperative hospital stays were collected. Comparisons were performed according to country regions and surviving and nonsurviving cases.\u003c/p\u003e \u003cp\u003e \u003cb\u003eRegulations for Liver Transplantation in International Patients\u003c/b\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eAccording to guidelines, only LDLT can be performed for International patients[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. LDLT can be performed among relatives up to the fourth degree of consanguinity. Spouses should be married for at least 2 years or the liver disease should start following the marriage. Donors and recipients who are not relatives, are friends, or at least recognize each other are regarded as unrelated. Altruistic donations are not accepted in Turkey. When no kinship relationship exists between donors and recipients, they should administer to the TMH Ethical Committee (TMH subunit) to show the absence of financial relationship. No payment is required for the ethical committee application.\u003c/p\u003e \u003cp\u003eThe ethical committee comprises the following: Deputy provincial police chief or director of the department of combating migrant smuggling and border gates, Medical doctor, Psychiatrist, Lawyer, and Social worker.\u003c/p\u003e \u003cp\u003eThe Ministry of Health appoints and pays all committee members. The Commission investigates the accuracy of the information and documents submitted and decides on the ethical suitability of the transplant when it is convinced that there is no unethical or illegal situation between the recipient and the donor according to their professions.\u003c/p\u003e \u003cp\u003eThe documents for the ethical committee are presented in SDC, Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Routine ethical committee meetings are performed every 15 days; however, this committee can immediately unite in urgent conditions. Decisions are taken according to majority vote.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePreoperative workup for living donors\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSteps\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eItems\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFirst Step\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInforming the donor regarding the surgery and postoperative period. Psychiatry consultations. Introducing the donor to the donor right protector. Quitting oral contraceptive drugs for females\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecond Step\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eGeneral blood tests\u003c/span\u003e: ABO-Rh typing, complete blood test, coagulation tests, liver function tests, kidney function tests, lipid profile, serological tests (hepatitis B, hepatitis C, hepatitis A, human immunodeficiency virus, syphilis, cytomegalovirus [CMV], Epstein\u0026ndash;Barr virus [EBV], toxoplasma, rubella, and varicella)\u003c/p\u003e \u003cp\u003eChest X-ray, electrocardiography\u003c/p\u003e \u003cp\u003eUrinalysis\u003c/p\u003e \u003cp\u003eOccult blood and parasite in the stool\u003c/p\u003e \u003cp\u003eB-HCG for females\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThird Step\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdvanced blood test: tumor markers (Ca 19\u0026thinsp;\u0026minus;\u0026thinsp;9, carcinoembryonic antigen [CEA], alpha fetoprotein [AFP], and prostate-specific antigen [PSA]), thyroid function tests, copper, vitamin B12, folic acid, ceruplasmin, rheumotoid factor, protein C activity, protein S activity, anti-thrombin III, transferrin, and iron\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFourth Step\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHeart consultation when the donor is older than 35 years old\u003c/p\u003e \u003cp\u003ePulmonologist consultation when any symptom is noted\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFifth Step\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRadiological studies: dynamic liver computed tomography (CT) with volumetry, liver magnetic resonance with cholangiography (MRCP)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSixth Step\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUltrasonography-guided liver biopsy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTo rule out the possibility of forgery, photos of passports of donors and recipients are sent to the local department of combating migrant smuggling and border gates. The migrant smuggling office primarily investigates fake and suspicious documents. All International patients and donors should bring Turkish-translated documents that show kinship relationship.\u003c/p\u003e \u003cp\u003eRecipients and donors should bring their family tree or family book or marriage certificate or birth certificate with them. Although local offices (Apostille) certify the authenticity of signatures in the documents, all documents are sent to the Consulate for approval. Consulate offices either approve the documents or certify that the donor and recipient with the mentioned passports have a kinship relationship. The passports of donors and recipients should be translated to Turkish and notarized.\u003c/p\u003e \u003cp\u003ePrecautions have been taken following incidences of organ trafficking attempts and difficulties in documentation. Despite having a kinship relationship, patients and donors from countries in which suspicious organ trafficking attempts had occurred should be sent to the local ethical committee for thorough evaluation. The suspicious attempts are all controlled by General Directory of Security. As organ trafficking is closely monitored in our country, some temporary changes can be implemented, including the suspension of paired organ transplantation in international patients.\u003c/p\u003e \u003cp\u003eIn every transplant center, there should be a living donor right advocator who is responsible to the TMH. Donor right advocator gives information to the donor about the rights. Before the onset of donor evaluations, all donors are initially met by a donor right advocator and then a psychiatrist. A donor right protector is a hospital social worker who assesses the existence of influence over donors, information about donors\u0026rsquo; financial and accommodation status, and the possibility of coercion and exploitation[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. As emphasized in the previous studies, evaluation of donors by social workers are crucial[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePreoperative Framework for International Patients\u003c/h2\u003e \u003cp\u003ePsychiatry consultations are performed before donor evaluation. The psychiatrist evaluates donor anxiety, psychological status, decision-making capacity, motivation for donation, ability to cope with stress, and voluntariness of donation (SDC,Tables\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Before the evaluation, information about the transplantation process, risk of complications, treatment options in the event of complications, and recent success rates are conveyed to the patients.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePreoperative workup for recipient candidates\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroups\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eItems\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eABO-Rh typing, complete blood test, coagulation tests, liver function tests, kidney function tests, lipid profile, tumor markers (Ca 19\u0026thinsp;\u0026minus;\u0026thinsp;9, CEA, AFP, and PSA), thyroid function tests, copper, vitamin B12, folic acid, ceruplasmin, rheumotoid factor, protein C activity, protein S activity, anti-thrombin III, transferrin, iron, and autoimmune markers (when the patient has autoimmune hepatitis diagnosis or cryptogenic liver cirrhosis)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSerological Test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHepatitis B, hepatitis C, hepatitis A, human immunodeficiency virus, syphilis, CMV, EBV, toxoplasma, rubella, and varicella\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMicrobiological test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRectal, nasal, urinary, and blood cultures\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRadiological test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDynamic abdomino\u0026ndash;pelvic CT,\u003c/p\u003e \u003cp\u003eWhen the patient has hepatocellular carcinoma; dynamic contrast MR, positron emission tomography and cranial CT\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConsultations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDentistry, psychiatry, gastroenterology, cardiology, and other departments when needed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEndoscopic evaluations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEsophagogastroduodenoscopy, colonoscopy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecial test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFactors II, V, methylenetetrahydrofolate reductase (MTHR), plasminogen activator inhibitor (PAI) gene mutation when portal vein thrombosis is noted\u003c/p\u003e \u003cp\u003eMetabolic tests when metabolic disease is observed in pediatric cases\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDistribution of patients according to their country of origin\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eMiddle Asia and North Africa\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eEurope and Balkan\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eAsia\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCountry\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eNumber of Patients (%\u003c/b\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eCountry\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eNumber of Patients (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eCountry\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eNumber of Patients (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBahrain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAlbania\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (1.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAfghanistan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 (0.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlgeria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e92 (37.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBulgaria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (2.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAzerbaijan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4 (1.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDjibouti\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEngland\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (0.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIndonesia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 (0.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDubai\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMontenegro\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22 (9. 1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGeorgia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4 (1.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMorocco\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36 (14.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eKosovo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (0.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eKazakhstan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 (0.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIvory Coast\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMacedonia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (1.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMongolia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 (0.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIraq\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMoldova\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (0.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUzbekistan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 (0.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCameroon\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRomania\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (1.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePakistan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4 (1.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQatar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSerbia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (2.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTurkmenistan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 (0.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLibya\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUkrainian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (0.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEgypt\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMauritania\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSudan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSaudi Arabia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (0.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTunisian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (0.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLebanon\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (2.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePalestine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJordan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (7. 8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e175 (72.1%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e49 (20.1%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e19 (7.8%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic data of the recipients, blood groups, kinship relationship of donors, MELD scores, presence of HCC, presence of ascites, presence of encephalopathy, mean GWRW hospital stay preoperatively, and surgery types (donor demographics are provided)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e99 (40.7)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMale\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e144 (59.3)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePatient age (year)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;Ss\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.9\u0026thinsp;\u0026plusmn;\u0026thinsp;24.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eMedian (Min\u0026ndash;Max)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37.4 (0\u0026ndash;70.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHeight (cm)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;Ss\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e141.6\u0026thinsp;\u0026plusmn;\u0026thinsp;44.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eMedian (Min\u0026ndash;Max)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e165 (58\u003cem\u003e\u0026ndash;\u003c/em\u003e195)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eWeight (kg) (\u0026lt;\u0026thinsp;18 years old) (n\u0026thinsp;=\u0026thinsp;94)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;Ss\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.7\u0026thinsp;\u0026plusmn;\u0026thinsp;10.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eMedian (Min\u0026ndash;Max)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.2 (4.8\u0026ndash;45)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eBMI (kg/m\u003c/b\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e) (\u0026gt;\u0026thinsp;18 years old) (n\u0026thinsp;=\u0026thinsp;149)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;Ss\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eMedian (Min\u0026ndash;Max)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (16\u0026ndash;39)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBlood groups\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100 (41.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e101 (41.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eB\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (12,.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eAB\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (4.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComorbidities\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eExist\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e82 (34.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eDonor\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e1st degree\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e161 (66.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e2nd degree\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (14)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e3rd degre\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (7.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e4th degree\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (3.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eUnrelated\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (8.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003ePreoperative hospital stay (days)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;Ss\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.4\u0026thinsp;\u0026plusmn;\u0026thinsp;68.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eMedian (Min\u0026ndash;Max)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (1\u0026ndash;64)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePositive culture results during admission\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36 (16.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePresence of HCC\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (7.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003ePostoperative hospital stay (days)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;Ss\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.8\u0026thinsp;\u0026plusmn;\u0026thinsp;11.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eMedian (Min\u0026ndash;Max)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (4\u0026ndash;65)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMELD score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;Ss\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.5\u0026thinsp;\u0026plusmn;\u0026thinsp;6.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eMedian (Min\u0026ndash;Max)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (9\u0026ndash;32)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePresence of ascites\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e182 (75.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGWRW ratio\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePediatric\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eMedian (Min\u0026ndash;Max)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.5 (0.9\u0026ndash;5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAdult\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eMedian (Min\u0026ndash;Max)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.1 (0.7\u0026ndash;1.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSurgery type\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003ePediatric\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eAdult\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMonosegment\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eReduced left lateral lobe\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eLeft lateral lobe\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eLeft lobe\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eRight lobe\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eLeft lobe\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (4.1%)\u003c/p\u003e \u003cp\u003e50 (20.5%)\u003c/p\u003e \u003cp\u003e32 (13.1%)\u003c/p\u003e \u003cp\u003e2 (0.9%)\u003c/p\u003e \u003cp\u003e134 (55.1%)\u003c/p\u003e \u003cp\u003e15 (6.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePresence of encephalopathy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88 (36.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDonors\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (year)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;Ss\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eMedian (Min\u0026ndash;Max)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.9\u0026thinsp;\u0026plusmn;\u0026thinsp;9.2\u003c/p\u003e \u003cp\u003e32 (18\u0026ndash;52)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eMale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e112 (46%)\u003c/p\u003e \u003cp\u003e131 (54%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI (kg/m\u003c/b\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;Ss\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eMedian (Min\u0026ndash;Max)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.47\u0026thinsp;\u0026plusmn;\u0026thinsp;3,19\u003c/p\u003e \u003cp\u003e24.4 (17\u0026ndash;32)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eHCC, hepatocellular carcinoma; MELD, model for end-stage liver disease; GWRW, graft-weight-recipient-weight; BMI, body mass index\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparisons of countries by regions\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eRegions\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMiddle East and Africa\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEurope and Balkan\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAsia\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eMELD score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;Ss\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.18\u0026thinsp;\u0026plusmn;\u0026thinsp;6.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20.42\u0026thinsp;\u0026plusmn;\u0026thinsp;7.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19.64\u0026thinsp;\u0026plusmn;\u0026thinsp;5.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003csup\u003e\u003cb\u003eaa\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e0.214\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eMedian (Min\u0026ndash;Max)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (7\u0026ndash;42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21(2\u0026ndash;35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21.5 (8\u0026ndash;27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003ePreoperative hospital stay (days)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;Ss\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33.07\u0026thinsp;\u0026plusmn;\u0026thinsp;29.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e65.64\u0026thinsp;\u0026plusmn;\u0026thinsp;138.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e26.43\u0026thinsp;\u0026plusmn;\u0026thinsp;25.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003csup\u003e\u003cb\u003eaa\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e0.290\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eMedian (Min\u0026ndash;Max)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (1\u0026ndash;238)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22 (1\u0026ndash;648)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16 (1\u0026ndash;97)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eBMI (kg/m\u003c/b\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e) (\u0026gt;\u0026thinsp;18 years old)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;Ss\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.59\u0026thinsp;\u0026plusmn;\u0026thinsp;4.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24.63\u0026thinsp;\u0026plusmn;\u0026thinsp;3.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27.05\u0026thinsp;\u0026plusmn;\u0026thinsp;3.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003csup\u003e\u003cb\u003eaa\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e0.298\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eMedian (Min\u003c/em\u003e\u0026ndash;\u003cem\u003eMax)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (16.5\u0026ndash;38.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24.3 (15.2\u0026ndash;35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28.3 (21\u0026ndash;32)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eBlood groups\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71 (39.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22 (44.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003csup\u003e\u003cb\u003ed\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e0.923\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75 (41.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21 (42.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 (35.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eB\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (12.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (12.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (14.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eAB\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (6.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePositive culture results during admission\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (19.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (10.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003csup\u003e\u003cb\u003ed\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e0.077\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHCC\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (12.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (21.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003csup\u003e\u003cb\u003ed\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e0.043*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMortality\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (14.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (16.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003csup\u003e\u003cb\u003eb\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e0.291\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEtiology\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAutoimmune hepatitis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (8.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (7.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003csup\u003e\u003cb\u003ed\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e0.543\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBiliary atresia\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48 (26.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (8.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (21.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003csup\u003e\u003cb\u003ed\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e0.012*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCryptogenic\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (19.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (10.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003csup\u003e\u003cb\u003ed\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e0.066\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHBV\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (6.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (10.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003csup\u003e\u003cb\u003ed\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e0.542\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHCV\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (7.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (4.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (28.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003csup\u003e\u003cb\u003ed\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e0.033*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNASH\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (10.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (4.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003csup\u003e\u003cb\u003ed\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e0.243\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePFIC\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (6.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003csup\u003e\u003cb\u003ed\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e1.000\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003e\u003cem\u003eaa\u003c/em\u003e\u003c/sup\u003e\u003cem\u003eKruskal\u0026ndash;Wallis test\u003c/em\u003e \u003csup\u003e\u003cem\u003eb\u003c/em\u003e\u003c/sup\u003e\u003cem\u003ePearson chi-square test\u003c/em\u003e \u003csup\u003e\u003cem\u003ed\u003c/em\u003e\u003c/sup\u003e\u003cem\u003eFisher\u0026ndash;Freman\u0026ndash;Halton Test *p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003ePFIC, progressive familial intrahepatic cholestasis; HBV, hepatitis B virus; HCV, hepatitis C virus; NASH, non-alcoholic steatohepatitis; HCC, hepatocellular carcinoma; MELD, model for end-stage liver disease; BMI, body mass index\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eBefore discharging the patients and donors, they are informed about postoperative precautions. Special informative documents are provided to the patients. In the outpatient department, we assess the clinical well-being of the patients and evaluate whether they have learned the precautions.\u003c/p\u003e \u003cp\u003eObtained results were statistically analyzed using the Number Cruncher Statistical System (NCSS) 2022 (NCSS LLC, Kaysville, UT, USA). Descriptive analyses for quantitative variables were presented as means, standard deviations, medians, and minimum and maximum values; qualitative variables were expressed as frequencies and percentages. The Kruskal\u0026ndash;Wallis test was employed for comparisons between the groups of parameters that did not show normal distribution, and the Mann\u0026ndash;Whitney U test was used for evaluations according to the two groups. The Pearson chi-square test, Fisher\u0026rsquo;s exact test, and Fisher\u0026ndash;Freeman\u0026ndash;Halton test were employed for comparing qualitative data. The Kaplan\u0026ndash;Meier test was performed for overall survival analysis. The difference between survival rates was examined with the Log Rank test. Statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 and confidence interval of 95%.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 875 patients underwent LDLT in ACU Hospital from November 2016 to November 2024. Only 41 deceased donor liver transplantations (DDLTs) were performed during this period (4.4% of all transplantations). Of the 875 patients, 243 (27.7%) came from abroad for LDLT. The distribution of patients according to their country of origin is shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eThe preoperative findings are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Regarding comorbidities, 46 (18.9%), 14 (5.8%), 14 (5.8%), 5 (2.1%), and 1(0.4%) patients had diabetes mellitus, arterial hypertension, coronary artery diseases, chronic kidney diseases, and congenital immune deficiency, respectively. All donor hepatectomies were performed via open surgery.\u003c/p\u003e \u003cp\u003eRoutine blood cultures taken during the first admission to the transplantation unit were positive in 36 (16%) cases, and these cases were treated before the transplantation. CMV IgM was detected in 14 cases (6%), all of whom were pediatric cases. Seropositivities of viral serologies were 91.3%, 83.3%, 87.3%, 85%, and 77% for CMV IgG, EBV IgG, toxoplasmosis IgG, rubella IgG, and varicella IgG, respectively. All pediatric cases were vaccinated, regardless of missed doses. Although the patients were screened for IgM and IgG in the preoperative period, polymerase chain reaction (PCR) test was preferred in the postoperative period.\u003c/p\u003e \u003cp\u003eThe distribution of etiologies of patients is depicted in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eOf 243 patients, 19 (7.8%) had HCC. The mean number of HCC was 3.6\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1, and the mean diameter of the biggest HCC lesion was 4.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.6 (2\u0026ndash;10) cm. These patients are still being followed without recurrences. Postoperative complications were categorized using the Clavien\u0026ndash;Dindo classification. Complications were classified into the following: grade I, 55 (22%); grade II, 10 (4%); grade IIIA, 29 (14%); and grade IIIB, 48 (33%). Sepsis was observed in 21% of 243 cases. Bile complications were noted in 49 cases (20.2%). These complications were managed using either endoscopic retrograde cholangiopancreatography (ERCP) (32 [13.2%]) or percutaneous transhepatic cholangiography (PTC) (19 [7.8%]).\u003c/p\u003e \u003cp\u003eOf the patients, 27 (11.1%) were diagnosed with acute cellular rejection and managed using high-dose steroids.\u003c/p\u003e \u003cp\u003eThe comparisons of country regions are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eThe overall mortality rate of pediatric and adult patients was 14.9% and 12.8%, respectively. The 1-year survival rate of pediatric and adult patients was 87% (n\u0026thinsp;=\u0026thinsp;82) and 92% (n\u0026thinsp;=\u0026thinsp;137), respectively. The 3-year survival rate of pediatric and adult patients was 80% (n\u0026thinsp;=\u0026thinsp;75) and 90% (n\u0026thinsp;=\u0026thinsp;135), respectively. The 3-year survival analysis results of pediatric and adult patients are depicted in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eWhen we compared the model for end-stage liver disease (MELD) scores, preoperative hospital stay, preoperative positive culture rates, ascites and encephalopathy prevalence rates, and postoperative complication rates among surviving and nonsurviving cases, only postoperative complications demonstrated a significant difference between the two groups (P\u0026thinsp;=\u0026thinsp;0.001). Regarding complications, only postoperative bleeding (p\u0026thinsp;=\u0026thinsp;0.003), pneumonia (p\u0026thinsp;=\u0026thinsp;0.33), and vascular conditions (p\u0026thinsp;=\u0026thinsp;0.001) were significant. P values for comparisons of mean MELD scores, preoperative hospital stay, preoperative positive culture rates, and ascites and encephalopathy prevalence rates were 0.175, 0.584, 0.385, 0.074, and 0.76, respectively. Four patients who underwent retransplantation due to primary nonfunction and hepatic artery thrombosis were noted. Patients with primary nonfunction were pediatric cases and retransplanted from other parents. One of them died owing to sepsis. One adult patient had hepatic artery thrombosis, and he underwent retransplantation from cadaveric transplantation.\u003c/p\u003e \u003cp\u003eAll recipients completed their 6-month follow-up. In the first-year follow-up, 242 (99%) patients sent their recent medical reports. During the follow-up period, 35 (14.4%) patients were invited back to Turkey owing to suspicion of biliary complications and were subsequently managed using ERCP. A total of 16 (6.5%) patients were re-invited owing to abnormal laboratory test results, necessitating further evaluations.\u003c/p\u003e \u003cp\u003eNo donor mortality was reported among the donors during the study duration in Turkey. Moreover, no donor morbidity with Clavien\u0026ndash;Dindo Classification scores of \u0026gt;\u0026thinsp;3 was noted during the early postoperative period. The mean hospitalization duration following donor hepatectomy was 4.3 (3\u0026ndash;6) days. Donors were invited to the hospital at 1 week following discharge for routine control and sent to their countries. Even after they returned to their countries, donors were followed for 1 year. We prepared the hospital records and a letter for the local office and local doctors regarding patient follow-up. During the clinical follow-up of the donors in their countries, 213 (87.6%) and 165 (67.9%) completed their 6-month and 1-year follow-up, respectively. Only 3 (1%) patients developed incision hernia during follow-up.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eLiver transplantation is a life-saving procedure for acute liver failure, ESLDs, liver cancers, and metabolic diseases. Patients from countries lacking liver transplant procedures, sufficient cadaveric donors, or adequate healthcare services attempt to seek treatment options abroad. The World Health Assembly in 2004 declared that organ trade is an issue requiring immediate attention. Members were warned about taking precautions against transplant tourism and sale of organs[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Transplant tourism poses risks of surgical complications, poor graft outcomes, increased mortality, and significantly increased infectious complications. Transplant tourism is considered illegal owing to loss of traceability, transparency, and continuity of care, along with its associated ethical issues[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the DOI, transplant tourism was distinguished from travel for transplantation[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In travel for transplantation, the government and health professional should follow the recommendations and principles stipulated by the DOI and WHO. Regulations in Turkey align with the WHO and DOI and are regularly updated. Cases of organ trafficking had been attempted in our country in previous years, most of which were associated with fake documents approved by the Consulate offices. To address this concern, some transplant centers opened crime services wherein special police officers are employed to regulate documents. In our center, we verify the documents of international patients for the authorities combating migrant smuggling. In our center, the combating migrant smuggling office identified four cases of forgeries in passports during the routine controls of passports of International patients. The legal process was initiated for these four cases. They were sent to the court, and surgeries were not performed. The police department searched the suspicious intermediaries, and the recipients were sent back to their countries. Regarding transparency and traceability, all legal and medical documents are stored in the hospital and the TMH Organ Transplantation Monitoring System. Furthermore, certain regulations are based on national values, including the significance of family. As the donor candidates are willing to undergo a complex surgery, possible complication risks should also be accepted by the spouses. Therefore, the lack of spouse approval prevents donation of a competent adult.\u003c/p\u003e \u003cp\u003eLiver transplant patients from 38 different countries visit Turkey owing to its geographical position. Being just in the middle of Asia and Europe, Turkey demonstrates transportation advantages. As the number of LDLT is low in European countries and Turkey is the second country worldwide with the highest number of LDLT, Turkey draws significant attention for several countries[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Moreover, the low cost of LDLT in Turkey attracts several International patients. In the United Kingdom, Korea, the USA, and Taiwan, an LDLT for noncitizens would cost approximately 878,000 USD, 150,000\u0026ndash;250,000 USD, 500,000\u0026ndash;800,000, and 84,000 USD, respectively[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In Turkey, the cost of LDLT is approximately 45,000\u0026ndash;65,000 USD[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The price encompasses organ transplantation and postoperative follow-up. In case of long hospital stay due to unexpected complication, additional budget may be offered, which has occurred in 42 (17.2%) patients. Nonetheless, compared with other Asian counterparts and the USA, Turkey is highly affordable. As being very attractive, 27.7% of all LDLTs in our center are international cases. This ratio is 3.1% in South Korea and 5% in the USA[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In countries with high cadaveric donation rates, international patients can be listed in cadaveric liver transplantation[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. However, countries with limited cadaveric donation, LDLT is the only way for international patients. Although this situation appears like a limitation, as observed in our study, 27.7% of the patients are international cases.\u003c/p\u003e \u003cp\u003eData on the survival rates of patients who are traveling abroad are insufficient. A study conducted in South Korea reported 1- and 3- year survival rates of 96% and 92%, respectively. However, in this study, the mean MELD score of the patients was lower and the need for hospitalization before transplantation was shorter than our cases. This finding indicates that our patients are arriving in poorer health and with infections. In Asia, the actual 1-year survival rate is 78.7%\u0026ndash;97.8%, whereas that in the USA is 81%[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The actual survival rates for international patients who had LDLT are 90% and 88% at 1 and 3 years, respectively, consistent with our results[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The survival rate difference depends on the patients\u0026rsquo; general condition and difficulty of transplantation. The biliary atresia rate was 86% in the study by Kabiling et al., whereas 30% in the study by Kim et al[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In our center, the postoperative hospital stay of the recipients and donors was shorter than that reported in the study by Kim et al[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Kim et al. revealed that the mean hospital stays of adult recipients and donors were 39.8 and 12.1 days, respectively[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Under normal conditions, according to the regulations, overseas patients are prohibited to obtain organ from national deceased donor owing to limited health donation[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In 2024, the number of DDLTs was 188, whereas that of LDLT was 1,543[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The limited number of cadaveric organs is not offered to international patients as the organs are used for national patients. However, in urgent cases following LDLT, such as hepatic artery thrombosis, or primary nonfunction livers, centers can refer to the TMH for cadaveric liver transplantation. As the cadaveric donation is highly limited in Turkey, finding an organ from the national system is challenging. Therefore, generally, centers attempt to find new living donor candidates. In our center, the DDLT rate is \u0026lt;\u0026thinsp;5%.\u003c/p\u003e \u003cp\u003ePediatric cases account for 38% of the total number of patients. The leading indication for liver transplantation at our center is biliary atresia, representing 22.6% of all patients and 59.1% of pediatric cases. In the study by Kim et al., the rate of biliary atresia among international pediatric cases is 90.6%[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Patients with biliary atresia encounter several challenges, including previous surgeries, low body weight, portal vein pathologies, and recurrent cholangitis, all of which may increase the risk of complications. The study indicates pediatric cases exhibit significantly higher mortality rates \u003csup\u003e15\u003c/sup\u003e. Similarly, Chen et al. reported reduced survival rates among international patients with biliary atresia[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. These overseas patients tend to be more severely ill than local patients. Moreover, some pediatric patients lack necessary vaccinations, extending the waiting period for live vaccinations before transplantation. The present study revealed that 6% of our cases tested positive for CMV IgM. Vaccinations and screening programs for viral infections and endemic diseases are crucial for overseas patients.\u003c/p\u003e \u003cp\u003eThe high mean MELD score and the presence of infection during admission demonstrate that the patients are referred to us late or not optimally treated in their respective countries. In the study by Kim SH et al., the MELD score of international patients was 16, which was lower than our study[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Similarly, among noncitizens and nonresident liver transplant cases in the study by Braun HJ et al., the mean MELD score was 16[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The high MELD score and the existence of infection have caused increased preoperative hospital stay and complication risks. To overcome late admission and achieve optimal patient management, local physicians should be informed about early consultation to transplant centers. The limited access to transplantation in these countries has led to decreased awareness and healthcare. Therefore, we invited four gastroenterologists and twelve general surgeons from various countries to share knowledge and support the development of organ transplantation programs in their home countries.\u003c/p\u003e \u003cp\u003eSeveral indications of liver transplantation have been noted in our cases, with non-alcoholic steatohepatitis (NASH) cirrhosis being the leading indication among adults. This rate aligns with the worldwide trend in NASH rates[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. This finding indicates that patients are coming from diverse locations, not just specific regions. In the study by Braun HJ et al., hepatitis C virus was identified as the leading indication for liver transplantation for noncitizen and nonresident patients in the USA[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In the study by Kim SH, hepatitis B virus was the leading indication for overseas patients[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePatients traveling from abroad frequently present with one donor candidate who typically lack prior radiological images. As they do not have an available donor, we had to select graft with graft-weight-recipient-weight between 0.8 and 1.0 or multiple bile openings on graft. Although these cases carry risk of small-for-size syndrome or bile complications, no small-for-size syndrome-related mortalities are noted.\u003c/p\u003e \u003cp\u003eThe success of organ transplantation extends beyond surgical outcomes; it also encompasses medical follow-up, managing complications, screening for infections, prompt detection of potential malignancies, and monitoring for possible drug side effects. At our center, the bile complication rate is approximately 20% across all patients, including adults and pediatrics. This rate is lower than that reported by several living donor liver centers. In a previous meta-analysis, the biliary complication rates in LDLT ranged 12%\u0026ndash;35%[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. All our patients who have encountered biliary complications have been treated with repeated ERCP and PTC, underscoring the significance of continuity of care. To effectively manage complications, transplant centers should include experienced gastroenterologists and interventional radiologists. The DOI Custodian Group recommends that to facilitate timely communication regarding patient care, a system of international support and cooperation among health authorities should be established. In addition to managing complications, prevention, awareness, and proper care are essential during the postoperative period. Therefore, comprehensive information should be provided before discharge, and follow-up assessments are conducted[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Collaboration is crucial for the long-term survival of patients[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. To prevent CMV and pneumocystis infections, we prefer prophylactic treatment. For CMV prophylaxis, we prefer administering oral valganciclovir for 3 months following liver transplantation for adult cases and 6 months for pediatric cases. CMV PCR is performed when CMV infection is suspected. For \u003cem\u003ePneumocystis jirovecii\u003c/em\u003e infection prophylaxis, trimethoprim\u0026ndash;sulfamethoxazole is administered for 3 months. Patients with hepatitis B were followed up with anti-HbsAg measurements. Hepatitis B immunoglobulin is administered to high-risk patients whose anti-HbsAg levels are \u0026lt;\u0026thinsp;100 IU/L.\u003c/p\u003e \u003cp\u003eA significantly increased risk of infection, with rates estimated at 45%\u0026ndash;50%, represents a primary transplant tourism-associated concern[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Studies have reported that transplant tourism is associated with an 85-fold higher risk of infection than domestic transplants[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The following are the main factors contributing to this increased risk: (1) the prevalence of endemic diseases, (2) variability in the screening of donor infectious diseases, (3) inadequate patient education, and (4) absence of prophylactic measures[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eConsequently, a well-structured LDLT framework can help prevent organ trafficking. Adhering to the guidelines set by the DOI and WHO improves the quality of healthcare for international patients.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eACU\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAcibadem Atakent\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAFP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAlpha fetoprotein\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBMI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBody mass index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCa 19\u0026thinsp;\u0026minus;\u0026thinsp;9\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCarbohydrate Antigen 19\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCEA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCarcinoembryonic antigen\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCMV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCytomegalovirus\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eComputed tomography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDOI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDeclaration of Istanbul\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDDLT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDeceased donor liver transplantation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEBV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEbstein\u0026ndash;Barr virus\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eERCP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEndoscopic retrograde cholangiopancreatography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eESLD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEnd-stage liver disease\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGWRW\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGraft-weight-recipient-weight\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHBV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHepatitis B virus\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHCC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHepatocellular carcinoma\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHCV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHepatitis C virus\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLDLT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLiving donor liver transplantation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMELD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eModel for end-stage liver disease\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMRI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMagnetic resonance imaging\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMRCP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMagnetic resonance with cholangiography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMTHR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMethylenetetrahydrofolate reductase\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNASH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNon-alcoholic steatohepatitis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNCSS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNumber Cruncher Statistical System\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePAI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePlasminogen activator inhibitor\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePCR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePolymerase chain reaction\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePET\u0026ndash;CT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePositron emission tomography\u0026ndash;computed tomography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePFIC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eProgressive familial intrahepatic cholestasis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePSA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eProstate-specific antigen\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePTC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePercutaneous transhepatic cholangiography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTMH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTurkish Ministry of Health\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Acibadem Ethical Committee approved the study protocol (ATADEK-2024/14), Inform consent forms that were signed before the operation state that the data of the patients’ would be used for future scientific studies.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent fot publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData supporting the findings of this study are available upon request from the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interest\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eT.U.Y. participated in conception of the study, study design, statistical analysis, review of the analysis, article writing, and revision. A.O. participated in conception of the study, study design, drafting the article, Ö.F.Ö. participated in conception of the study, collecting the data, article writing, M.C.G. participated in review of the analysis and article revision, M.Y. participated in review of the analysis, collecting the data, article revision, F.O.Ö participated in statistical analysis, and revision. V.E, participated in review of the analysis and article revision. H.K. participated in conception of the study, study design, review of the analysis, article writing, and revision..\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eWHO-ONT Collaboration. INTERNATIONAL REPORT ON ORGAN DONATION AND TRANSPLANTATION ACTIVITIES 2023. https://www.transplant-observatory.org/.\u003c/li\u003e\n \u003cli\u003eShimazono Y. The state of the international organ trade: a provisional picture based on integration of available information. \u003cem\u003eBull World Health Organ\u003c/em\u003e. 2007;85(12):955. doi:10.2471/BLT.06.039370\u003c/li\u003e\n \u003cli\u003eManzano A, Monaghan M, Potrata B, Clayton M. The invisible issue of organ laundering. \u003cem\u003eTransplantation\u003c/em\u003e. 2014;98(6):600-603. doi:10.1097/TP.0000000000000333,\u003c/li\u003e\n \u003cli\u003eAkoh JA. Key issues in transplant tourism. \u003cem\u003eWorld J Transplant\u003c/em\u003e. 2012;2(1):9. doi:10.5500/WJT.V2.I1.9\u003c/li\u003e\n \u003cli\u003eSteering Committee of the Istanbul Summit. Organ trafficking and transplant tourism and commercialism: the Declaration of Istanbul. \u003cem\u003eThe Lancet\u003c/em\u003e. 2008;372(9632):5-6. doi:10.1016/S0140-6736(08)60967-8\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eTHE DECLARATION OF ISTANBUL ON ORGAN TRAFFICKING AND TRANSPLANT TOURISM (2018 Edition)\u003c/em\u003e.\u003c/li\u003e\n \u003cli\u003eSağlık Bakanlığı. \u003cem\u003eORGAN NAKLİ HİZMETLERİ Y\u0026Ouml;NETMELİĞİ\u003c/em\u003e. Accessed May 1, 2025. https://www.resmigazete.gov.tr/eskiler/2022/12/20221209-3.htm\u003c/li\u003e\n \u003cli\u003eDindo D, Demartines N, Clavien PA. Classification of surgical complications: A new proposal with evaluation in a cohort of 6336 patients and results of a survey. \u003cem\u003eAnn Surg\u003c/em\u003e. 2004;240(2):205-213. doi:10.1097/01.SLA.0000133083.54934.AE,\u003c/li\u003e\n \u003cli\u003eŞahin B, Bican Demir A, Kaya E. Independent Living Donor Advocate in Organ Transplantation: An Ethical and Application Guide. \u003cem\u003eUludağ \u0026Uuml;niversitesi Tıp Fak\u0026uuml;ltesi Dergisi\u003c/em\u003e. 2025;51(2):331-339. doi:10.32708/uutfd.1653254\u003c/li\u003e\n \u003cli\u003eFadhil RAS, Al Abdulghani A, Alabdulla M, et al. Psychosocial Evaluation of Prospective Living Kidney Donors in Qatar: A Profile of Prospective Donors, Process, and Outcomes. \u003cem\u003eTransplant Direct\u003c/em\u003e. 2025;11(5):e1785. doi:10.1097/TXD.0000000000001785\u003c/li\u003e\n \u003cli\u003eMartin DE, Capron AM, Fadhil RAS, et al. Prevention of Trafficking in Organs, Tissues, and Cells. \u003cem\u003eTransplantation\u003c/em\u003e. 2025;109(1):88-97. doi:10.1097/TP.0000000000005212\u003c/li\u003e\n \u003cli\u003eRela M, Rammohan A. Why are there so many liver transplants from living donors in Asia and so few in Europe and the US? \u003cem\u003eJ Hepatol\u003c/em\u003e. 2021;75(4):975-980. doi:10.1016/J.JHEP.2021.05.036/ATTACHMENT/E9B078D8-38EF-4FDF-BF85-D068B8689880/MMC1.PDF\u003c/li\u003e\n \u003cli\u003eLiver transplant Cost Worldwide - Transplants | MediGence. Accessed May 2, 2025. https://medigence.com/hospitals/transplants/liver-transplant\u003c/li\u003e\n \u003cli\u003eKabiling CS, Chen CL, Concejero A, et al. Section 18. Professional Framework For Liver Transplantation For Overseas Patients. \u003cem\u003eTransplantation\u003c/em\u003e. 2014;97(Supplement 8S):S75-S79. doi:10.1097/01.TP.0000446282.66675.24\u003c/li\u003e\n \u003cli\u003eKim SH, Hwang S, Song GW, et al. Institutional standard framework and experience of living donor liver transplantation for overseas non-Korean patients at Asan Medical Center. \u003cem\u003eKorean Journal of Transplantation\u003c/em\u003e. 2021;35(2):93-99. doi:10.4285/KJT.20.0045,\u003c/li\u003e\n \u003cli\u003eBraun HJ, Amara D, Shui AM, et al. International Travel for Liver Transplantation: A Comprehensive Assessment of the Impact on the United States Transplant System. \u003cem\u003eTransplantation\u003c/em\u003e. 2022;106(2):E141-E152. doi:10.1097/TP.0000000000003970,\u003c/li\u003e\n \u003cli\u003eChen CL, Fan ST, Lee SG, Makuuchi M, Tanaka K. Living-donor liver transplantation: 12 Years of experience in Asia. \u003cem\u003eTransplantation\u003c/em\u003e. 2003;75(3 SUPPL.). doi:10.1097/01.TP.0000046533.93621.C7,\u003c/li\u003e\n \u003cli\u003eOlthoff KM, Abecassis MM, Emond JC, et al. Outcomes of adult living donor liver transplantation: Comparison of the adult-to-adult living donor liver transplantation cohort study and the national experience. \u003cem\u003eLiver Transplantation\u003c/em\u003e. 2011;17(7):789-797. doi:10.1002/LT.22288,\u003c/li\u003e\n \u003cli\u003eKabiling CS, Chen CL, Concejero A, et al. Section 18. Professional framework for liver transplantation for overseas patients: Traveling for living donor liver transplantation. \u003cem\u003eTransplantation\u003c/em\u003e. 2014;97(8):S75-S79. doi:10.1097/TP.0000000000000060\u003c/li\u003e\n \u003cli\u003eM\u0026uuml;ller PC, Kabacam G, Vibert E, Germani G, Petrowsky H. Current status of liver transplantation in Europe. \u003cem\u003eInternational Journal of Surgery\u003c/em\u003e. 2020;82:22-29. doi:10.1016/j.ijsu.2020.05.062\u003c/li\u003e\n \u003cli\u003eMajumdar A, Tsochatzis EA. Changing trends of liver transplantation and mortality from non-alcoholic fatty liver disease. \u003cem\u003eMetabolism\u003c/em\u003e. 2020;111. doi:10.1016/j.metabol.2020.154291\u003c/li\u003e\n \u003cli\u003eHassouneh R, Beran A, Rosenheck M, et al. Risk factors for biliary strictures and leaks after living-donor liver transplantation: a systematic review and meta-analysis. \u003cem\u003eJournal of Gastrointestinal Surgery\u003c/em\u003e. 2024;28(11):1870-1882. doi:10.1016/j.gassur.2024.08.009\u003c/li\u003e\n \u003cli\u003eBababekov YJ, Ven Fong Z, Chang DC, Simpson MA, Yeh H, Pomposelli JJ. Is liver transplant education patient-centered? \u003cem\u003eLiver Transplantation\u003c/em\u003e. 2017;23(8):1070-1072. doi:10.1002/LT.24801,\u003c/li\u003e\n \u003cli\u003eMcGuire BM, Rosenthal P, Brown CC, et al. Long-term management of the liver transplant patient: Recommendations for the primary care doctor: Special feature. \u003cem\u003eAmerican Journal of Transplantation\u003c/em\u003e. 2009;9(9):1988-2003. doi:10.1111/J.1600-6143.2009.02733.X,\u003c/li\u003e\n \u003cli\u003eHoppmann N, Massoud O. Medical care of liver transplant patients. \u003cem\u003eExpert Rev Gastroenterol Hepatol\u003c/em\u003e. 2020;14(10). doi:10.1080/17474124.2020.1797483,\u003c/li\u003e\n \u003cli\u003eBabik JM, Chin-Hong P. Transplant Tourism: Understanding the Risks. \u003cem\u003eCurr Infect Dis Rep\u003c/em\u003e. 2015;17(4). doi:10.1007/S11908-015-0473-X,\u003c/li\u003e\n \u003cli\u003eAllam N, Al Saghier M, El Sheikh Y, et al. Clinical outcomes for Saudi and Egyptian patients receiving deceased donor liver transplantation in China. \u003cem\u003eAmerican Journal of Transplantation\u003c/em\u003e. 2010;10(8):1834-1841. doi:10.1111/j.1600-6143.2010.03088.x\u003c/li\u003e\n \u003cli\u003eBabik JM, Chin-Hong P. Transplant Tourism: Understanding the Risks. \u003cem\u003eCurr Infect Dis Rep\u003c/em\u003e.\u003cem\u003eCurrent Medicine Group LLC 1\u003c/em\u003e. 2015;17(4). doi:10.1007/s11908-015-0473-x\u003cstrong\u003e\u003cbr clear=\"all\"\u003e\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Living Donor Liver Transplantation, Travel for Transplantation, Organ Trafficking, Complication, International","lastPublishedDoi":"10.21203/rs.3.rs-9120224/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9120224/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Organ shortage, high medical costs, long waiting periods, and the absence of liver transplantation led individuals to seek other alternatives, including travel for transplantation. Although associated with several difficulties, travel for transplantation is a legal solution to this impossibility. This study aimed to present patients who travel to our center for living donor liver transplantation (LDLT).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This retrospective descriptive study was conducted in the Acibadem Atakent Organ Transplantation Unit from November 2016 to November 2024 among patients who had traveled abroad. The framework, preoperative evaluation, and legal documents required for preventing organ trafficking were comprehensively explained. Data of patients’ country origins, demographic data, clinical findings, and infectious status were collected from hospital records. Mortality rates, postoperative complications, treatment options of biliary complications, and follow-up results were also gathered.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Overall, 243 patients traveled abroad from 38 different countries. Patients from the Middle East and Africa constituted 72% of all patients. Pediatric cases comprised 38% of all cases. The leading indication for pediatric liver transplantation was biliary atresia. The main indication for adult liver transplantation was non-alcoholic steatohepatitis. Mean model for end-stage liver disease score was 19. The overall survival rate was 86% among all patients. Biliary complications were observed in 49 (20%) patients, all of whom were successfully treated.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e A well-structured framework for LDLT is effective in preventing organ trafficking. Following the guidelines of the Declaration of Istanbul and World Health Organization enhances the quality of healthcare in LDLT of patients who travel abroad.\u003c/p\u003e","manuscriptTitle":"Travel for Translantation; Framework and Experience of Living Donor Liver Transplantation against Organ Trafficking","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-22 08:26:40","doi":"10.21203/rs.3.rs-9120224/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-04T12:43:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"39152908655631843481404503757541622666","date":"2026-04-24T05:16:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"233533268867725142351564777027715911473","date":"2026-04-23T18:40:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"167764348372576252699444698391607147731","date":"2026-04-20T08:04:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"253080660866383856558745356060175471548","date":"2026-04-20T07:04:01+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-15T06:26:28+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-13T15:02:47+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-23T08:04:27+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-20T19:54:47+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Surgery","date":"2026-03-20T19:49:05+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b5da9f30-6283-42e1-9b2e-eeb1e709b11d","owner":[],"postedDate":"April 22nd, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-04T12:43:22+00:00","index":70,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-22T08:26:46+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-22 08:26:40","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9120224","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9120224","identity":"rs-9120224","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}