[4] Since the procedure carries relatively high risks, is resource-intensive, and requires major life modifications after surgery, it is reserved for dire circumstances.

[citation needed] Judging the appropriateness/effectiveness of liver transplant on case-by-case basis is critically important (see Contraindications), as outcomes are highly variable.

Assessment of a person's transplant eligibility is made by a multi-disciplinary team that includes surgeons, medical doctors, psychologists and other providers.

Some examples include: Importantly, many contraindications to liver transplantation are considered reversible; a person initially deemed "transplant-ineligible" may later become a favorable candidate if the circumstances change.

Other nonspecific presentation may include malaise, anorexia, muscle ache, low fever, slight increase in white blood count and graft-site tenderness.

For example, systems which use a machine to pump blood through the explanted liver (after it is harvested from the body) during a transfer have met some success [citation needed](see Research section for more).

[citation needed] Historically, LDLT began with terminal pediatric patients, whose parents were motivated to risk donating a portion of their compatible healthy livers to replace their children's failing ones.

[9][page needed][10] It was followed by Christoph Broelsch at the University of Chicago Medical Center in November 1989, when two-year-old Alyssa Smith received a portion of her mother's liver.

It is considered more technically demanding than even standard, cadaveric donor liver transplantation, and also poses the ethical problems underlying the indication of a major surgical operation (hemihepatectomy or related procedure) on a healthy human being.

The donor's liver will regenerate approaching 100% function within 4–6 weeks, and will almost reach full volumetric size with recapitulation of the normal structure soon thereafter.

The LDLT donor's immune system does diminish as a result of the liver regenerating, so certain foods which would normally cause an upset stomach could cause serious illness.

Other risks of donating a liver include bleeding, infection, painful incision, possibility of blood clots and a prolonged recovery.

The accessibility of adult parents who want to donate a piece of the liver for their children/infants has reduced the number of children who would have otherwise died waiting for a transplant.

Liver transplantation is unique in that the risk of chronic rejection also decreases over time, although the great majority of recipients need to take immunosuppressive medication for the rest of their lives.

[citation needed] As with many experimental models used in early surgical research, the first attempts at liver transplantation were performed on dogs.

The earliest published reports of canine liver transplantations were performed in 1954 by Vittorio Staudacher at Ospedale Maggiore Policlinico in Milan, Italy.

[28] The first attempted human liver transplant was performed in 1963 by Thomas Starzl, although the pediatric patient died intraoperatively due to uncontrolled bleeding.

[29] Multiple subsequent attempts by various surgeons remained unsuccessful until 1967, when Starzl transplanted a 19-month-old girl with hepatoblastoma who was able to survive for over one year before dying of metastatic disease.

[5] An alternative method involves machine perfusion, in which oxygenated, preservation solutions are continually pumped through the liver prior to transplantation.

[5] A 2014 study showed that the liver preservation time could be significantly extended using a supercooling technique, which preserves the liver at subzero temperatures (-6 °C)[33] Donation after circulatory death (DCD) has become an increasingly important source of organs for transplantation, with categories ranging from uncontrolled to controlled DCD (cDCD) donors.

[34] To mitigate these issues, there has been a rising interest in normothermic regional perfusion (NRP), a technique that temporarily restores oxygenated blood flow to organs after death, thereby improving their viability prior to recovery.

[citation needed] NRP works by reversing the detrimental effects of warm ischemia on cellular energy substrates and antioxidants, thereby reconditioning the organs before transplantation.

This technique, often facilitated by extracorporeal membrane oxygenation (ECMO) technology, allows for organ assessment and optimization, reducing the risk of graft failure.

[34] NRP can be established either abdominally or thoracoabdominally, depending on the intended organs for transplantation, with specific techniques and monitoring protocols in place to ensure optimal outcomes.

[34] Through the utilization of NRP, Dr. Fondevila et al. at Hospital Universitario La Paz have achieved successful transplantation of livers that have undergone extensive warm ischemic periods of up to 2.5 hours prior to recovery.

[35] This has resulted in biliary complication and graft survival rates comparable to those observed in controlled DCD livers that have experienced significantly less warm ischemia.

The controversy stems from the view of alcoholism as a self-inflicted disease and the perception that those with alcohol-induced damage are depriving other patients who could be considered more deserving.

The changing status of cannabis has resulted in many patients who never abused any substance – merely used one – either being turned down for transplants, forced to stop a useful medicine suggested by their doctors, or both.

They removed Mr. Smith from a transplant waiting list for "non-compliance of our substance abuse contract",[40] despite his own oncologist at Cedars-Sinai having recommended that he use the cannabis for his pain and chemotherapy.

In both cases, the patients acceded to the hospital's demand and stopped using cannabis, despite its therapeutic benefits for them, but were both sent back to the bottom of the transplant list.