Domino Liver Transplantation Using the Explanted Native Liver of a Multivisceral Transplant Recipient: A Pediatric Case Report and Systematic Review
David Walls, Jenelle L. Pederson, Piyush Gupta, Jordan R. Wilson, Brian Nguyen, Gustaf Herlenious, Thomas M. Fishbein, Carolina Rumbo, Cal S. Matsumoto, Gabriel E. GondolesiABSTRACT
Background
Children awaiting liver transplantation face donor scarcity and waitlist mortality. Domino liver transplantation (DLT), or re‐use of a structurally normal explanted liver, has expanded the donor pool in metabolic disease, but the multivisceral transplant (MVT) recipient, whose normal native liver is removed when a liver‐inclusive visceral allograft is implanted, is rarely used. We report a pediatric DLT from an infant MVT explant and review all prior reports.
Methods
Our case report presentation is followed by a systematic review using PRISMA 2020. MEDLINE, Embase, and PubMed were used from inception to August 21, 2025, with conference‐proceedings and citation searching for any report of DLT using the explanted native liver from a MVT recipient or combined liver–intestine transplant recipient, without age or language restriction. Two reviewers screened and appraised the evidence.
Results
Our case was a 4‐month‐old boy who underwent a MVT for near‐total enterectomy complicated with a gastric, duodenal, and bladder fistula. His structurally normal native liver was transplanted across ABO incompatibility into an 11‐month‐old girl with biliary atresia and ~1% predicted survival. The MVT recipient remains well at last follow‐up; the domino recipient died of intracranial hemorrhage three weeks after transplantation, with normal liver function. Three prior reports including 4 cases exist worldwide (1997–2023): one adult‐recipient case, one pediatric abstract, and one series of two children given domino left‐lateral‐lobe grafts from combined liver–intestine recipients. Index recipients consistently retained stable graft function; domino recipients were prone to biliary and vascular complications.
Conclusions
DLT from an MVT explant is feasible, including across ABO incompatibility, and can create two recipients from one donor. In our case the domino graft functioned immediately, but the recipient died from complications of her pretransplant critical illness; consistent with the literature, domino outcomes appeared to be driven more by recipient pretransplant severity than by graft quality. Standardized protocols, staged consent, and registry tracking are needed before wider adoption.