A review conducted by Andrea Peloso and colleagues from University Hospitals of Geneva, Geneva University Hospital, accepted on December 12, 2025, in Hepatobiliary & Pancreatic Diseases International, analyzes the role of imaging in deceased and living liver donors. The article, published June 22, highlights how pre-retrieval imaging can improve graft selection, operative planning, and transplant outcomes.
The review examines the challenges faced during liver transplantation decision-making. In deceased donation cases, teams must quickly determine if a liver is suitable for transplantation while assessing fat accumulation and vascular anatomy that could affect procurement or implantation. For living donations, accurate estimation of graft and remnant liver volume as well as identification of biliary variants are crucial to reduce postoperative complications. While biopsy remains an important tool for assessment, it is invasive and time-consuming.
Peloso and colleagues found that each imaging modality presents distinct advantages and limitations. Ultrasound is described as accessible and inexpensive, but its accuracy may be limited by operator skill or patient factors such as obesity or mild steatosis. Computed tomography provides fast assessment of hepatic steatosis with high specificity using attenuation-based measures like Hounsfield units; however, borderline cases may still require biopsy confirmation. Magnetic resonance imaging offers the most accurate non-invasive quantification of liver fat, but its cost and limited availability restrict routine use in deceased donors. For vascular mapping, computed tomography angiography effectively identifies most clinically relevant arterial and portal venous variants. In living donor procedures, CT or MRI-based volumetry generally provides sufficient accuracy for planning surgeries, while magnetic resonance cholangiopancreatography helps identify biliary anatomy but still requires intraoperative confirmation.
According to the authors, "the evidence points to a practical change in how transplant imaging should be understood." They said that rather than being just a preoperative checklist item, imaging can serve as a framework connecting graft quality with surgical feasibility and recipient risk management strategies. Future improvements will depend on standardized protocols across centers along with better alignment between radiological findings, histology results, and intraoperative observations.
The review concludes that improved reliability in donor imaging could help expand the pool of usable organs without compromising safety standards at transplant centers. More dependable modalities might allow identification of grafts previously declined while guiding higher-risk organs toward additional testing or alternative preservation techniques such as machine perfusion. For living donors specifically, enhanced volumetric analysis could support safer individualized surgery plans. The authors suggest further validation studies are needed before radiomics- or artificial intelligence-based tools can become trusted aids in real-world clinical settings.
