Living & Giving
University Health Doctors Perform Nation’s First Seven-Pair Living Donor Liver Transplant
By Nick Blevins
Dr. Tarunjeet Klair, MD, University Health System’s Surgical Director of the Living Donor Liver Transplant program
In April 2026, Dr. Tarunjeet Klair, MD, surgical director of University Health System’s Living Donor Liver Transplant program and his team became responsible for successfully completing the largest living donor liver transplant chain to date in the country, granting seven recipients a renewed lease on life, and seven donors the opportunity to enact one of the most profoundly empathetic gestures of altruism a human can perform. The high degree of complex medical expertise and time-sensitive logistical coordination involved secured more time, not only for the donors and recipients, but for all those who come after, by advancing our capabilities in taking back control over our health; right here in San Antonio.
Scene In SA spoke with the good doctor to understand some of the intricacies behind this monumental achievement, as well as Dr. Klair’s experiences and thoughts on the field today.
This interview has been edited for clarity.
First, what is a living donor liver transplant?
In a living donor liver transplant, we remove either the right lobe of the liver or the left lobe of the liver. We can also donate a smaller part of the liver called the left lateral segment if the recipient is a baby. In our program here at University Health, we have a living donor liver transplant program for all age groups, starting from infancy to adulthood. We have the whole range of living donor transplants available.
Now, if it is an adult donating to an adult — which is the most common variant — we can remove as much as 70% of the liver, as long as the liver is healthy enough. That's why we have a slew of testing that is performed. As long as the liver is healthy enough, the liver cells, called hepatocytes, start the regeneration process about 24 hours after the surgery. The process is so rapid that one cell becomes two, two becomes four; it's a process called hyperplasia of the liver.
The remaining liver that's left behind in the donor would double its size in about two to three weeks after donation. The process of regeneration is the most rapid in the first couple of weeks. In fact, the liver function in the donor returns back to its baseline about 14 days after the donation process.
That is the scientific basis of doing living donor transplantation. If the liver did not regenerate, we would not be able to do living donor liver transplantation. Usually by about six to twelve months after the donation process, the liver has reached at least 80% of its original size, if not larger. As long as the donor's liver is healthy, they will always achieve this.
This is an operation that's been around for more than 30 years. 1000s of living donor liver transplants have been completed worldwide in multiple different countries, and now we have data from 1000s of cases re-demonstrating the safety and efficacy of the procedure.
So, is there an infinite supply of livers?
First of all, not every liver transplant center in the country can perform a living donor transplant. It is something a minority of centers have the ability of performing. The surgical skill set, the infrastructure, the support services, and the logistics that are needed to perform living donor liver transplantation are quite separate from that of a deceased donor liver transplant center.
We have a system in place where the donors can apply through an online portal. Our team reviews their applications, then we bring them in for a thorough evaluation. If everything is found suitable by the committee, then we move forward and perform the transplant. This is a very coordinated process, and a very expedited process, so that no time is wasted. We have dedicated people working on this, which leads us to being one of the largest volume living donor programs in the country, with one of the best outcomes.
Dr. Klair, center, and his team at work (courtesy University Health)
Congratulations on your team’s incredible achievement: the seven-pair living donor liver transplant.
What we did was a seven-way liver pair exchange. Paired exchanges are basically modalities where incompatible donors are able to still get their recipients transplanted by switching with another pair. Typically, those occur in a "two-by-two" format, which means two donors, two recipients. That's the most straightforward way of doing a paired exchange.
Say there are seven different pairs out there, and they cannot directly donate; the donors cannot donate to the recipients. In this particular circumstance, we were able to arrange a sequence of events where all seven of those donors were able to move forward with donation, not directly to the recipients, but through a chain — through a paired exchange — and those seven recipients who would have otherwise not received a transplant were able to get a life-saving transplant.
Our center did the first liver paired exchange in the United States in 2019, and those were the simple two-by-two formats. Over the last few years, we have become more experienced, more sophisticated, and I've been able to do these pairs with increasing frequency — and with more pairs involved.
You're setting up this framework that efficiently maximizes donations.
Who knows in the absence of a paired exchange how long they would have had to wait? Some may have never received one, and some would have had to wait on the deceased donor wait list, for years, potentially. Some people even lose their life while waiting. Doing the seven-way paired exchange significantly compressed the timeline in which [our patients] were able to receive a life-saving transplant.
How do you encourage people to undergo liver donation surgery?
Dr. Klair and team, behind the donors and recipients involved in the seven-pair living donor liver transplant (courtesy University Health)
[Champion for Life is] a very valuable [donor advocate] program, because as you would imagine, if somebody was a recipient who was in need of a life-saving transplant, it would not be easy to communicate that to your loved ones, to be your donors. After all, it's asking somebody to make a huge sacrifice from their daily life. Even though living donor liver transplants have now been around for more than 30 years — it is a very well established and standardized surgery — at the end of the day, a healthy person is coming forward, undergoing a major operation; it's a huge sacrifice. That is not an easy ask for a recipient to make of somebody in their community, or even outside of their community.
I think this program has been hugely successful because altruistic people, people who would like to help others, exist in our communities. It's just about getting the message to them, and the Champion for Life program enables recipients of different personality types to overcome their hesitation and get the message out. That allows us to get the donors in, and we take it from there.
Do you find that there are folks out there who may be hesitant to donate simply because they don't understand how it works?
Definitely. First of all, there is some misinformation also out there, and there is some information that is a decade old in its accuracy.
Previously, the surgeries carried a bit higher risk, and they were done with the open technique, where the donors receive a relatively larger incision on their abdomen to undergo the donation. Over the last year and a half, our center has adopted the robot-assisted donor hepatectomy, where we are now able to do donation surgeries using the da Vinci robotic surgical system. This allows us to make much smaller incisions in the donor, which translates to a better recovery for the donor. Not only that, but because of our experience, the complication rate in the donors is very low.
If this type of information is accurately presented, a lot more people would be interested. That's why one of our big jobs is to get the right information to the referring doctors and the community: what does this surgery look like in 2026? What are the outcomes? What is it that you're able to do?
So, yes, I do think there is hesitancy, because not only are the patient population not fully informed, a lot of people in the healthcare sector also don't really know about living donor liver transplantation. If you’re a doctor and you weren’t trained in a center that did living donor transplantation, you wouldn’t really know about that; and if you don't know about it, it's hard to talk to your patients about it. That's why it’s on us as those who are in this field, to not only help the patients, but also help our colleagues catch up with the information.
Have you seen an increased interest in living donor transplants?
I think it varies depending on which part of the country you are in, and which hospital you get referred to. If you were referred to our hospital in our program, we would be really encouraging living donor transplantation, because we have it available. We know we can do it well. We have the right tools, the right team, and we have excellent outcomes for both the donors and the recipients. Unfortunately, living donor liver transplantation is not widely available in the country. If you end up going to a center where they don't have living donor transplantation, you will not be offered that modality, so there’s a bit of a geographical variation.
I've noticed that there is an increasing interest in living donor transplantation across multiple centers in the country. Every year we are seeing a slight increase in the national volumes. I have colleagues across the country who have shown a lot of interest, and have spoken to other centers regarding the best way to start and run a successful program.
I can imagine that with your team's recent success, you would have other health systems reaching out. Is that happening? With a system so rooted in communication, networking, and plugging disparate pieces together, do you foresee a greater reach for this specific program?
I think so, and I hope so. Over the last many years, we have been starting to get a lot of inquiries from donors and recipients outside of our catchment area. We've had patients from bigger cities in Texas, and sometimes outside of our state, reach out to us because of our expertise in this surgery, and they've traveled all the way over here to get their surgeries done.
I would like that to become more prominent, because I feel that we have the ability to help a greater number of people. We are working with our marketing team to spread the message about our abilities to the other bigger cities in Texas and beyond. Other centers have also reached out to us, centers in Dallas and Houston have referred patients to us for living donor transplantation, which they found too complex to do. Because of our experience, we've now performed more than 500 living donor liver transplants in this center. I think only two other centers in the country historically have performed a greater number. So, because of our experience, we do get patients referred from other centers to us. Patients try to find us online or through social media to get referred to us. But I feel that we can grow that. I feel that the word needs to get to a greater number of people, because there's still a fair number of people who are suffering because of lack of transplantation. I feel if they knew about living donor transplantation and if they knew about the current data, about the outcomes in the donors and the recipients, they would be a lot more interested in pursuing this modality.
Photo by Bethany Castro
What is your perspective on the state of the field?
There have been a lot of developments in the last couple of years that have advanced the field of liver transplantation, but all the modalities need to move forward — not just one — because what may work for one patient may not work for the other.
Some of the modalities in deceased donor liver transplantation that have carried the field forward significantly are the newer pumps that are out there. Now, we can put the livers removed from deceased donors on pumps, which have the ability of preserving the livers for a longer period of time, and sometimes, making livers that were not so good for transplant being good enough for transplant.
We have also increased the number of liver transplants through what we call donation after cardiac death.
There’s liver transplantation that is also a curative modality for certain cancers; liver cancer, for example, for which it was around for quite some time, but now with newer medications and technologies, we are able to help patients who have a much more advanced stage of the cancer. Because of newer immunotherapy modalities and local regional treatments, these people can become eligible for liver transplantation.
Some patients with colon cancer, where the cancer has spread to the liver, can also be eligible for liver transplantation, and we offer that here in our center. We also offer liver transplantation for bile duct cancer. In the last couple of years, we’ve been able to help people who are challenged with very high amounts of obesity. People who were previously declined for liver transplantation because of challenges with their weight have now been able to receive a combined living donor liver transplantation with bariatric surgery.
You might have heard about sleeve gastrectomy, or “sleeve surgeries”. We've now performed a pilot series of eight such surgeries, combining the sleeve gastrectomies with living donor liver transplantation. We have embarked on what we call the “metabolic optimization program” for patients with fatty liver disease or obesity, who have had challenges in obtaining liver transplants, to find a way to optimize their health to allow for liver transplantation.
The field is growing in multiple different areas, whether it be in cancer, metabolic, machine profusion, donation after cardiac death, or robotics. Each one of those modalities has been adopted here at University Health. We have physician champions, and others, who are championing these areas, and we are really excited because I think if we continue to embrace all these areas, we'll be able to stay competitive in helping our patients.
How would one initiate the process of donation?
Individuals who are considering liver donation — whether it’s for a given recipient, or to somebody on the waitlist, which we call “anonymous non-directed donors” — are Good Samaritans who are helping somebody in need. Any type of donor can feel free to apply.
Once an application is submitted online, our coordinators will reach out to provide a thorough education about this procedure, so that the individual can figure out whether it's the right thing for them to do or not. It is a safe and effective procedure, but it is not a minor thing. It’s a major abdominal surgery, done with a robot-assisted technique. It has excellent outcomes, but it has to be done in a person of sound body and mind, because the health and safety of the donors is our number one priority.
Now, there are donors and recipients I know in other centers across the state and the country, who might have been declined for a living donor liver transplantation. Because this modality is not so frequently available, I encourage such pairs to contact us for a second opinion. We are able to offer transplantation, even when they've been declined at another center.
We can offer a second opinion purely through a virtual visit. Donors and recipients can send us their records online, and we can do the visit without having them come in person. We don't want people to just get declined and not seek a second opinion.
You're extremely busy saving lives.
When I started here in 2016, we were doing five living donor liver transplants a year. Now, it's closer to 80; this year we'll probably do 200.
The program has become busier, because for every patient that we transplant, we probably receive 10 referrals. The beautiful part of this field though, is that even though we are very busy, the satisfaction at the end of the day is so huge that it makes up for all the work.
The team has doubled in numbers since I joined. We have a lot of young, talented surgeons who've joined in the last four years. That is key, because this is a team sport. Even though I'm sitting in front of you talking about the program, there are other really amazing people who are working on it, day in and day out. We divide and conquer our responsibilities, and that's the way to do it. Younger surgeons are doing more work. They're learning the newer technologies. Someday, they will be taking the torch forward.
I think by building the team and the infrastructure, we've been able to do more and more. We don't want our workforce to be a limitation for our patients. So, as we've seen the program grow, we are trying to grow the infrastructure to catch up with the work that we’re doing and the volumes that we’re able to maintain. ■
It’s a big decision, with a huge impact. If you or somebody you know are interested in becoming a donor, please visit universityhealth.com/services/transplant-care/living-donation
If you know the perfect advocate for someone in need of a transplant — or if that advocate is you — check University Health’s Champion for Life program at universityhealth.com/services/transplant-care/living-donation/champion-for-life
