Living Donor Training During ASTS Fellowship: Disparities in Autonomy Between Kidney and Liver Donation. A National...

Living donor transplantation should be a cornerstone for kidney and liver transplant surgeons. However, achieving technical independence, especially in living donor liver transplantation (LDLT), remains a challenge. This survey evaluates the experiences and barriers faced during the American Society of Transplant Surgeons (ASTS) Fellowship Program and proposes solutions to improve autonomy in living donor transplantation.

A 93-item questionnaire was distributed via LimeSurvey to former ASTS Fellows, gathering demographic information, training experiences, and autonomy levels in living donor kidney (LDKT) and liver transplantation (LDLT) after the two-year fellowship. Responses were received from 95 participants. We performed descriptive analyses and exploratory paired comparisons between LDKT and LDLT domains.

A total of 95 former fellows initiated the survey; 41 (43.6%) completed all items and were included in the analyses. The survey revealed significant differences in independence levels between LDKT and LDLT. While 82.9% of fellows felt very or completely confident in LDKT, only 29.2% felt similarly for LDLT (p < 0.001). A majority (90.2%) believed the ASTS fellowship structure enabled independence in LDKT, but only 9.7% thought the same for LDLT (p < 0.001). Robust training in LDKT was reported, with 63.4% of fellows achieving independence in donor nephrectomy, compared to only 14.6% in donor hepatectomy (p < 0.001). Fellows performed a median of 30 living donor nephrectomies as primary surgeons, but only 4 hepatectomies during the fellowship (p < 0.0001). Low LDLT case volumes, lack of structured curricula, and limited opportunities to act as primary surgeons were key barriers. 68.3% felt fully or mostly prepared to lead a living donor programme in LDKT, compared to 7.3% in LDLT (p < 0.0001).

The ASTS fellowship provides an excellent foundation for LDKT, fostering independence in laparoscopic and robotic approaches. However, independence in LDLT remains difficult to achieve under the current structure. Solutions include formalized curricula, mandated primary surgeon roles in LDLT procedures, and double-console robotic systems for guided learning. Addressing these gaps is essential to prepare future transplant surgeons for the increasing demands of living donor transplantation programs.