Children’s Surgeons Perform World’s Youngest Domino Liver Transplant

ATLANTA (October 6, 2025) - Surgeons at Children's Healthcare of Atlanta performed what is believed to be the world's youngest domino liver transplant (DLT), a procedure in which a patient with a metabolic disease receives a donor liver, while their native liver is transplanted into another patient without the metabolic disease but who has end-stage liver disease. Without the metabolic disorder, the healthy liver functions normally in the organ recipient. Dr. Bhargava Mullapudi, the surgical director of abdominal transplant at Children's, and Dr. Richard Hendrickson, pediatric surgeon, performed this ground-breaking transplant. Drs. Mullapudi and Hendrickson are two of the few physicians in the country dually-trained in pediatric surgery and transplant surgery with specialization in complex tumor removals. This is the third domino transplant conducted at Children's, but the first in which both patients were receiving care at Children's.

Patient A, age two, was diagnosed at birth with a rare, metabolic genetic disorder that prevents the liver from processing certain proteins, leading to a lifetime of complications. To correct this disorder, Patient A underwent a liver transplant. The original liver was then transplanted into Patient B, age one, who suffered from a rare, potentially fatal, liver disease. In a DLT, Patient A's donated liver functions normally in Patient B due to the lack of the genetic defect causing the metabolic disorder. Patient B now has a normal, healthy liver. The entire process took nearly 24 hours.

"A domino liver transplant is a very intricate and complex procedure involving careful coordination," said Dr. Mullapudi. "Our teams recognized both patients were in our care at the same time and were similar in size. DLTs in such small patients can be technically challenging due to the size of the blood vessels. We worked meticulously to manage these simultaneous transplants to help both patients have the best possible outcomes."

DLTs are rare, with approximately 185 performed in the U.S. between 1996 and 2020. However, according to physicians, the relatively new procedure allows for an increase in livers available for transplantation, shortening the wait on the transplant list by alleviating the crisis of the lack of healthy organs.

"We're proud to be on the leading edge of this new treatment path for patients with metabolic conditions and end-stage liver disease," said Dr. Hendrickson. "Our teams continue to work hard and creatively to try to provide the best care for our patients to live long and healthy lives."

Both pediatric patients were cared for by hepatologists, anesthesiologists and intensive care doctors at Children's to help them fully recover after a complex operation. While they will need to take various anti-rejection and immunosuppressant medications, they are expected to live their lives free of liver disease.

The Children's multidisciplinary liver transplant team provides full pre-, peri-, and post-transplant services and has performed more than 660 liver transplants since the program's inception in 1988. Recently the team has begun to utilize donor-derived cell-free DNA testing for noninvasive transplant surveillance, which allows them to detect early warning signs of rejection, reducing the number of biopsies for patients.