Living donor liver transplantation (LDLT) requires rigorous donor selection to ensure safety; however, high donor ineligibility rates remain a major challenge. Evidence regarding stage-specific patterns of donor exclusion within structured evaluation pathways is limited. This study aimed to describe the stage-wise distribution of exclusion reasons among potential living liver donors within a structured evaluation pathway.

This retrospective observational study included consecutive potential living liver donors evaluated at a public-sector transplant center in Pakistan between May 2016 and December 2024. Donors underwent a standardized three-step evaluation protocol. Ineligibility factors were grouped as psychosocial, clinical, liver-related, ethical/legal, and radiological. Associations between factor groups and evaluation stage were assessed using the chi-square test and Cramer’s V.

Of 469 evaluated donors, 292 (62.3%) were ineligible. Exclusions occurred in step-1 in 161 (55.1%), step-2 in 104 (35.7%), and step-3 in 27 (9.2%) donors. Liver-related factors predominated in step-1 (73.9%; Cramer’s V = 0.689; p < 0.001), whereas radiological factors were the leading cause of step-2 exclusion (77.9%; Cramer’s V = 0.799; p < 0.001). Psychosocial and clinical factors were more frequent in step-3.

Donor ineligibility in LDLT demonstrates distinct stage-wise patterns within a structured evaluation pathway. These findings provide a process-level understanding of how exclusion reasons are distributed across evaluation stages.