Scaravilli V, Bosone M, Turconi G
… +12 more, Bonetti C, Cappelli F, Cirillo G, Di Pellegrino S, Ferrari F, Colombo SM, Lozio F, Caccamo L, Castellano G, Dondossola DE, Zanella A, Grasselli G
Acute kidney injury (AKI) is common after liver transplantation, but difficult to diagnose with serum creatinine and urinary output. This study evaluated the early risk stratification capability of urinary tissue inhibit...Acute kidney injury (AKI) is common after liver transplantation, but difficult to diagnose with serum creatinine and urinary output. This study evaluated the early risk stratification capability of urinary tissue inhibitor of metalloproteinases-2 and insulin-like growth factor binding protein-7 (u[TIMP-2]*[IGFBP-7]) in a prospective adult liver transplantation cohort. u[TIMP-2]*[IGFBP-7] was measured 6 and 36 hours after graft reperfusion, with AKI and acute kidney disease diagnosed according to KDIGO and ADQI criteria at 7-day and 90-day windows. Subclinical AKI was defined as u[TIMP-2]*[IGFBP-7] >0.30 without clinical AKI. Among 78 included patients, AKI occurred in 45% (10.3%, 11.7%, and 23.4% for stages 1, 2, and 3). At 6 hours, 46% had u[TIMP-2]*[IGFBP-7] >0.30, predicting AKI (stage ≥1) with an OR of 3.23 ( p =0.01); at 36 hours, 37% had u[TIMP-2]*[IGFBP-7] >0.30, predicting stage 3 AKI with an OR of 4.22 ( p =0.009). Serum creatinine/urinary output criteria predicted AKI only in 10% and 18% at 6 and 36 hours, respectively. Subclinical patients with AKI (24%) had higher risks of acute kidney disease (42% vs. 26%), early allograft dysfunction (32% vs. 18%), graft loss (16% vs. 4%), and longer intensive care unit stays. u[TIMP-2]*[IGFBP-7] is a valuable biomarker for early AKI risk stratification after liver transplantation, with subclinical AKI representing a distinct, clinically relevant phenotype.
To compare perioperative and long-term graft and patient survival of liver retransplantation using static cold storage (SCS) and machine perfusion. We queried the UNOS database from 2018 to 2024 to analyze patients under...To compare perioperative and long-term graft and patient survival of liver retransplantation using static cold storage (SCS) and machine perfusion. We queried the UNOS database from 2018 to 2024 to analyze patients undergoing adult liver retransplantation alone. Logistic regression analyses were conducted for early graft loss (EGL), perioperative mortality at 30 and 90 days, and 1-year mortality. We identified 1754 liver retransplants, of which 100 were performed using machine perfusion. Median recipient age in the machine perfusion group was 54.0. Logistic regression analysis demonstrated a 79.0% decrease in 30-day EGL ( p =0.02, OR 0.211) with improved 30-day and 90-day mortality by 77.0% and 66.0%, respectively ( p =0.03, OR 0.233, p =0.03, OR 0.343). SCS was associated with 69% increased risk of 1-year mortality ( p =0.01, OR, 0.306). Liver retransplantation outcomes are superior when machine perfusion preservation is used compared with SCS. Machine perfusion should be considered in all cases undergoing liver retransplantation.
In 2019, the United Network for Organ Sharing (UNOS) policy for patients with hilar cholangiocarcinoma (hCCA) changed from granting a MELD exception score of 22 with 10% escalation every 3 months to a median MELD at tran...In 2019, the United Network for Organ Sharing (UNOS) policy for patients with hilar cholangiocarcinoma (hCCA) changed from granting a MELD exception score of 22 with 10% escalation every 3 months to a median MELD at transplant minus three (MMaT-3) without escalation, after completion of an approved neoadjuvant protocol. Using the UNOS registry, we compared waitlist and post-transplant outcomes in hCCA patients who received exception points in the pre-MMaT (October 1, 2015-November 15, 2018) and the MMaT eras (May 15, 2019-July 1, 2022). We also compared these outcomes to those of propensity-matched HCC patients. Our study demonstrated that the probability of liver transplant (LT) significantly increased in hCCA patients during the MMaT era. One-year LT probability rose from 56.0% to 73.6% ( p <0.001), and 3-year LT probability improved from 72.1% to 79.6% ( p <0.001). Furthermore, waitlist mortality also dropped, with 3-year waitlist mortality decreasing from 26.6% to 17.6% ( p =0.04). Post-transplant survival remained unchanged in both eras. Compared with HCC patients, hCCA patients in the pre-MMaT era had lower LT probability (1-year: 56.0% vs. 75.0%, 3-year: 72.1% vs. 82.1%; p <0.001) and higher waitlist mortality (3-year dropout: 26.6% vs. 13.1%; p <0.001). Conversely, in the MMaT era, hCCA patients had a similar LT probability to HCC patients. However, although significantly improved, waitlist mortality remained higher in hCCA patients compared with HCC patients (3-year dropout: 17.6% vs. 14.%; p =0.02). Under the MMaT policy, hCCA patients have improved access to LT with improved waitlist survival.
Socioeconomic status (SES) is a well-established determinant of liver transplantation (LT) outcomes, but prior studies have treated SES as a static baseline attribute, assessed only at fixed milestones such as 1- or 5-ye...Socioeconomic status (SES) is a well-established determinant of liver transplantation (LT) outcomes, but prior studies have treated SES as a static baseline attribute, assessed only at fixed milestones such as 1- or 5-year mortality. Although the existing body of work has established the importance of SES in post-transplant care, this approach overlooks the dynamic and time-sensitive nature of socioeconomic risk across the recovery trajectory, potentially missing critical details that could inform timely and targeted interventions. Using the United Network for Organ Sharing registry, we analyzed 105,907 adult recipients of LT from 2005 to 2022. Follow-up was divided into 4 intervals defined using sliding-window and time-varying Cox analyses to detect the earliest onset of ZIP code-level median household income and Social Deprivation Index (SDI) effects on survival. Interval-specific clinical, surgical, and demographic covariates were selected using least absolute shrinkage and selection operator regression, and income and SDI quartiles were incorporated separately into multivariable Cox models with time-varying covariates to assess independent associations with mortality. During the immediate and early postdischarge periods, neither income nor SDI was independently associated with mortality. Beginning at 4-12 months, higher SDI was significantly associated with increased mortality (HR: 1.12, 95% CI: 1.02-1.23), with the effects intensifying over time (time-varying HR: 1.38, 95% CI: 1.10-1.73). Income-related disparities emerged later, becoming significant during long-term follow-up beyond 1 year, when lower income quartiles were independently associated with excess mortality (lowest quartile: HR: 1.17, 95% CI: 1.11-1.24). These findings demonstrate that socioeconomic vulnerability after LT is not fixed but evolves over time. This study introduces a time-resolved framework that identifies when SES factors first become consequential, highlighting actionable windows for targeted interventions to reduce inequities in post-transplant care.
Román-Calleja BM, Ruiz-Margain A, Duarte-Rojo A
… +8 more, Flores-Silva F, Martinez-Cabrera CF, Gutiérrez-Rosas LE, Valencia-Peña BA, Cantú-Brito C, Chalasani N, Aguilar-Salinas CA, Macías-Rodríguez RU
Physical exercise improves liver and body composition markers in metabolic dysfunction-associated fatty liver disease (MASLD), but its effects on cerebral hemodynamics and cognitive function in patients with MASLD remain...Physical exercise improves liver and body composition markers in metabolic dysfunction-associated fatty liver disease (MASLD), but its effects on cerebral hemodynamics and cognitive function in patients with MASLD remain unexplored. We aimed to evaluate the effect of a monitored 16-week exercise intervention on cerebral hemodynamics and cognitive function in patients with MASLD. In this randomized clinical trial, 40 obese patients with MASLD were randomized to either a control group (n=20) on a caloric restriction diet, or an intervention group (n=20) receiving diet plus exercise. The exercise intervention consisted of gradual increases in daily steps and resistance training. Both groups also received monthly classic literature readings to ensure comparable cognitive engagement throughout the study. Transcranial Doppler ultrasound and neurocognitive tests were assessed as primary outcomes. Secondary outcomes included body composition and liver disease parameters. Participants were 60% female, with a mean age of 47±8 years. Intervention adherence was >80%. Daily steps doubled in the intervention group (from 5178 to 10,161; p <0.001) with no changes in controls. The intervention group showed an 8.4% reduction in peripheral arterial stiffness ( p =0.002), 10.4% reduction in resistance index ( p <0.001), and 19.2% decrease in pulsatility index ( p <0.001) with no significant changes in controls. Cognitive function improved in the intervention group, with a 5.9% increase in MoCA score ( p =0.005) and 6.6% increase in Addenbrooke score ( p <0.001). Both groups showed a significant reduction in BMI and body fat percentage (-5.2% and 10.5% intervention, vs. -2.7% and 3.8% in controls). A structured, monitored exercise program improves cerebral hemodynamics, arterial stiffness, and cognitive function in patients with MASLD (NCT05520697).
Geographic variation in liver transplant access in the United States has spurred interest in spatial accessibility to care. There is currently no consensus about which measure should be used for spatial accessibility. We...Geographic variation in liver transplant access in the United States has spurred interest in spatial accessibility to care. There is currently no consensus about which measure should be used for spatial accessibility. We used 2015-2022 data from the Scientific Registry of Transplant Recipients and the National Center for Health Statistics to calculate county listing-to-death ratios (LDRs) for liver transplants. We used a 2-step floating catchment area approach to define a novel measure of spatial accessibility (Spatial Accessibility Ratio, SPAR). We compared this measure to other accessibility measures using generalized linear models and Vuong's non-nested hypothesis test. Across 3108 included counties, SPAR ranged from 0.56 to 9.98; 29% of counties and 65% of the population had a SPAR ≥1 (mean or better accessibility to liver transplant). SPAR outperformed distance ( p <0.001), rurality ( p <0.001), and healthcare resource-based measures ( p <0.001) in predicting population-based transplant access; SPAR remained significantly associated with LDR after adjustment for other county-level factors. Sensitivity analyses revealed that the association between SPAR and LDR was modified by socioeconomic characteristics and geographic region. This measure may be used in future research on spatial accessibility, including developing interventions to improve access to liver transplant for patients in low-accessibility areas.
Liver Transpl
· 2026 Apr · PMID 41150867
·
Full text
The 2025 International Liver Transplantation Society (ILTS) Congress, held in Singapore, brought together a global, multidisciplinary community to explore innovations and persistent challenges in liver transplantation (L...The 2025 International Liver Transplantation Society (ILTS) Congress, held in Singapore, brought together a global, multidisciplinary community to explore innovations and persistent challenges in liver transplantation (LT). The congress included seven pre-congress workshops, 92 scientific sessions, and featured 270 expert speakers. More than 1100 participants from 71 countries took part in the event. A new focus was the growing importance of strategic leadership and financial governance in sustaining and expanding liver transplant programs. A series of presentations, symposiums, and workshops focused on leadership and financial governance brought together clinical and administrative leaders to explore the operational frameworks and economic strategies critical to the long-term sustainability of liver transplant programs. Discussions emphasized the need for robust reimbursement models, clear cost-effectiveness frameworks, and integration of emerging technologies into diverse healthcare systems.
The controlled attenuation parameter (CAP), derived from ultrasound-based transient elastography, is a useful tool for noninvasive assessment of hepatic steatosis. However, its prognostic significance for graft outcomes...The controlled attenuation parameter (CAP), derived from ultrasound-based transient elastography, is a useful tool for noninvasive assessment of hepatic steatosis. However, its prognostic significance for graft outcomes in living donor liver transplantation (LDLT) has not been examined. This study aimed to investigate the predictive value of CAP measurements in estimating the risk of graft failure in LDLT recipients. We retrospectively analyzed 146 adult-to-adult LDLT procedures performed at our transplant center between January 2014 and June 2024. Graft survival was assessed using multivariate Cox regression models stratified by graft-to-recipient weight ratio (GRWR), using 0.8% as the standard cutoff. There was a positive correlation between CAP values and histological grades of graft steatosis. Among recipients with GRWR ≥0.8% (n=66), CAP was not significantly associated with graft survival. In contrast, among recipients with GRWR <0.8% (n=80), higher CAP values were independently associated with worse graft survival ( p =0.04), along with donor age ( p =0.02). Among recipients with GRWR <0.8%, the median CAP values in those who developed grade A or B small-for-size syndrome (SFSS) were significantly higher than those who did not develop SFSS ( p =0.04 and p =0.03, respectively). Furthermore, graft survival outcomes were significantly differentiated by CAP value, even within histological grade 0 donor livers. In conclusion, higher CAP values were associated with increased risk of SFSS and graft failure in LDLT recipients with GRWR <0.8%. Incorporating CAP into graft selection and pretransplant risk assessment may improve recipient outcomes, particularly when using small grafts in LDLT.
Yodoshi T, Stunguris J, De Angelis M
… +13 more, Van Roestel K, Hensley J, Avitzur Y, Bandsma RHJ, Jones N, Kamath B, Miserachs M, Wiggins C, Selzner N, Ghanekar A, Cattral M, Sayed BA, Ng VL
Living donor liver transplantation (LDLT) confers the best survival to children with end-stage liver disease, yet racial and socioeconomic barriers often preclude access to a biologically or emotionally related donor. An...Living donor liver transplantation (LDLT) confers the best survival to children with end-stage liver disease, yet racial and socioeconomic barriers often preclude access to a biologically or emotionally related donor. Anonymous nondirected LDLT (A-LDLT), whereby altruistic strangers donate, could close this gap and diminish reliance on deceased-donor LT (DDLT), but its equity and efficacy have not been fully quantified. We therefore analyzed all 422 consecutive pediatric liver transplants at a large Canadian center from January 2005 to March 2023. In this retrospective cohort study, we compared recipient demographics, clinical characteristics, waitlist duration, and survival outcomes across A-LDLT (n=62), directed living donor liver transplantation (n=174), and DDLT (n=186) groups. Children who underwent A-LDLT were disproportionately Black or Indigenous, more often lived in single-parent households, and more frequently spoke a non-English primary language, indicating that anonymous donation reached sociodemographically disadvantaged groups. After adjusting for age, diagnosis, era, and pediatric end-stage liver disease/MELD score, median wait time for cholestatic disease was 104 days with A-LDLT versus 138 days with DDLT-a 20% reduction-while operative complexity, vascular or biliary complication rates, and intensive-care stay were comparable to directed LDLT. One-, 5-, and 10-year patient survival rates after A-LDLT were 100%, 98% and 98%, respectively, mirroring directed living donor liver transplantation and exceeding DDLT (96%, 94%, and 93%). Graft survival showed the same pattern. Integrating anonymous nondirected donors enlarges the living donor pool, decreases time to transplantation for vulnerable children, and preserves the superior long-term outcomes achieved with living donor organs. Embedding A-LDLT alongside DDLT can reduce disparities and enable timely, life-saving transplantation for children without directed donors while maintaining the advantages associated with living donor grafts.
Færden IH, Bliksøen MM, Liavåg OM
… +11 more, Hou J, Majeed WM, Torp MK, Reims HM, Lindholm E, Porte RJ, Tønnessen TI, Line PD, Strand-Amundsen R, Hagness M, Pischke SE
The global shortage of donor livers has led to an increased reliance on extended-criteria donor livers, including those from donors after circulatory death. Utilizing marginal livers necessitates distinguishing between i...The global shortage of donor livers has led to an increased reliance on extended-criteria donor livers, including those from donors after circulatory death. Utilizing marginal livers necessitates distinguishing between injured but recoverable livers and those that are irreversibly damaged. Bile duct injury, prevalent in these grafts, poses significant risks, as ischemic injuries can be challenging to assess and may lead to recipient bile duct strictures and ultimately graft failure. This study aimed to identify objective measurements that enhance existing viability criteria and facilitate the diagnosis of ischemic injuries. We employed ex situ machine perfusion (MP) to monitor porcine livers subjected to standardized biliary injury (BileINJ), standardized global liver injury (GlobalINJ), and no injury (CTRL, total n=23). Using microdialysis catheters and pCO 2 sensors, we analyzed liver tissue, hilar plate, and bile duct, in addition to standard viability assessments, collecting data on 77 variables. Principal component analysis indicated distinct clustering of the GlobalINJ and partially the BileINJ group away from the CTRL group during MP. Feature extraction models highlighted microdialysate lactate, lactate/pyruvate ratio, glycerol, tissue pCO 2 , and blood gas hematocrit as critical indicators for classifying liver state. Histopathological evaluations confirmed group-specific liver and bile injuries. We identified unique metabolic patterns that differentiate ischemically injured from non-injured porcine livers and were able to distinguish liver and biliary injury. Real-time monitoring of livers using microdialysis and tissue pCO 2 during MP is feasible and clinically available. Measurements taken in the hilar plate show the ability to identify bile duct damage while not introducing measurement devices to the vulnerable bile duct itself. Our findings enable more objective and timely selection of transplantable livers and warrant further investigation in clinical studies.
Gong S, Ma L, Wang B
… +3 more, Zhou S, Xia Q, Feng M
Liver Transpl
· 2026 Apr · PMID 41104546
·
Full text
The objective of this study was to assess the safety and feasibility of duct-to-duct anastomosis (DDA) in pediatric liver transplantation with left-sided grafts. The Roux-en-Y hepaticojejunostomy (HJ) represents the gold...The objective of this study was to assess the safety and feasibility of duct-to-duct anastomosis (DDA) in pediatric liver transplantation with left-sided grafts. The Roux-en-Y hepaticojejunostomy (HJ) represents the gold standard for biliary reconstruction in pediatric liver transplantation. Nevertheless, the feasibility of DDA in pediatric liver transplantation remains a topic of contention and is a relatively limited technique. A total of 3307 pediatric recipients who underwent LT at Renji Hospital between October 2006 and October 2023 were enrolled in the study. Of these, 218 underwent DDA with high hilar dissection and patch anastomosis, in accordance with a prospective protocol. A comprehensive analysis was conducted to determine the risk factors for exclusion from DDA and the outcomes of recipients of DDA. The mean operative time was significantly shorter in the DDA group (DDA vs. HJ=6.5 h vs. 7.0 h, p <0.001). A minimum of 1 year of follow-up revealed that biliary complications occurred in 8 cases of recipients of DDA (3.7%) and 1 case of a recipient of HJ (1.6%), with no statistically significant difference ( p =0.69). No significant difference was observed in mortality between the DDA and HJ groups (DDA vs. HJ=1.8% vs. 1.6%, p >0.99). The graft survival rates at 1 and 3 years after DDA were 98.2% and 96.8%, respectively. However, patients with Langerhans cell histiocytosis may be unsuitable candidates for DDA due to their elevated rates of DDA exclusion and biliary complications. Appropriate learning and decision-making processes ensure the safety and feasibility of DDA, with excellent perioperative and long-term outcomes. It is therefore recommended that DDA should be considered the first choice for biliary reconstruction in eligible pediatric patients of transplant.