Connor AA, Hobeika MJ, Semaan S
… +20 more, Sengupta U, Rizk E, Lindberg SA, Mobley CM, Cheah YL, Simon CJ, Schroder P, Baio F, Sanghvi M, Liu H, Moore LW, Patel KA, Todd J, Victor DW, Kodali S, Basra T, Jones-Pauley MR, Gaber AO, Saharia A, Ghobrial RM
Portable normothermic machine perfusion (pNMP) may improve outcomes of liver transplantation (LT) compared to static cold storage (SCS), though variables associated with outcomes in pNMP compared with SCS remain unclear....Portable normothermic machine perfusion (pNMP) may improve outcomes of liver transplantation (LT) compared to static cold storage (SCS), though variables associated with outcomes in pNMP compared with SCS remain unclear. This single-center, retrospective study reports outcomes of LTs from donation after brain death (DBD) and donation after circulatory death (DCD) grafts by preservation type (pNMP vs. SCS) between January 2015 and December 2024. During the study period, 1723 LTs were performed on 1652 patients, including 1202 DBD SCS, 373 DBD pNMP, 41 DCD SCS, and 107 DCD pNMP grafts. Graft survival (GS) probabilities at 1 and 3 years were 88.1% (95% CI: 86.6-89.7) and 79.4% (77.3%-81.5%) overall, 88.4% and 80% for DBD SCS, 87.6% and 78% for DBD pNMP, 80.5% and 60.7% for DCD SCS, and 90.3% and 82.3% for DCD pNMP, respectively. In univariable, both with and without matching (pNMP vs. SCS), and multivariable models, DCD SCS had worse GS compared with DBD SCS, DBD pNMP, and DCD pNMP, which did not significantly differ. GS for pNMP grafts (n=407 LTs) was negatively associated with recipient MELD, liver cancer diagnosis, and lower median hepatic artery flow on pump, but not with bile production and lactate values. However, in addition to these parameters, GS for SCS grafts (n=1180 LTs) was also negatively associated with DCD donors, total preservation time, and recipient age at transplant. Overall, this study demonstrates improved GS and marginal donor utilization, and an increased number of critical recipients associated with pNMP use compared to SCS use, enabling longer preservation time and functional assessment of grafts via hepatic artery flow.
Bedoyan SM, Whitehead BA, Mysore KR
… +6 more, Anderson SG, Mitchell J, Anand R, Squires JE, Chapin CA, Society of Pediatric Liver Transplantation (SPLIT)
Liver transplantation (LT) is the standard of care for children with end-stage liver disease, but waitlist mortality remains high, especially among infants. ABO-incompatible (ABO-I) LT offers a strategy to expand the don...Liver transplantation (LT) is the standard of care for children with end-stage liver disease, but waitlist mortality remains high, especially among infants. ABO-incompatible (ABO-I) LT offers a strategy to expand the donor pool, though concerns over antibody-mediated rejection have limited widespread use. We analyzed outcomes of recipients of ABO-I LT using the Society of Pediatric Liver Transplantation (SPLIT) registry from 2011 to 2022, a prospective, multicenter database capturing over 75% of pediatric LTs in the United States and Canada. Clinical characteristics, posttransplant complications, and graft and patient survival were compared between matched ABO-I and ABO-compatible (ABO-C) recipients. Recipients of ABO-I transplant were matched 1:5 with recipients of ABO-C using year of transplant, age, and clinical status at the time of transplant. A center-level survey assessed institutional practices regarding ABO-I LT. Among 3372 pediatric recipients of LT, 155 received ABO-I grafts and were matched to 775 recipients of ABO-C grafts. Recipients of ABO-I had higher rates of ventilator support, parenteral nutrition, and ICU care at the time of transplant compared with recipients of ABO-C. There was no statistically significant difference in 3-year graft (87.8% vs. 92.6%, p =0.06) or patient survival (93.9% vs. 96.6%, p =0.11) between ABO-I and ABO-C groups. In children ≤2 years of age, there was a higher incidence of early portal venous thrombosis in the ABO-I group (8.5% vs. 3.7%, p =0.025). Survey responses revealed substantial variability in center ABO-I eligibility criteria, desensitization protocols, and immunosuppressive strategies. Outcomes for pediatric recipients of ABO-I and ABO-C LT within the SPLIT registry are comparable, supporting broader implementation of ABO-I LT to reduce pediatric waitlist mortality. Variability in institutional practices underscores the need for prospective studies to inform standardized protocols and optimize outcomes.
The Dallas consensus conference on liver transplantation for alcohol-associated hepatitis (2020) provided a framework for the selection of liver transplant candidates with alcohol-associated liver disease (ALD) regardles...The Dallas consensus conference on liver transplantation for alcohol-associated hepatitis (2020) provided a framework for the selection of liver transplant candidates with alcohol-associated liver disease (ALD) regardless of sobriety period. The primary aim of this study is to describe our experience with the implementation of this approach to a broader population with ALD. We established a new interdisciplinary ALD clinic in a large integrated health care system in Texas for expedited assessment for liver transplant (LT) candidacy. Candidates who had short sobriety were mandated to follow this pathway. Selected patients were seen through a structured interdisciplinary clinic pathway before and after transplantation with an ALD hepatologist, surgeon, coordinator, and transplant psychologist. Between 2021 and 2024, 114 patients [MELD 25 (21-28), 47% female] were referred to the ALD clinic. Alcohol use disorder (AUD) and mental health-related comorbid conditions were high. Overall, 97 (85%) were willing to participate in AUD counseling and mental health evaluation, and attendance with the ALD clinic was high (78%). The most common form of treatment preference was outpatient peer support groups (81%) and individual therapy (50%). Among the referrals, 23% were denied LT candidacy; 12% died during their evaluation, and 50% were approved to proceed to LT evaluation. Among LT candidates, 13% clinically improved to the point where they no longer required LT, and 32% patients received a LT. In intent-to-treat analysis, survival at 1 year was similar for patients who were referred to the ALD clinic as compared with ALD patients referred to the overall transplant program through the traditional mechanisms (89.5 vs. 82.9, p =0.22). There were no deaths related to alcohol use. Relapse to alcohol use occurred in 6 patients (16%); 4 were defined as slips, and 2 had sustained alcohol use; relapse rates were similar to non-ALD clinic patients ( p =0.258). Successful early LT assessment can be achieved in the setting of a structured pathway with excellent survival and low rates of relapse. Patients are adherent to recommendations and actively engage before and after LT once the appropriate programmatic structure is created.
Medina-Morales E, Shah Y, Xynogala A
… +11 more, Trivedi HD, Ochoa-Allemant P, Saberi B, Bonder A, Tafesh Z, Amin A, Lingiah V, Niazi M, Gaglio PJ, Paterno F, Lunsford KE
In 2022, the United Network for Organ Sharing (UNOS) revised the liver transplant allocation policy to calculate the median MELD at Transplant minus 3 points (MMaT-3) around the donor hospital instead of the transplant c...In 2022, the United Network for Organ Sharing (UNOS) revised the liver transplant allocation policy to calculate the median MELD at Transplant minus 3 points (MMaT-3) around the donor hospital instead of the transplant center, aiming to reduce disparities among MELD exception candidates. We evaluated the impact of this revised policy on waitlist outcomes in patients with or without hepatocellular carcinoma (HCC). Using the OPTN/UNOS registry, we identified all adult transplant candidates between October 8, 2015, and March 31, 2024, and stratified by policy eras: Pre-MMaT-3 (n=25,580), MMaT-3 Recipient (n=13,311), and MMaT-3 Donor (n=10,027). Fine-Gray competing risk models were performed to estimate waitlist removal due to dropout (death or removal due to clinical deterioration), due to clinical improvement, or transplantation by HCC status. During Pre-MMaT-3, candidates with HCC had a significantly higher probability of transplant than those without HCC [adjusted subdistribution hazard ratio (aSHR) 2.03, 95% CI: 1.95-2.12, p <0.001]. This advantage declined in the MMaT-3 Recipient era (aSHR 1.39, 95% CI: 1.31-1.47, p <0.001) and disappeared in the MMaT-3 Donor era (aSHR 0.98, 95% CI: 0.88-1.09, p =0.73). Waitlist dropout, initially similar for HCC candidates than non-HCC (aSHR 0.93, 95% CI: 0.86-1.01, p =0.08), increased following MMaT-3 Recipient (aSHR 1.21, 95% CI: 1.07-1.36, p =0.01) and Donor (aSHR 2.06, 95% CI: 1.64-2.60, p <0.001) eras. Importantly, within-HCC cohort, waitlist mortality analysis improved after the MMaT-3 Donor era ( aSHR 0.79, p =0.01), while maintaining reduced wait times and stable transplant rates. The MMaT-3 Donor policy effectively deprioritized HCC for transplantation, while improving waitlist mortality within the HCC group. Ongoing evaluation is essential to guide equitable liver allocation.
Multi-listing (ML) increases the odds of transplantation compared with single-center listing. However, not all patients have equivalent access to ML. The recent allocation policy change prioritized distance from the dono...Multi-listing (ML) increases the odds of transplantation compared with single-center listing. However, not all patients have equivalent access to ML. The recent allocation policy change prioritized distance from the donor hospital in an attempt to decrease geographic disparities. This study assessed access to liver transplant (LT) given ML practices before and after the acuity circles policy change. United Network for Organ Sharing data were queried for LTs between January 1, 2016, and November 1, 2024. Patients were grouped by listing at one versus multiple centers and by acuity circle era (ACE). Cohort characteristics and comparisons were described using chi-square and Wilcoxon rank tests. Multivariable logistic regressions and propensity score match (PSM) were performed to assess associations between ML and LT. The final cohort consisted of 105,030 patients; 4084 (3.9%) were multi-listed. Racial/ethnic minority groups, less educated, and publicly insured candidates were less often multi-listed. ML was positively associated with LT in all analyses (overall: OR=1.180, p <0.001; PSM: OR=1.164, p =0.001; pre-ACE: OR=1.127, p =0.015; post-ACE: OR=1.218, p <0.001). Education, race/ethnicity, and insurance type were also associated with LT across all analyses. ML patients were more often transplanted at their primary center with a significant increase in primary center LT post-ACE (53.4% vs. 63.4%, p <0.001). ML and LT had a positive correlation. There was a negative association between minority groups and ML as well as LT. Although acuity circles decreased geographic disparities, they did not change ML accessibility across candidates.
Recompensation is emerging as a concrete outcome for patients with effective disease-modifying treatments for cirrhosis. Delisting due to clinical improvement (DCI) from the liver transplant (LT) waitlist may serve as a...Recompensation is emerging as a concrete outcome for patients with effective disease-modifying treatments for cirrhosis. Delisting due to clinical improvement (DCI) from the liver transplant (LT) waitlist may serve as a proxy for recompensation. This study investigated factors associated with time on the waitlist and risk of relisting. This was a retrospective cohort study of patients listed for LT between January 1, 2005, and December 12, 2024, using the Organ Procurement and Transplantation Network (OPTN) database. Timing of DCI was categorized as: <1 year, 1-3 years, and ≥3 years. Of 127,168 patients, 6.9% achieved DCI. The proportion of patients experiencing DCI was highest for hepatitis B virus (9.9%), alcohol-associated liver disease (8.3%), and autoimmune hepatitis (8.2%). Median time to DCI was 2.5 years: 19% were delisted in <1 year, 39% in 1-3 years, and 42% in ≥3 years. Among patients waitlisted as Child-Turcotte-Pugh (CTP) class B or C, only 40.6% improved to CTP A at DCI. Relisting after DCI occurred in 9.6%, with 33% of these driven by hepatocellular carcinoma. In multivariable analysis, only patients with both MELD score improvement ≥3 points and CTP class improvement had significantly lower relisting risk after DCI (adjusted HR 0.52; p <0.001), but not those meeting either criterion individually. Additional relisting predictors included albumin <3.5 g/dL at DCI, male sex, and cirrhosis etiology (all p <0.001). The occurrence of DCI is variable across disease etiologies. Achieving combined improvement in MELD and CTP class may better identify durable clinical improvement and guide safe waitlist removal decisions.
Thirty-day readmission after liver transplantation (LT) is a key quality metric associated with early morbidity, increased healthcare utilization, and worse long-term outcomes. Most reported readmission rates range from...Thirty-day readmission after liver transplantation (LT) is a key quality metric associated with early morbidity, increased healthcare utilization, and worse long-term outcomes. Most reported readmission rates range from 25-46%, yet predictors remain inconsistently defined due to reliance on administrative data or single-center cohorts. We performed a retrospective cohort study of adult deceased donor LT recipients in the prospectively-collected American College of Surgeons National Surgical Quality Improvement Program-Transplant (TransQIP) registry from 3/2017 to 12/2019. The primary outcome was unplanned hospital readmission within 30 days of discharge. We characterized the incidence, timing, and causes of readmission and identified independent predictors. Multivariable logistic regression was used to identify independent predictors of readmission. Among 1,164 recipients, 497 were readmitted within 30 days (43%). 30-day readmissions were typically brief, with a median length of stay of 4 days (IQR 2-8). LT-specific procedural interventions occurred in 147 readmitted patients (29.6%), indicating that most readmissions were driven by non-procedural medical complications. In multivariable analysis, post-discharge organ-space surgical site infection (OR 61.0, 95% CI 8.2-458, p <0.001), post-discharge sepsis (OR 9.9, 95% CI 1.1-91, p =0.047), and post-discharge urinary tract infection (OR 4.7, 95% CI 1.7-13.0, p =0.030) were the strongest predictors of readmission. Protective factors included functional status ≥70% (OR 0.74, 95% CI 0.56-0.97, p =0.030). Exploratory analyses identified distinct risk profiles for post-discharge UTI and organ-space SSI. Thirty-day readmission after LT is common, occurs early after discharge, and is driven by post-discharge infectious complications, specifically UTI and organ space SSI. Functional status is independently protective. These findings highlight actionable targets to reduce early readmissions after liver transplantation.
Liver transplantation (LT) has transformed the prognosis of patients with end-stage liver disease and hepatocellular carcinoma, offering excellent long-term survival. However, post-transplant outcomes can be jeopardized...Liver transplantation (LT) has transformed the prognosis of patients with end-stage liver disease and hepatocellular carcinoma, offering excellent long-term survival. However, post-transplant outcomes can be jeopardized by allograft rejection and by recurrent or de novo liver disease, which may progress to graft fibrosis, cirrhosis, and liver-related complications. Noninvasive tests (NITs) have emerged as powerful tools for evaluating steatosis, fibrosis, and portal hypertension in native liver disease, but their optimal role after LT remains uncertain and variably defined. In this review, we summarize the current evidence regarding the performance of NITs for the assessment of graft fibrosis, steatosis, and portal hypertension in the post-transplant setting, contextualizing well-established principles regarding NITs derived from native liver disease within the post-LT setting, where NITs may have additional and still underexplored potential. We aim to provide a practical, clinically oriented use of NITs in routine post-LT care, enabling earlier detection of complications and more personalized graft monitoring.
Living donor liver transplantation (LDLT) reduces wait‑list mortality in children, but its long‑term advantages over deceased donor liver transplantation (DDLT) and how socioeconomic context shapes outcomes in a universa...Living donor liver transplantation (LDLT) reduces wait‑list mortality in children, but its long‑term advantages over deceased donor liver transplantation (DDLT) and how socioeconomic context shapes outcomes in a universal healthcare system remain uncertain. We compared long‑term outcomes after pediatric LDLT versus DDLT and evaluated modification by socioeconomic status (SES). We linked clinical data for pediatric liver transplants in Ontario, Canada, from 1991 to 2021 to provincial health administrative data, yielding 449 recipients (189 LDLT, 260 DDLT) who underwent their first transplant. Over the 30-year period, LDLT recipients had superior patient and graft survival. After adjustment, DDLT was associated with a higher risk of mortality [adjusted hazard ratio (aHR) 2.1, 95% CI 1.0-4.3], graft failure (aHR 2.1, 95% CI 1.0-4.3), and chronic kidney disease (adjusted subdistribution HR 5.3, 95% CI 1.4-15.3), compared with LDLT. SES profoundly modified long-term outcomes: among DDLT recipients, lower neighborhood income and higher material deprivation were strongly linked to worse survival and increased graft loss. In contrast, LDLT moderated these socioeconomic disadvantages, with recipients showing comparable outcomes regardless of their SES ( p for interaction <0.01). In this population-based cohort study, LDLT was associated with significantly better long-term patient and graft survival and a lower risk of chronic kidney disease compared with DDLT. Socioeconomic disadvantage negatively impacted outcomes primarily among DDLT recipients, highlighting the need to improve equitable access to LDLT and to strengthen targeted post-transplant support for socioeconomically vulnerable families.