Shirini K, Kamberi SS, Muthukrishnan S
… +10 more, Alattar O, Patel R, Nieves F, Arcerito M, Alvarez-Casas J, Malik S, Shetty K, Maluf DG, Bhati C, Meier RPH
J Liver Transpl
· 2026 Feb · PMID 41716904
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Liver grafts with over 50% macrosteatosis are often deemed marginal, but organ shortages necessitate exploring their use. We conducted five transplants with deceased donor grafts containing 50%-90% macrosteatosis, ensuri...Liver grafts with over 50% macrosteatosis are often deemed marginal, but organ shortages necessitate exploring their use. We conducted five transplants with deceased donor grafts containing 50%-90% macrosteatosis, ensuring donor age <55 years, CIT ≤6 hours, and recipient laboratory MELD score ≤30. Two patients required reoperations due to thrombotic complications (acute HAT and PVT), and hospital stay ranged from 6 to 26 days. All patients survived beyond one year with functioning grafts. These findings suggest the feasibility of using high-macrosteatosis grafts in intermediate- to low-laboratory-MELD recipients, albeit with potential thrombotic risks.
Access to transportation is a key social determinant of health outcomes and a required component of liver transplant eligibility. We assessed the feasibility, acceptability, and preliminary effectiveness of a transportat...Access to transportation is a key social determinant of health outcomes and a required component of liver transplant eligibility. We assessed the feasibility, acceptability, and preliminary effectiveness of a transportation assistance program among at-risk liver transplant candidates (TAP-LT) in a pilot randomized controlled trial. Adult participants were recruited from a single urban high-volume transplant center at an initial LT evaluation clinic visit in 2022. Included participants either reported transportation barriers on a screening survey or were Medicaid-insured. Participants were randomized 1:1 to intervention (Lyft rideshares to any healthcare-related visit) or control (usual care) arms, with the study end at the time of listing decision. In all, 42 LT candidates were enrolled in the TAP-LT trial (N=21 per arm) with an 78.6% retention rate. Median age was 56 years (IQR 47-62), 61.9% were male, 85.7% Hispanic, and 81.0% had Medicaid. Nine (42.9%) of 21 intervention participants completed a Lyft ride with a median number of 8 (4-18) rides per rider; 89.6% of ordered rides were completed. At the end of the study, patient satisfaction with medical care, assessed by the RAND PSQ-18, was high in both arms. All 100% of intervention participants reported being more likely to attend medical visits because of the TAP-LT program, and there were no safety concerns. A total of 10 in the intervention versus 6 in the control arm were listed ( p =0.37); median time to waitlisting was 131 days (42-228) and did not differ by study arm ( p =0.79). Our pilot trial demonstrates Lyft rideshares to be feasible and highly acceptable to LT candidates (ClinicalTrials.gov, Number NCT05080595), supporting the conduct of a larger efficacy trial.
Liver transplantation (LT) for unresectable colorectal liver metastases (CRLM) has regained interest after the TransMet trial, which reported 5-year survival exceeding 70%. However, estimates of transplant benefit (TB) a...Liver transplantation (LT) for unresectable colorectal liver metastases (CRLM) has regained interest after the TransMet trial, which reported 5-year survival exceeding 70%. However, estimates of transplant benefit (TB) are lacking. This study provides a first external validity assessment of the TransMet criteria and estimates the 5-year TB using a real-world international cohort. A retrospective multicenter study included 61 TransMet-eligible patients with unresectable CRLM who underwent LT between 2006 and 2020 across seven centers. Matching-adjusted indirect comparisons were used to improve comparability, with sensitivity analyses on effective sample size. Survival was analyzed using Kaplan-Meier curves and restricted mean survival time up to 5 years. Weighted multivariable Cox regressions were employed to assess prognostic factors after transplantation. The 5-year restricted mean survival time was identical in the weighted cohort (effective sample size=19) and the TransMet LT arm (51.0 mo). Sensitivity analysis yielded a 5-year restricted mean survival time consistent with residual imbalance (48.2 mo, ESS=35). KRAS mutation (HR: 5.90, 95% CI: 1.89-18.4), right-sided primary tumor (HR: 4.17, 95% CI: 1.40-12.4), and female sex (HR: 5.73, 95% CI: 1.04-31.6) were associated with poorer survival; CEA≥80 ng/mL emerged as a potential prognostic factor (HR: 6.3, 95% CI: 1.73-22.6) across alternative specifications. The estimated 5-year TB of LT versus chemotherapy was 22.5 months (95% CI: 15.5-29.6). The findings of this first real-world assessment of the TransMet trial criteria and 5-year TB estimation in unresectable CRLM point to reasonable prognostic candidates and support evaluating the inclusion of CRLM in LT allocation models. We advocate expanded multicenter data to reach sufficient prognostic stratification through well-calibrated, highly discriminative studies.
Kaplan A, Klarman S, Winters A
… +11 more, Kriss M, Hughes D, Sharma P, Asrani S, Hutchison A, Myoung P, Pomposelli J, Gordon F, Duarte-Rojo A, Devuni D, Fortune B
Limited information on the business practices of liver transplant (LT) centers worldwide has been published. Characterizing this data could help identify best practices as well as opportunities for improvement. As such,...Limited information on the business practices of liver transplant (LT) centers worldwide has been published. Characterizing this data could help identify best practices as well as opportunities for improvement. As such, the International Liver Transplant Society (ILTS) Business Practice Committee conducted a global online survey of LT centers, which was sent to the ILTS membership. Questions focused on 5 main domains: transplant practice and volumes, workforce, finances, quality assessment and performance improvement, and overall program function. Data was compared across program geographic regions and transplant volume. A total of 89 discrete centers were represented, of which 76.4% were academic/university-affiliated, and about one-third each were from Europe (36.0%) and North America (31.5%). The top 3 problems programs reported were finances/funding (60.7%), adequate program support/guidance (48.3%), and transplant volumes (43.8%). In all, 59.6% of respondents felt their salary was undercompensated, consistent across geographic regions. In addition, 69.7% felt their center was not adequately funded to meet program goals, with programs in Europe (N=28/32, 87.5%) and Oceania (N=2/3, 66.7%) most impacted. Transplant surgeon retainment was noted as more difficult for lower volume programs (<50 liver transplants/year, N=13/31). Nearly half (42.7%) of all programs felt under-resourced to provide high-quality care, and the majority (80.9%) felt there was room for growth and improvement under their current model. While international concerns varied widely among LT centers, inadequate salary and center funding, low transplant and referral volumes, and staff retainment were persistent themes. Focusing on adopting region-specific best practices and developing transplant systems of care that focus on these elements is critical to provide optimal care to LT patients worldwide.
Early reoperation for bleeding after liver transplantation (ERBALT) is associated with increased morbidity and mortality. However, no reliable predictive tool is currently available. The primary aim was to evaluate the p...Early reoperation for bleeding after liver transplantation (ERBALT) is associated with increased morbidity and mortality. However, no reliable predictive tool is currently available. The primary aim was to evaluate the predictive ability of conventional coagulation tests and viscoelastic assays for identifying patients at risk of ERBALT within the first 7 days following liver transplantation (LT). A total of 275 patients who underwent LT at a tertiary center were screened in this prospective observational study. Conventional coagulation tests and viscoelastic assays were obtained at 4 time points: (1) postinduction, (2) end of the anhepatic phase, (3) 10 minutes after reperfusion (R10), and (4) 60 minutes after reperfusion (R60). Other recognized perioperative risk factors for ERBALT were recorded. A predictive score was developed based on the weighted coefficients from multivariable logistic regression. The final analysis included 222 patients, of whom 25 (11.26%) required ERBALT. These patients had more advanced liver disease (Child-Pugh score: 10 (8-11) vs. 8 (6-9), p =0.002) and required significantly higher volumes of fluids (4000 (3000-5750) mL vs. 3000 (2500-4000) mL, p =0.002) and blood products intraoperatively (80% vs. 51.3%, p =0.005). The score included R60-CTINTEM ≥230 seconds (4 points), R60-CT EXTEM ≥85 seconds (2 points); and intraoperative transfusion of ≥4 units of red blood cells (1 point) yielding a total score ranging from 0 to 7. Only 1% of patients with a score ≤3 required ERBALT, compared to 47.8% of those with a score of 7. The viscoelastic assay demonstrated strong predictive value for early reoperation for bleeding after LT. The proposed risk score could facilitate the timely correction of coagulation and potentially improve clinical outcomes after LT.
Hepatocellular carcinoma (HCC) disproportionately affects racial/ethnic minorities and socioeconomically disadvantaged populations. We assessed how race/ethnicity, insurance type, and neighborhood deprivation relate to H...Hepatocellular carcinoma (HCC) disproportionately affects racial/ethnic minorities and socioeconomically disadvantaged populations. We assessed how race/ethnicity, insurance type, and neighborhood deprivation relate to HCC stage at diagnosis, treatment receipt, and survival in an integrated health care system. We conducted a retrospective cohort study of 3441 adults diagnosed with HCC between 2006 and 2019 within Kaiser Permanente Northern California. Multivariable Cox regression models evaluated associations between race/ethnicity, insurance type, neighborhood deprivation index (NDI), and key outcomes: advanced-stage HCC (Barcelona Clinic Liver Cancer stage C), receipt of curative or any treatment, and 5-year survival. Among patients with HCC (median age 65 y; 75.0% male), 42.6% were White, 8.4% Black, 21.9% Hispanic/Latinx, and 24.6% Asian/Pacific Islander (API). Advanced-stage HCC was more common among Black (32.6%) and although HCC treated patterns did not differ by race/ethnicity, insurance type, or neighborhood deprivation index, API patients had lower odds of presenting with advanced-stage HCC (adjusted odds ratio, 0.62, 95% CI 0.48-0.81) and had better 5-year survival (adjusted hazard ratio 0.74; 95% CI 0.64-0.87) compared with White patients. Residence in a more socioeconomically deprived neighborhood was associated with worse 5-year survival (adjusted hazard ratio, 1.20; 95% CI, 1.01-1.41) relative to residence in less deprived areas. These findings highlight persistent inequities in HCC stage at diagnosis and survival, with API patients experiencing more favorable outcomes and individuals from socioeconomically deprived neighborhoods facing worse long-term survival. Efforts to reduce structural barriers and improve early detection are needed to narrow these disparities.
Watson CJE, Macdonald S, White D
… +15 more, Bridgeman C, Gaurav R, Swift L, Webster R, Iype S, Crick K, Pollok JM, Ceresa CDL, Paul S, Martin J, Upponi SS, Currie I, Foukaneli T, Kosmoliaptsis V, Butler AJ
Liver Transpl
· 2026 Jul · PMID 41631847
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Donor livers may contain occult fibrin, which is associated with adverse transplant outcomes in livers donated after brain death (DBD) and circulatory death (DCD). Ex situ normothermic machine perfusion (NMP) may allow f...Donor livers may contain occult fibrin, which is associated with adverse transplant outcomes in livers donated after brain death (DBD) and circulatory death (DCD). Ex situ normothermic machine perfusion (NMP) may allow fibrinolytic therapy before transplantation. Before undertaking a large efficacy study for the prophylaxis of cholangiopathy, we wished to assess the safety of a protocol comprising alteplase and fresh frozen plasma (FFP), the latter as a source of plasminogen, and also to ascertain which of the 4 possible treatment strategies was associated with the greatest fibrin breakdown, as judged by D-dimer release. Eighty livers, 40 DBD and 40 DCD, were randomized to 1 of 5 groups of 16 each, receiving 10 mg or 20 mg alteplase, 1 or 2 units (250 mL) of FFP, with alteplase and FFP being delivered into either the hepatic artery cannula or portal reservoir at the start of NMP. The primary endpoint was bleeding post-transplant. Forty-four of 64 treated livers were transplanted, as were 12 of the 16 control livers receiving FFP alone. There was no increase in post-implant bleeding or blood transfusion requirement of any alteplase-treated liver compared with the FFP alone control group. All 4 alteplase groups were associated with more D-dimer release than the FFP alone control group; 10 mg alteplase was as effective as 20 mg, and delivery into the portal reservoir was as effective as delivery into the hepatic artery cannula. The protocol achieving release of most D-dimers involved 10 mg alteplase being delivered directly into the portal reservoir containing 2 units of FFP. Portal delivery was found to be more straightforward than infusion into the hepatic artery cannula. The combination of alteplase with FFP appeared safe, with no bleeding complications.
Liver transplant (LT) recipients are at risk of post-transplant diabetes mellitus (PTDM), and the incidence varies by region. We explored the relationship between county-level food environment and PTDM and whether food i...Liver transplant (LT) recipients are at risk of post-transplant diabetes mellitus (PTDM), and the incidence varies by region. We explored the relationship between county-level food environment and PTDM and whether food insecurity mediates regional variation. First-time LT recipients from July 2004 to December 2022 without pre-existing diabetes were identified in the UNOS SRTR database. Data on 3 measures of healthy food access at the county level were obtained: population experiencing food insecurity, low-income population with low access to grocery stores (food deserts), and ratio of unhealthy to healthy food options (food swamps), all expressed by quartile. The primary endpoint was PTDM. Subdistribution hazard models were used to estimate associations, adjusting for demographic and clinical characteristics and county-level social vulnerability. Mediation analyses quantified the extent to which the food environment explained regional variation in PTDM. A total of 68,273 LT recipients met the inclusion criteria; 15.5% developed PTDM. All 3 food environment measures were independently associated with higher PTDM risk, even after adjustment for recipient, donor, and county-level factors. These measures were also significant mediators of regional variation in PTDM. Food insecurity mediated 48% of regional variation in PTDM, while food deserts and food swamps mediated 20% and 23%, respectively. LT recipients in counties with decreased access to healthy foods were significantly more likely to develop PTDM. Food environment accounted for a meaningful proportion of regional differences in PTDM. Identifying and addressing food insecurity among LT recipients may represent a modifiable pathway to improve long-term outcomes.