Multiple bile ducts (MBDs) in liver grafts present a significant risk for biliary complications (BCs) following living donor liver transplantation (LDLT). However, a standardized approach for managing these cases remains...Multiple bile ducts (MBDs) in liver grafts present a significant risk for biliary complications (BCs) following living donor liver transplantation (LDLT). However, a standardized approach for managing these cases remains unclear. We aim to evaluate various biliary reconstruction procedures and identify the most effective strategies for minimizing complications. We conducted a retrospective analysis of 1780 microsurgical biliary reconstructions in LDLT between 2006 and 2022. Outcomes were assessed based on the conduit used and anastomotic techniques, focusing on duct-to-duct reconstructions and duct-to-jejunum (D-J) anastomoses. Technical refinements, including biliary stent insertion, ipsilateral bile duct anastomosis, figure-of-8 suturing over the junction of anastomosis, and centralization anastomosis for size discrepancies, were applied. Among the 1780 LDLTs, 23.1% have MBDs. The BC rate for single bile ducts was 11.2% (131/1169), while MBDs had 14.7% (58/394). BLs were significantly higher in MBD grafts compared with single bile ducts (6.1% vs. 2.1%, p =0.001), with no significant difference in stricture formation ( p =0.76). In adult LDLT using right lobe graft, the 2-to-2 duct-to-duct reconstructions had the highest BC rate of 16.6% (25/150), while D-J anastomoses with 2-to-2 configuration had the lowest BC rate of 0% (0/21). Overall, there were significantly higher BCs among duct-to-duct than D-J anastomoses (12.5% vs 2.6%, p =0.001) in adult LDLT using right lobe graft. D-J anastomoses offer a viable alternative with fewer complications for MBDs. Tailored strategies and technical refinements can mitigate the complications associated with MBD reconstruction.
Liver transplantation (LT) in critically ill patients with chronic liver disease is a high-risk procedure. Recent studies show that the frequency of intensive care unit (ICU) LTs has risen, and outcomes of such transplan...Liver transplantation (LT) in critically ill patients with chronic liver disease is a high-risk procedure. Recent studies show that the frequency of intensive care unit (ICU) LTs has risen, and outcomes of such transplants have improved significantly. Variation in practices and the impact of center experience with ICU LTs on outcomes is unknown outside of acute liver failure (ALF). This study evaluated the impact of center experience with ICU LT on outcome metrics. Using the United Network for Organ Sharing database, we conducted a retrospective analysis of adult liver transplants performed 2014-2023 in which the patient was in an ICU before transplant, excluding those listed for multiorgan, retransplant, or ALF. Critical care requirements, in-hospital, 1-year, and 3-year mortality, and retransplant were compared by center ICU LT volume quartiles. In total, 9542 ICU LTs were performed across 130 centers (12.8% of total LTs). Over half of U.S. centers performed fewer than 5 ICU LTs per year on average, while the centers in the highest quartile performed nearly two-thirds of all ICU LTs in this period. Utilization of dialysis and of concurrent critical care therapies in ICU LT recipients was higher at high-volume centers ( p <0.05). In-hospital, 1-year, and 3-year mortality for ICU LTs overall were 6.2%, 10.4%, and 23.1%, respectively, with no differences across center volume quartiles (all p >0.05). Adjusting for severity of illness, center volume of ICU LTs in the prior year was associated with a small but significant reduction in 1-year post-ICU LT mortality: aOR 0.96 per 5 ICU LTs ( p <0.001). Expansion of LT for ICU candidates does not appear to threaten center-based metrics and may even offer important benefits to future candidates.
Early allograft failure (EAF) after living donor liver transplantation (LDLT) remains a clinical challenge. Existing prediction models developed for deceased donor transplantation poorly apply to LDLT due to distinct sur...Early allograft failure (EAF) after living donor liver transplantation (LDLT) remains a clinical challenge. Existing prediction models developed for deceased donor transplantation poorly apply to LDLT due to distinct surgical and physiological factors. This study identifies clinical determinants of EAF and develops an LDLT-specific prediction model. We conducted a multicenter retrospective cohort study from 17 high-volume LDLT centers (January 2016-December 2020) with external validation at a tertiary center in Saudi Arabia (January 2015-December 2022). The primary outcome was EAF (graft loss or patient death ≤90 d). Multivariable mixed-effects logistic regression identified preoperative/intraoperative risk factors. The EAGLE-LDLT model was constructed using postoperative laboratory values. Performance was compared against established models (EAD, MEAF, A2ALL) using ROC analysis and decision curve analysis. The development cohort included 2944 adult LDLT recipients (67.7% male; median age 55 y; median MELD 14) with a 5.5% EAF rate. External validation included 1020 recipients (median MELD 21, 6.7% EAF). Independent risk factors for EAF were MELD (OR 1.06, 95% CI 1.04-1.08), donor BMI (OR 1.05, 95% CI 1.00-1.10), portal vein thrombosis (OR 1.73, 95% CI 1.13-2.63), and hepaticojejunostomy (OR 1.58, 95% CI 1.06-2.36). The EAGLE-LDLT model incorporating peak ALT (>468 U/L), peak INR (>1.9), and bilirubin (>3.5 mg/dL) and INR (>1.3) at POD7, demonstrated superior discrimination (AUC=0.81) compared with MEAF (AUC=0.77, p =0.004), EAD (AUC=0.67, p <0.001), and A2ALL (AUC=0.65, p <0.001). EAGLE-LDLT achieved balanced sensitivity (75.0%) and specificity (73.7%), effectively stratifying patients into high-risk (15% of patients; 40.4% EAF incidence) and low-risk groups. Preoperative and intraoperative clinical factors predict EAF in LDLT. The EAGLE-LDLT model accurately identifies LDLT recipients at the highest risk for EAF postoperatively.
Hepatocellular carcinoma (HCC) is a cancer of older adults, yet the extent to which age versus comorbidity burden drives outcomes is underexplored. Understanding this distinction is critical to avoid both under-treatment...Hepatocellular carcinoma (HCC) is a cancer of older adults, yet the extent to which age versus comorbidity burden drives outcomes is underexplored. Understanding this distinction is critical to avoid both under-treatment and over-treatment in older adults with HCC. Adult patients with a diagnosis of HCC or cirrhosis were identified from the National Inpatient Sample, years 2016-2018. Age was categorized as <45, 45-64, 65-74, and ≥75 years. Comorbidity burden was assessed with the Hospital Frailty Risk Score (HFRS). Nested multivariable logistic regression models were used to examine the effect of comorbidity adjustment on the association between age and in-hospital mortality, stratifying by HCC status. Among 426,633 patients, 26,653 (6.2%) had HCC, and 5.9% died in the hospital. Comorbidity burden varied significantly by age, with HCC patients ≥65 years having a more than 2-fold increased prevalence of comorbidities such as coronary artery disease and heart failure ( p <0.001 for each). Among patients with HCC, age was associated with in-hospital mortality in unadjusted models (Age 45-64 y: OR=1.35; 95% CI: 1.02, 1.78; p =0.04; Age 65-74 y: OR=1.32, 95% CI: 1.00, 1.74; p =0.048). Adjustment for HFRS attenuated the association between age and in-hospital mortality such that it was no longer significant. In contrast, HFRS remained associated with mortality in fully adjusted models; each point increase in HFRS was associated with a 15% increased odds of in-hospital mortality (95% CI: 1.14, 1.16; p <0.001). Among a nationally representative cohort of hospitalized patients with HCC, comorbidity burden-not chronological age-was associated with in-hospital mortality. These findings highlight the importance of considering measures of physiologic reserve when engaging in treatment decision-making in patients with HCC, and moving beyond a focus on chronologic age as a predictor of outcomes.
Living donor liver transplantation (LDLT) is an established therapy with curative intent for pediatric and adult patients with acute liver failure and end-stage liver disease. Donor safety remains paramount and commences...Living donor liver transplantation (LDLT) is an established therapy with curative intent for pediatric and adult patients with acute liver failure and end-stage liver disease. Donor safety remains paramount and commences during preoperative evaluation and assessment. Given the importance of the topic, the International Liver Transplantation Society and International Living Donor Liver Transplantation Group consensus conference on Living Liver Donor Safety was convened in March 2025 (Toronto, Canada). Recommendations were based on the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system for assessment of recommendations, and the Danish model of consensus was followed. This report presents 28 recommendations from the working group focused on addressing clinically relevant questions related to the preoperative aspects of living donor safety including assessment of donor acceptability (age, body mass index and hepatic steatosis; medical conditions and contraindications), medical and surgical workup (liver function and procoagulant workup; anatomical considerations and safe remnant), and psychosocial evaluation (timing and team; underlying conditions; non-directed, paired, and anonymous directed donors; urgent living donor workups for acute liver failure).
The success of living donor liver transplantation (LDLT) has bridged the growing gap between organ demand and availability in patients with liver failure or liver cancer. Safety of the living liver donor (LLD) is paramou...The success of living donor liver transplantation (LDLT) has bridged the growing gap between organ demand and availability in patients with liver failure or liver cancer. Safety of the living liver donor (LLD) is paramount, and astute intraoperative management plays a critical role in ensuring optimal outcomes for them. Given that intraoperative surgical and anesthesia practices vary widely across centers, the International Liver Transplantation Society (ILTS) and the International Living Donor Liver Transplantation Group (iLDLT Group) convened a global consensus conference in Toronto in March 2025 to develop guidelines for intraoperative management of the LLD. This manuscript details the recommendations on intraoperative considerations for the safety of LLD developed by Working Group II of the Consensus Scientific Committee, using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system for assessment of recommendations, and the Danish model of consensus. Working Group II focused on intraoperative monitoring, fluid and ventilation strategies, surgical techniques for vascular and biliary division, surgeon and center-specific experience, and intraoperative crises planning. These guidelines aim to support both established and emerging LDLT teams to ensure high-quality and safe intraoperative care for the LLD.
Wilson EA, Khan MQ, Kyaw AMM
… +14 more, Magistri P, Tejedor M, Kathirvel M, Moral K, Shankar S, Mao S, Alconchel F, Di Maira T, Mathew JS, Patel MS, Syn N, Chadha R, Hakeem AR, Rammohan A
The 2025 Annual Congress of the International Liver Transplantation Society (ILTS), themed " Advancing Liver Transplantation: Embracing Innovation for the Future ," was held from May 28 to 31 in Singapore. The meeting of...The 2025 Annual Congress of the International Liver Transplantation Society (ILTS), themed " Advancing Liver Transplantation: Embracing Innovation for the Future ," was held from May 28 to 31 in Singapore. The meeting offered a comprehensive scientific program, featuring 92 sessions and 7 pre-congress workshops spanning living donor liver transplantation, advanced surgery, anesthesia and critical care, transplant oncology and immunology, basic science, pediatrics, and more. The program emphasized collaboration and innovation to advance patient outcomes in liver transplantation. In this report, the ILTS Vanguard Committee summarizes the key proceedings of the congress.
Bridging and downstaging are indications for locoregional therapy (LRT) in hepatocellular carcinoma (HCC) within the context of liver transplantation (LT). Stereotactic body radiation therapy (SBRT) is an emerging LRT mo...Bridging and downstaging are indications for locoregional therapy (LRT) in hepatocellular carcinoma (HCC) within the context of liver transplantation (LT). Stereotactic body radiation therapy (SBRT) is an emerging LRT modality in these settings. We conducted a systematic review and meta-analysis to assess the efficacy and safety of SBRT as bridging or downstaging therapy. A comprehensive search of PubMed, Embase, and Cochrane Library was performed through July 21, 2025. We included randomized and non-randomized studies evaluating SBRT in LT candidates or potential candidates with HCC, reporting outcomes such as radiologic or pathologic response, overall/disease-free survival, waitlist dropout, pre-LT/post-LT mortality, recurrence, adverse events, radiation-induced liver disease, fibrosis at LT, and liver function decline. Single-arm meta-analyses using random-effects models were performed to estimate pooled proportions with 95% CIs. Risk of bias was assessed using the MINORS tool. Nineteen studies (664 lesions in 476 patients; 381 underwent LT) were included. SBRT demonstrated favorable radiological and pathological response rates when used as bridging or downstaging therapy in liver transplant candidates with HCC, with a pooled radiological objective response (CR + PR) of 61.2% and pathological response of 83.8%. The 5-year overall survival and disease-free survival rates were 76.8% and 71.3%, respectively. Adverse events were infrequent, with grade ≥3 toxicities occurring in only 1.2% of patients. Subgroup analysis restricted to bridging-only studies yielded comparable trends. SBRT is a safe and effective bridging or downstaging therapy for HCC patients awaiting LT.
Vissa A, Far AT, Lai JC
… +3 more, Mehta NJ, Kolli KP, Ge J
Liver Transpl
· 2025 Dec · PMID 41452149
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TIPS is commonly used to treat complications of portal hypertension. Hernia incarceration is a complication of the TIPS procedure that is poorly understood and not well documented. We examine this complication in a large...TIPS is commonly used to treat complications of portal hypertension. Hernia incarceration is a complication of the TIPS procedure that is poorly understood and not well documented. We examine this complication in a large, single-center cohort of TIPS patients and compared it to a cohort of patients with refractory ascites managed with serial large-volume paracentesis alone to determine whether TIPS itself increases incarceration risk. We identified 259 adults who underwent TIPS and 644 adults with refractory ascites managed with serial large-volume paracentesis at the University of California, San Francisco (UCSF) between 2015 and 2024. We extracted structured variables and unstructured documentation from the UCSF Clinical Data Warehouse. We used OpenAI's GPT-4o, a large language model, and manual chart review to identify post-TIPS hernia incarceration and clinical information from unstructured notes. We calculated time to events and used LASSO-Cox regression to identify risk factors associated with incarceration. Of 259 patients, 12.7% (33) developed post-TIPS incarceration with a median time to event of 31 days (IQR: 10-109). In comparison, only 0.9% (6/644) of large-volume paracentesis patients developed hernia incarceration. Within the TIPS cohort, patients with hernia incarcerations were more likely to have existing umbilical hernias (87.9% vs. 29.2%, p <0.01) and higher serum albumin (3.2 vs. 2.8 g/dL, p <0.01) compared to those without incarceration. Multivariate Least Absolute Shrinkage and Selection Operator-Cox regression showed the presence of an umbilical hernia pre-TIPS (HR=3.1, 95% CI: 1.8-5.4, p <0.01), serum creatinine at TIPS (HR=1.3, 95% CI: 1.0_1.6, p =0.04), serum albumin at TIPS (HR=1.7, 95% CI: 1.0-2.8, p =0.04) were predictors of post-TIPS incarcerated hernia development. In the incarcerated hernia group, 36.4% underwent hernia repair at a median of 0.5 days (IQR: 0-259), 18.2% received liver transplant at 55 days (IQR: 6-152), and 24.2% died at 422 days (IQR: 261-747), all measured from the time of incarceration diagnosis. Of the patients who did not develop incarcerated hernias, 6.2% underwent hernia repair (for non-incarcerated hernias), 23.0% received a transplant, and 16.4% died after TIPS. Kaplan-Meier analysis showed no significant difference in mortality between the incarceration and no-incarceration group (2-y probability of 13.7% vs. 12.8%, log rank p =0.32). In sensitivity analyses including abdominal binder use, post-TIPS abdominal binder (HR=3.1, 95% CI: 1.7-5.6, p <0.01) and pre-TIPS umbilical hernia (HR=2.8, 95% CI: 1.6-4.9, p <0.01) remained significant predictors, while serum creatinine dropped out as a significant variable, suggesting binder use may be a marker of ascites or hernia severity. TIPS substantially increases hernia incarceration risk compared to serial paracentesis alone, with 12.7% of patients in this single-center cohort developing incarceration at a median of 1 month after TIPS. The presence of a known umbilical hernia prior to TIPS had the strongest association with this complication. Serum creatinine and albumin association also suggests ascites severity as a contributor. Identifying pre-TIPS risk factors could facilitate the development of targeted strategies to mitigate post-TIPS complications.
Kim A, Li L, Hamraz R
… +13 more, Nguyen M, Razzaq R, Patel V, Asgharpour A, Yakubu I, Garland L, Parmar K, Muthiah M, Lim WH, Ng CH, Patel S, Siddiqui MS, Bui AT
A better understanding of weight trajectories in liver transplant (LT) recipients is essential to improving clinical outcomes. We utilized Generative Artificial Intelligence (GenAI) to identify and visualize factors that...A better understanding of weight trajectories in liver transplant (LT) recipients is essential to improving clinical outcomes. We utilized Generative Artificial Intelligence (GenAI) to identify and visualize factors that exist but are not observable (latent factors or LF) that result from limitations in current knowledge or statistical approaches to model weight in LT recipients. Using GenAI, weight trajectories were modeled in 562 adult LT recipients with available weight data up to 36 months post-LT. Each weight trajectory was treated as an 8-dimensional vector (defined as time at LT to 3, 6, 9, …, 36 mo) to convert longitudinal weight data into cross-sectional data. Multivariate analyses were performed to determine the relationship between latent factors governing weight trajectories and clinical parameters. Two discernable patterns, or LF 1 and LF 2 , were identified from the GenAI model to incorporate individual patient trajectories that explained 99% of the weight after LT. Each patient's weight trajectory, thus, represented the combination of the LF 1 and LF 2 . LF 1 , the dominant latent factor, demonstrated rapid weight flux early after transplant (<12 mo), followed by gradual persistent weight gain for 36 months. LF 2 was less prevalent and demonstrated 2 distinct trajectories: (A) initial weight gain in the first 12 months followed by weight loss and weight stabilization by 24-30 months, and (B) initial weight loss followed by rapid and continued weight gain after the first 12 months post-LT. In multivariate analysis, MASH cirrhosis and male gender were the strongest clinical predictors of future weight gain. Using a novel statistical approach (GenAI), we identified key weight gain trajectories in LT recipients to be incorporated into clinical practice for risk stratification and mitigation.