Living donor liver transplantation (LDLT) is a life-saving procedure for patients with end-stage liver disease. As its use expands worldwide, ensuring the safety and well-being of live liver donors (LLD) is of paramount...Living donor liver transplantation (LDLT) is a life-saving procedure for patients with end-stage liver disease. As its use expands worldwide, ensuring the safety and well-being of live liver donors (LLD) is of paramount importance. Published evidence on early postoperative complications after living donor hepatectomy-those occurring within 90 days of surgery-is limited, and standardized postoperative care protocols are lacking. The International Liver Transplantation Society (ILTS) and the International Living Donor Liver Transplantation Group (iLDLT Group) convened a consensus conference in Toronto in March 2025 to develop guidelines for the safe care of the LLDs. This manuscript details the recommendations on early postoperative considerations for the safety of LLDs developed by Working Group III (WGIII) 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. WGIII addressed four key areas: (1) standardized postoperative care, (2) early biliary complications, (3) early postoperative liver dysfunction, and (4) early postdischarge follow-up. This report emphasizes the need for vigilant postoperative monitoring in specialized units, with access to experienced providers and defined clinical pathways. Structured clinical and psychosocial follow-up protocols, perioperative prophylaxis for surgical site infections and venous thromboembolism, and management of early biliary and vascular complications are discussed. These may help standardize care, reduce complications and improve short-term outcomes in LLDs.
Living liver donation is a critical component for addressing organ shortage and improving outcomes for patients with end-stage liver disease. As the prevalence of living donor liver transplantation (LDLT) increases world...Living liver donation is a critical component for addressing organ shortage and improving outcomes for patients with end-stage liver disease. As the prevalence of living donor liver transplantation (LDLT) increases worldwide, understanding and optimizing long-term donor health is paramount. The 2025 International Liver Transplantation Society and International Living Donor Liver Transplantation Society (ILTS-iLDLT) Consensus Conference convened experts in the field of liver transplantation to establish evidence-based guidelines focused on the long-term medical, psychological, and social considerations following living liver donation. The aim of this working group was to integrate current evidence and expert consensus on donor follow-up protocols, risk assessment, and management strategies to promote long-term donor health, quality of life, and living liver donor programs globally to safeguard the welfare of this unique population.
Campos-Varela I, Cespedes C, Palacio E
… +10 more, Quiroga S, Roson N, Dodge JL, Vargas-Accarino E, Rodríguez-Martinez A, Dopazo C, Cardenas G, Simon-Talero M, Vargas V, Castells L
Liver Transpl
· 2026 Jun · PMID 41408875
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Sarcopenia is associated with poor outcomes in patients with cirrhosis. While computed tomography (CT)-derived skeletal muscle index (SMI) is considered the gold standard for diagnosis in this setting, its use is limited...Sarcopenia is associated with poor outcomes in patients with cirrhosis. While computed tomography (CT)-derived skeletal muscle index (SMI) is considered the gold standard for diagnosis in this setting, its use is limited due to cost, radiation exposure, and availability. Our aim was to evaluate whether simple, non-radiating, easy-to-use methods, including ultrasound (US), bioelectrical impedance analysis (BIA), and anthropometry, could accurately identify sarcopenia in this population. A total of 250 patients with cirrhosis who underwent an abdominal CT scan were enrolled prospectively in this single-center, cross-sectional study. Within 1 month, the patients underwent assessments including anthropometry, handgrip strength, BIA [including body protein index (BPI)], and US of the psoas and thigh. Sarcopenia was defined by CT-based SMI at L3 (<50 cm 2 /m 2 in men, <39 cm 2 /m 2 in women). Thigh and psoas muscle thickness (normalized by height 2 ) and BPI showed moderate to strong correlations with SMI (ρ=0.42-0.71). Multivariable models combining thigh or psoas US with BMI and calf circumference achieved AUROCs of 0.837 and 0.822, respectively. A model using BPI and BMI showed comparable accuracy (AUROC, 0.844). Interobserver agreement for US measurements was high (Lin's coefficients 0.66-0.93). Thigh stiffness (2D-SWE) and phase angle did not correlate with SMI. Non-radiating tools, such as US-based thigh and psoas measurements, BIA-derived BPI, and anthropometry, are accurate alternatives to CT for detecting sarcopenia in patients with cirrhosis. These tools are simple, safe, and reproducible, which supports their integration into routine clinical practice for sarcopenia screening and monitoring.
Hepatic steatosis, characterized by the accumulation of triacylglycerol in hepatocytes, complicates liver transplantation by increasing the risk of ischemia-reperfusion injury (IRI), leading to suboptimal graft outcomes....Hepatic steatosis, characterized by the accumulation of triacylglycerol in hepatocytes, complicates liver transplantation by increasing the risk of ischemia-reperfusion injury (IRI), leading to suboptimal graft outcomes. This condition has become a major cause of liver graft discarding, exacerbating the ongoing organ shortage for transplantation. Recent advances in ex vivo normothermic perfusion machines (NMPs) have provided promising solutions for reconditioning and preserving steatotic liver. NMP supports cellular metabolism and mitigates IRI by maintaining the physiological conditions. In addition, pharmacological strategies to reduce hepatic steatosis have been explored to increase graft viability. In this review, we summarize current insights into hepatic lipid metabolism and the molecular mechanisms underlying steatosis, while discussing emerging pharmacological defatting approaches. These interventions have the potential to address the challenges posed by hepatic steatosis, improve graft quality, expand the availability of transplantable livers, and enhance clinical outcomes of transplant candidates. Finally, we highlight current limitations and outline directions for future research and clinical applications.
Long-term mortality after liver transplantation (LT) largely reflects complications of immunosuppression, recurrent disease, and medical and surgical comorbidities, including metabolic syndrome, chronic kidney disease, c...Long-term mortality after liver transplantation (LT) largely reflects complications of immunosuppression, recurrent disease, and medical and surgical comorbidities, including metabolic syndrome, chronic kidney disease, cardiovascular disease, malignancies, and hernias. This document aims to provide best practice guidelines for the preventative and disease-specific management of non-graft-related complications in adult recipients beyond the first 90 days after liver transplant. A multidisciplinary writing group of transplant experts was tasked to formulate clinical questions (in PICO format) that arise during routine management of adult LT recipients. A systematic literature search was performed by a medical librarian. The expert panel reviewed the literature, generated guideline recommendations, and rated the level of evidence for each recommendation based on the Oxford Center for Evidence-Based Medicine. The panel categorized the strength of recommendations based on the level of evidence, risk-benefit ratio, and patient preferences. Multidisciplinary care and partnership between the transplant center and the primary care physician are essential for long-term care of the transplant recipient. Significant components of non-graft management guidelines are derived from retrospective cohort studies, systematic reviews, and extrapolation of data from the general population. This gap highlights the unmet need for robust prospective studies addressing the long-term care of liver transplant recipients.
Ying X, Oje AO, De Witte AJ
… +13 more, Slaughter JC, Spann AL, Jesudian AB, Rosenblatt R, Ng C, Sholle E, Reidy D, Pan Y, Annis J, Gupta DK, Brittain EL, Fortune BE, Izzy M
Cirrhotic cardiomyopathy (CCM) is subclinical cardiac dysfunction in patients with cirrhosis in the absence of overt coronary artery, valvular, or pericardial disease. Several complications of cirrhosis, including HRS-AK...Cirrhotic cardiomyopathy (CCM) is subclinical cardiac dysfunction in patients with cirrhosis in the absence of overt coronary artery, valvular, or pericardial disease. Several complications of cirrhosis, including HRS-AKI and ascites, are postulated to be exacerbated by the presence of CCM. Among patients with cirrhosis, the association between the severity of liver disease and features of CCM and its presence has yet to be well characterized. We performed a retrospective study of adult patients with cirrhosis who underwent liver transplant (LT) at 2 tertiary LT centers between 2015 and 2018. Echocardiographic studies obtained prior to LT were examined. Echocardiographic marker(s) of CCM were present in 347 patients. CCM status was determined in 208 of the 347 patients. Demographics, etiology of liver disease, liver disease severity indices (Child-Turcotte-Pugh, CTP; Model for End-Stage Liver Disease-Na, MELD-Na), and comorbidities were examined in multivariable models to assess their associations with pre-LT CCM presence and its component features. CCM was present in 48/208 (23%) patients. In multivariable models, the presence of moderate-to-severe ascites (aOR 2.4, p =0.043) and MELD-Na (aOR 1.22 per 5-point increase in MELD-Na, p =0.046) were associated with CCM. Moderate-to-severe ascites, higher MELD-Na, and CTP score were associated with component features of CCM (left ventricular ejection fraction, left atrial volume index, E/e', and septal e') after adjusting for confounders; higher MELD-Na and CPT scores were also associated with TrVMax. While patients with higher CTP, MELD-Na, and moderate-to-severe ascites were at elevated risk of HRS-AKI, the presence of CCM and its individual markers were not independently associated with HRS-AKI. In conclusion, among patients with cirrhosis who were LT candidates, the severity of liver disease was associated with the presence of CCM and its echocardiographic features. These data may inform patient selection and encourage early detection of CCM among patients with cirrhosis.
Jutras G, Roberts JP, Shui AM
… +2 more, Lee C, Lai JC
Liver Transpl
· 2026 Jun · PMID 41378690
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The decision to proceed with liver transplant (LT) must account for the risk of death without LT and the likelihood of survival after, a concept known as "survival benefit." A 2005 study suggested that deceased donor LT...The decision to proceed with liver transplant (LT) must account for the risk of death without LT and the likelihood of survival after, a concept known as "survival benefit." A 2005 study suggested that deceased donor LT (DDLT) survival benefit is achieved at a MELD score of 15, a threshold that persists today. This study reassesses that threshold in the context of MELD 3.0. Data from all adults listed for primary single-organ LT in the UNOS/OPTN registry (January 1, 2021-March 31, 2023) were analyzed. Those undergoing living donor LT were excluded. Using sequential stratification, Cox regression models comparing mortality between LT recipients and waitlist candidates estimated hazard ratios across MELD 3.0 subgroups. Among 21,594 LT candidates (median MELD 3.0, 22, IQR 16-30), LT recipients had a 95% lower adjusted mortality risk than waitlisted candidates (HR 0.05, 95% CI 0.04-0.07, p <0.001). This survival benefit varied by MELD 3.0 score, with an advantage emerging at MELD 3.0 ≥12. At MELD 3.0 of 12-14, DDLT reduced mortality by 46% (HR 0.54, 95% CI 0.30-0.96, p =0.04), while no significant survival benefit was seen below MELD 3.0 of 12, largely due to high post-LT mortality. In this analysis of UNOS/OPTN data, DDLT conferred a survival benefit at MELD 3.0 scores ≥12, revising the historical threshold of 15. However, MELD 3.0 alone does not capture the full complexity of LT candidacy. Factors such as refractory ascites, hepatic encephalopathy, frailty, and poor quality of life should also be considered when considering LT for the individual patient.
This prospective single-center cohort study evaluated histological findings in follow-up liver biopsies (fLBs) from 157 pediatric liver transplant recipients over the first 15 years after transplant. Between June 2018 an...This prospective single-center cohort study evaluated histological findings in follow-up liver biopsies (fLBs) from 157 pediatric liver transplant recipients over the first 15 years after transplant. Between June 2018 and June 2024, 204 fLBs were performed at 2, 5, 10, and 15 years in clinically stable patients. Biopsies were scored for inflammation (Rejection Activity Index, RAI) and fibrosis (Ishak), and assessed for C4d, plasma cells, autoantibodies, and donor-specific antibodies (DSAs). Despite normal liver function tests, histological abnormalities were common: 61/204 biopsies (29.9%) showed RAI ≥2, consistent with subclinical acute cellular rejection (SACR), and 37/204 (18.1%) had fibrosis stage ≥2. The incidence of SACR peaked at 5 years (37.2%) and declined thereafter ( p =0.04). Inflammation was strongly associated with fibrosis (OR=12.6; 95% CI: 5.4-29.3; p <0.001). Patients off steroids had increased odds of SACR (OR=1.96; 95% CI: 1.04-3.7; p =0.04) and fibrosis ≥2 (OR 8.78; 95% CI: 3.99-19.34; p <0.001). C4d positivity, observed in 30 cases, was associated with a significantly higher risk of SACR (OR=6.48; 95% CI: 2.8-14.9; p <0.001). Among SACR biopsies, plasma cell-rich infiltrates (21.3%) were significantly associated with C4d positivity (OR=8.55; 95% CI: 2.1-35.2; p =0.002) and autoantibody detection (OR=7.8; 95% CI: 0.95-65.5; p =0.03). DSAs-II were associated with SACR ( p =0.03) but not with fibrosis or C4d. These findings highlight the importance of protocol biopsies for detecting silent graft injury and guiding individualized immunosuppression in pediatric liver transplant recipients.
Oral dysbiosis is noted in liver cirrhosis. This may play a role in post-liver transplantation (LT) outcomes. This study aimed to assess the baseline oral microbiome and its association with early complications (ECs) wit...Oral dysbiosis is noted in liver cirrhosis. This may play a role in post-liver transplantation (LT) outcomes. This study aimed to assess the baseline oral microbiome and its association with early complications (ECs) within 6 months after LT. This prospective longitudinal study included 94 cirrhotic recipients (CRs) and their living donors. Patients were managed with a standardized immunosuppressive regimen and monitored for 6 months post-LT EC rejection, infection, biliary complications (BCs), and death. Pre-LT and post-LT saliva samples were processed for bacterial sequencing, qPCR validation, and cytokine profiling. The association between microbial abundance and EC was assessed. At baseline, CR exhibited a lower Bacteroidota and a higher abundance of Bacillota compared with donors. Streptococcaceae and Veillonellaceae were enriched in CR compared with their respective donors ( p <0.05, each). On follow-up, post-LT ECs were noted in 35/94 patients. Prominent Bacillota , Bacteroidetes , and Actinomycetota were noted at baseline in those who developed rejection, infection, and BCs, respectively. Species-level analysis, followed by qPCR validation, revealed complication-specific baseline microbial signatures: Escherichia marmotae (FC 3.9) for rejection, Prevotella salivae (FC 71) for infections, and Rothia (FC 301) and Lactobacillus rhamnosus (FC 51) in BCs. The baseline enrichment of Prevotella_7_sp2 , Klebsiella pneumoniae , and Staphylococcus was associated with sepsis-related mortality. Recipients with post-LT EC showed pro-inflammatory links ( Prevotella with IL-2, Streptococcus with IL-8). Baseline oral microbiome profiles were differentially abundant among individuals who developed post-LT ECs. Incorporating microbial signatures may enable noninvasive risk stratification after LT.