DR. JEAN CRAWFORD EMOND, M.D,

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This study developed a new scoring tool to predict which patients undergoing living donor liver transplantation are at the highest risk of losing their graft within 90 days. Using data from nearly 4,000 patients across 18 centers, the EAGLE-LDLT model—based on liver enzyme and clotting values in the first week after surgery—outperformed existing models and correctly identified 40% of high-risk patients. Surgeons can use this tool after transplant to flag patients who need closer monitoring or earlier intervention.

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This perspective piece reviews the current state of living donor liver transplantation in the United States, where it accounts for fewer than 10% of all liver transplants despite proven safety and benefit. Barriers include lingering fear of donor harm after a high-profile death in 2001, limited surgeon training, and the relative availability of deceased donor organs. The authors argue that expanding training programs and raising awareness are essential to grow living donation and address the persistent organ shortage.

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A prospective multicenter trial tested whether long-term liver transplant recipients could safely stop immunosuppression. Of 61 participants who attempted withdrawal, only 10 out of 17 who remained stable off drugs for a year were confirmed truly tolerant by biopsy. The study identified several biological signals in pre-withdrawal biopsies that may predict who can safely discontinue immunosuppression, a finding that could eventually reduce drug-related side effects for a small subset of patients.

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This study created a pretransplant prediction model to estimate the risk of early graft dysfunction after living donor liver transplantation, using only information available before surgery. Three factors predicted poor graft function: higher disease severity score, being hospitalized at the time of transplant, and receiving a smaller graft. The model can help surgeons better match donors to recipients before the operation to reduce complications.

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This 12-center North American study followed 360 patients who received a living donor liver transplant for liver cancer, including many whose tumors exceeded the standard size and number limits (Milan criteria). Ten-year survival exceeded 60% even for patients outside the criteria, and a newer scoring tool called the NYCA score correctly identified most of these "out-of-criteria" patients as low or acceptable risk. Living donor transplant offers good long-term outcomes for a broader group of liver cancer patients than current criteria allow.

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This large international study of 3,633 living donor liver transplant patients identified risk factors for the two most common surgical complications: bile leaks and narrowing of the bile duct connection. Multiple bile duct connections, a history of prior abdominal surgery, and blood type incompatibility were among the key risk factors, and both complications significantly shortened graft survival. Careful donor selection and surgical planning are critical to reducing these complications.

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Researchers analyzed two decades of national liver transplant data and found that while survival after transplant has steadily improved, survival from the time of waitlist listing has not. Over the same period, the rate of donated livers going unused rose significantly, as did the rate of patients dropping off the waitlist before receiving a transplant. This suggests that gains in post-transplant care are being offset by more patients dying while waiting, partly because usable organs are being declined.

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This review examines the current state of non-invasive biomarkers — genetic, protein, and immune signals — being developed to diagnose and predict complications after liver transplantation. Promising applications include detecting rejection earlier, guiding immunosuppression reduction, identifying fibrosis, and predicting kidney recovery, though most markers still lack the large-scale validation needed for routine clinical use. The authors frame this as a fast-moving field on the verge of changing how transplant patients are monitored and managed.

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This review covers surgical treatment options for cystic echinococcosis, a parasitic infection that commonly affects the liver. Both radical removal of the cyst with surrounding tissue and more conservative drainage approaches are effective, with recent data showing the conservative approach carries acceptable risk and low recurrence rates in experienced hands. Ultrasound remains the primary tool for staging and follow-up, and outcomes are best when a multidisciplinary team manages the case.

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This study looked at a complication called small-for-size syndrome (SFSS) that can occur after liver transplants from living donors. Researchers found that managing this condition effectively can improve patient outcomes, with most patients recovering through medical treatment, interventional radiology, or surgery, especially if they seek help early. However, patients are at a higher risk of losing the liver transplant if their bilirubin levels are over 10 mg/dL or their INR is above 1.6 a week after surgery, which emphasizes the importance of timely intervention.

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Researchers tested whether a painless ultrasound-based technique called vibration controlled transient elastography could reliably screen potential living donors for liver fat without requiring a biopsy. Among 79 donor candidates, the tool showed a meaningful correlation with MRI fat measurements and liver biopsy results, with acceptable sensitivity and specificity at defined score cutoffs. Integrating this screening step could reduce the number of invasive biopsies needed during donor evaluation.

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Researchers looked into the challenges and potential improvements in living donor liver transplants (LDLT) during a conference in October 2021. They found that issues like donor age, size, and blood type mismatches, along with a lack of awareness about the benefits of LDLT and a shortage of skilled surgeons, hinder its growth in the U.S. They recommend creating a national registry for better matching and improving surgical training to ensure more successful transplants, which could greatly increase the availability and effectiveness of these procedures.

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A national survey of 60 U.S. liver transplant programs examined how often and under what circumstances centers refer declined patients for a second opinion at another center. While all centers receive second-opinion referrals, only 25% frequently facilitate them for their own declined patients, and practices vary widely with no standardized process. Standardizing second-opinion pathways could improve equity for patients denied transplant listing.

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An international team of 15 high-volume liver transplant centers established reference benchmarks for living donor liver transplantation outcomes, similar to quality standards that exist for other surgical procedures. Living donor transplants matched or outperformed deceased donor transplants on most measures like graft loss and need for retransplantation, though bile leaks and hepatic artery clots remained higher. These benchmarks give transplant programs a concrete target for quality improvement and international comparison.

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A 10-year multicenter study of 2,645 liver transplant patients with liver cancer found that patients whose tumors were successfully shrunk to within transplant criteria before surgery had excellent long-term outcomes, similar to patients who always met criteria. Ten-year survival for the downstaged group was 52%, and patients whose cancer recurred after transplant lived longer if they were able to have surgical treatment of the recurrence. These data strongly support national policies allowing downstaged patients to receive liver transplants.

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Using national transplant registry data, this study found that patients who received simultaneous liver and kidney transplants with high liver disease severity scores had significantly higher rates of kidney graft failure at 90 days and one year compared to patients who received a kidney transplant after a prior liver transplant. For patients with a disease severity score of 25 or higher, sequential kidney transplantation may offer better kidney outcomes. These findings are relevant given the availability of a policy allowing priority kidney transplantation after liver transplant.

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Among 70 organ transplant recipients with confirmed COVID-19, only 51% developed detectable antibodies against the virus. Patients on more than two immunosuppressive drugs and those closer to the time of transplant were least likely to mount an antibody response. These findings raised early concern that transplant recipients may be less protected after COVID-19 infection and suggested they could be at particular risk without additional protective measures.

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A propensity-matched study compared 117 organ transplant recipients hospitalized with COVID-19 to 350 non-transplant patients and found no significant difference in mortality (23% in both groups) or need for oxygen support. Transplant recipients did require more COVID-specific treatments and intensive care, but their overall outcomes were similar. Chronic immunosuppression does not appear to independently worsen COVID-19 survival.

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An analysis of fellowship match data from 2006 to 2018 found that transplant surgery is one of the least competitive and least sought-after surgical subspecialties, with only 27% of applicants being U.S. medical graduates and a declining match rate over time. Nearly half of all transplant fellows came from just 28% of residency programs, suggesting uneven exposure. The findings call for targeted efforts to increase mentorship and early exposure to transplantation during residency training.

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This multicenter international study found that liver cancer patients on the transplant waitlist who had access to a living donor had a 33-49% lower risk of dying compared to those waiting for a deceased donor organ, even after accounting for differences between groups. The benefit was consistent across multiple cohorts and analysis methods, and was driven largely by eliminating the risk of being removed from the waitlist while waiting. The findings make a strong case for expanding living donor programs to improve outcomes for patients with liver cancer.

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Researchers validated a new scoring tool for selecting liver transplant candidates with liver cancer by testing it on data from 2,236 patients across eight international centers. The New York/California (NYCA) score—which incorporates how a patient's AFP tumor marker changes over time—outperformed older size-based criteria and correctly reclassified most patients previously excluded under those criteria into acceptable-risk categories. This score offers transplant programs a more accurate, biology-based way to decide who benefits from liver transplantation.

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The same serum samples sent to multiple liver transplant centers in one U.S. region produced MELD liver disease severity scores that differed by up to six points between centers — a gap large enough to change a patient's transplant priority. The discrepancy was driven largely by differences in how labs measure bilirubin, which interfered with creatinine measurements at high levels. These findings reveal a systemic fairness problem in organ allocation that standardized testing across centers could fix.

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Researchers from 12 centers across three continents developed a model — the West-East Downstaging model — to identify an upper limit of tumor burden beyond which successful liver transplantation after treatment becomes unrealistic for patients with liver cancer. The model combines tumor number, total size, and a blood tumor marker measured at first referral to predict cancer-related death after transplant. This intention-to-treat approach gives transplant teams a tool to counsel patients earlier and avoid futile downstaging attempts.

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A matched cohort study evaluated the drug tocilizumab — an anti-inflammatory agent — in 29 organ transplant recipients hospitalized with severe COVID-19. After matching for key risk factors, 90-day mortality did not differ significantly between those who received tocilizumab and those who did not (41% vs. 28%). The drug appeared safe but showed no clear survival benefit in this population, highlighting the need for larger trials.

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Among the first 90 solid organ transplant patients infected with COVID-19 in New York City, 30% had severe disease requiring ICU admission and 18% died—substantially higher than in the general population at the time. Most patients received hydroxychloroquine-based regimens, and immunosuppression was often reduced. This early report established the clinical baseline for transplant recipients with COVID-19 and shaped initial management approaches.

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Researchers compared weekly organ donation and liver transplant activity during the first three months of the COVID-19 pandemic to the same period the prior year in the United States, United Kingdom, and India. Transplant volumes fell sharply in all three countries, dropping over 80% at peak in the UK and India, with early signs of recovery by the end of the study period. The study documents the pandemic's severe disruption to life-saving transplant services and the policy adaptations used to maintain some activity.

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Medical students who assisted with organ procurements reported the experience was meaningful but lacked any formal educational structure. A survey of students who participated over several years found strong interest in surgery and donation but gaps in knowledge and guidance. The authors call for a standardized curriculum to make procurement education consistent and impactful.

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An infant who received a living-donor liver transplant developed COVID-19 hepatitis when the donor later tested positive for the virus. Liver function deteriorated but the patient recovered without losing the graft. This early case documented that COVID-19 can affect transplanted liver allografts and prompted questions about donor screening protocols.

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Using 13 years of national data on over 73,000 donor livers, this study found that livers available on weekends and at night were about 11% more likely to go unused even after accounting for organ quality — and the effect was strongest on weekend nights. The findings point to staffing patterns, logistics, and operational capacity as contributors to organ waste, beyond donor characteristics alone. Addressing these systemic inefficiencies could recover a meaningful number of usable livers each year.

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This review summarizes 31 studies examining whether the ratio of neutrophils to lymphocytes in the blood before treatment predicts liver cancer recurrence after liver resection or transplantation. Higher ratios — reflecting a shift in immune balance — were consistently linked to worse recurrence-free and overall survival after transplantation, though the association was less clear after resection. The neutrophil-lymphocyte ratio is a simple, inexpensive blood test that could be added to existing selection tools to better identify high-risk patients.

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Researchers developed the New York/California (NYCA) score, a new tool to select liver transplant candidates with liver cancer that goes beyond tumor size and count to include how the AFP blood marker changes over time before transplant. The score outperformed the standard Milan Criteria in predicting cancer-free survival and would allow 85% of patients currently excluded under Milan Criteria to safely receive a transplant. This model gives U.S. transplant programs a practical, evidence-based tool to expand liver cancer transplant eligibility.

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Surgeons reported their experience performing 51 fully laparoscopic liver removals for living donors, the first such large series from a US center, comparing outcomes to open donation. Laparoscopic donors had longer operations but similar complication rates, and graft survival in recipients was 94% at one year. The results support cautious expansion of fully laparoscopic living donor hepatectomy at centers with sufficient expertise.

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Donor livers from people over 70 are almost never used, even though studies show they can work well. Analysis of national data found that older grafts are systematically excluded by Medicare eligibility rules and center bias, not just medical evidence. Reconsidering these policies could meaningfully expand the organ supply.

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Children who receive livers from living donors—usually parents—have better long-term outcomes than those receiving deceased-donor organs, but living donor transplants remain rare in the U.S. This study found that living-donor recipients also showed immunological advantages, with lower rejection rates likely tied to the partial genetic match with a parent donor. The data make a strong case for expanding living donor programs for children.

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In patients without cirrhosis, portal vein blockage can cause parts of the liver to shrink while others compensate. This study examined liver atrophy patterns in such patients and found that surgical shunts to relieve portal hypertension allowed meaningful liver regeneration. These findings support surgical intervention rather than watchful waiting in non-cirrhotic portal vein thrombosis.

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This case report describes an 18-month-old girl with three simultaneous rare conditions — autosomal recessive polycystic kidney disease, Caroli syndrome, and hepatoblastoma — successfully treated with surgical resection alone without chemotherapy. Nine years later she remained tumor-free with stable kidney function. The case adds to a limited literature on managing concurrent pediatric liver tumors and cystic kidney disease.

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A nine-center study of 272 living donor liver transplants examined how differences in bile duct anatomy and reconstruction technique affected complications. Recipients whose bile duct connections used higher bile duct branches had the highest rates of bile duct complications — 56% by one year — while those who received a Roux-en-Y reconstruction had higher rates of blood vessel complications. These findings give surgeons more precise guidance on which reconstruction method to choose based on the donor's anatomy.

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Researchers studied nearly 2,100 liver transplants performed at one hospital between 1998 and 2016, looking at whether using "marginal" livers—organs that are older, have been preserved longer, or have other quality issues—produces acceptable results compared to standard or living-donor livers. They found that patients who received marginal livers had survival rates nearly identical to those who received standard livers, and the hospital successfully transplanted these lower-quality organs to almost half its patients without compromising overall outcomes or increasing deaths on the waiting list. This matters because marginal livers are typically rejected and wasted, but this hospital proved these organs can be safely used, which could allow more patients to receive transplants sooner and save more lives.