James V Guarrera

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Researchers analyzed 1,100 Reddit posts from the r/transplant community to understand how transplant patients, donors, and caregivers use social media. Kidney and liver topics dominated, most posts came from recipients, and the overall tone was positive — with the best-rated posts focused on sharing personal experiences. Reddit functions as a peer support and medical information forum for the transplant community, and the findings suggest value in formally integrating patient-generated insights into healthcare practice.

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Researchers measured pre-transplant blood levels of immune and inflammatory proteins in 279 liver transplant recipients to predict who would die within a year of surgery. Two markers — fractalkine and MMP3 — independently predicted early death and were combined into the Liver Immune Frailty Index (LIFI), which sorted patients into low, moderate, and high risk with one-year mortality rates of 2%, 10%, and 64%. LIFI outperformed all existing clinical scoring systems and could help surgeons decide which candidates are too immunologically compromised to survive transplant.

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A single US center compared outcomes for 109 donation-after-circulatory-death (DCD) liver transplants using hypothermic oxygenated machine perfusion (HMP-O2) versus traditional cold storage. Even though the HMP-O2 donors were older and higher risk, HMP-O2 recipients had far lower rates of ischemic cholangiopathy (1.6% vs. 10.6%) and zero cases of primary nonfunction versus 6.4% in the cold-storage group. This is the first US clinical series confirming that HMP-O2 can dramatically reduce the most serious complications of DCD liver transplantation.

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This meta-analysis pooled data from randomized trials and cohort studies to compare three machine perfusion strategies for liver preservation: hypothermic oxygenated perfusion (HOPE), normothermic machine perfusion (NMP), and normothermic regional perfusion (NRP). HOPE had strong trial evidence for reducing ischemic cholangiopathy and improving graft survival, NRP showed similar benefits in retrospective studies, and NMP showed no significant effect on either outcome. The findings help transplant teams choose among perfusion strategies, though the authors caution that the evidence base remains heterogeneous.

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Most patients with intrahepatic cholangiocarcinoma are diagnosed too late for surgery, and this review examines the expanding toolkit for those with locally advanced, unresectable disease. New immunotherapy combinations, targeted drugs, and liver-directed treatments are extending progression-free survival and enabling some tumors to be downstaged enough for resection. Liver transplantation is now emerging as a curative option for a subset of patients who respond well to treatment but cannot be resected.

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This study examined outcomes for 60 uninsured liver transplant patients covered by a state charity care program compared to 918 insured patients at the same center over 18 years. One-year and three-year patient survival were statistically identical across all insurance groups, and there was no difference in graft survival, hospital stay, or readmission rates. The results show that financial barriers to transplant can be successfully overcome with public assistance programs without compromising outcomes.

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Researchers from 10 transplant centers across 7 countries tested whether flavin mononucleotide (FMN) — a molecule released by damaged mitochondria — measured during hypothermic machine perfusion could predict which livers would fail after transplant. Analyzing 473 perfusate samples, they found FMN levels accurately predicted graft loss, cholangiopathy, and kidney failure, outperforming conventional donor risk scores. This validates FMN as a rapid, real-time quality test during machine perfusion that could help surgeons safely use more marginal livers.

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The American Society of Transplant Surgeons convened experts in surgery, ethics, and critical care to establish standards for normothermic regional perfusion (NRP), a procurement technique that restores circulation to donor organs before retrieval. The working group issued 14 recommendations covering terminology, the definition of death in the NRP context, and required training and communication protocols. The goal is to ensure NRP is practiced ethically and consistently across US transplant programs.

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This US randomized trial tested a portable hypothermic oxygenated machine perfusion device against standard cold storage in 179 liver transplant recipients. The machine perfusion group had lower rates of early allograft dysfunction (11% vs. 16%), fewer biliary strictures, and no cases of primary nonfunction compared to three in the cold storage group, though these differences did not reach statistical significance. The trial established the device's safety and noninferiority, providing regulatory groundwork for broader US adoption.

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This review examines why machine perfusion, despite strong evidence of benefit, is still not routine in liver transplantation. Key barriers include high device and perfusion solution costs, complex regulatory pathways that differ by country, limited reimbursement, and the logistical challenge of training teams and integrating perfusion into existing workflows. The authors call for coordinated action among clinicians, regulators, and industry to develop cost-effectiveness data and flexible reimbursement models.

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This paper takes a global look at why machine perfusion for solid organ preservation — a technique with roots going back to the 19th century — has not become standard clinical practice despite decades of evidence for its benefits. Barriers include cost, reimbursement gaps, regulatory complexity, and lack of training infrastructure, which vary substantially by region and healthcare system. The authors lay out a roadmap involving collaboration between transplant centers, regulators, and device manufacturers to make perfusion technology accessible worldwide.

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Patients with acute-on-chronic liver failure are critically ill and often penalized by organ allocation systems that favor more stable candidates, even though they urgently need transplant. Machine perfusion — both hypothermic and normothermic — can rehabilitate marginal donor livers that would otherwise be discarded, making those organs safe to transplant into higher-risk recipients. This review argues that machine perfusion offers a practical strategy to expand the donor pool specifically for this underserved patient population.

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This single-center study reviewed how thromboelastography (TEG), a test that directly measures clotting function, was used to guide blood transfusions in 89 cirrhosis patients. Despite TEG indicating that transfusions were often unnecessary, physicians still gave platelets and fresh frozen plasma to patients whose TEG results were normal. The findings point to a need for better clinician education about TEG interpretation, since using it correctly could reduce unnecessary transfusions in cirrhosis patients.

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This study compared the Liver Immune Frailty Index (LIFI) — based on three pre-transplant immune biomarkers — against 11 established clinical risk scores for predicting death after liver transplantation in 289 patients. LIFI had the highest discrimination of all scores tested, with LIFI-high patients having 58% one-year mortality versus 1.4% for LIFI-low, and the advantage held across all MELD levels. Adding immune profiling to pre-transplant assessment could meaningfully reduce futile transplants.

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This review summarizes five years of randomized trial data on hypothermic and normothermic machine perfusion for liver transplantation, finding that both techniques reduce early graft dysfunction and biliary complications in extended-criteria donor livers. Emerging applications include using machine perfusion to test organ viability before committing to transplant, extending preservation time for logistical flexibility, and expanding to pediatric recipients. There is now enough evidence to support wider clinical adoption, with further innovation expected to increase the number of transplantable livers.

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Using data from 22 high-volume transplant centers, this study established the first benchmarks for redo liver transplantation — repeat transplants in lower-risk patients excluding emergency re-transplants. In benchmark cases, one-year survival reached 90%, with complication rates up to 76%. However, redo transplants for primary nonfunction (where the first graft never worked) had substantially worse outcomes, showing the importance of risk-stratifying candidates before committing a scarce donor organ to a repeat procedure.

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This review summarizes the clinical evidence and mechanisms behind hypothermic machine perfusion for liver preservation, covering a decade of single-center studies and the launch of multicenter randomized trials. HMP works by protecting mitochondria during preservation and blunting the reperfusion injury that occurs when cold-stored livers are implanted, resulting in fewer biliary complications, less early dysfunction, and better patient survival. Widespread adoption awaits resolution of regulatory, financial, and logistical barriers.

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Liver transplantation for cancer has traditionally been limited to hepatocellular carcinoma within strict size criteria, but this review examines emerging evidence for expanding transplant to other liver-limited malignancies. For intrahepatic cholangiocarcinoma, colorectal metastases, and expanded hepatocellular carcinoma criteria, tumor biology and response to neoadjuvant therapy appear to predict outcomes better than size alone. A protocolized multidisciplinary approach is essential, and the field is moving toward individualizing transplant candidacy based on how a tumor behaves over time rather than just how big it is.

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The rise of highly effective hepatitis C antivirals and a growing shortage of donor organs has driven rapid adoption of transplanting organs from hepatitis C-positive donors into hepatitis C-negative recipients. This best-practice guideline from the American Society of Transplant Surgeons addresses pre- and post-transplant management for these cases, emphasizing the need for prompt antiviral therapy to avoid severe liver injury from donor-derived HCV infection. Programs without structured protocols risk erosion of public trust and patient harm.

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Intrahepatic cholangiocarcinoma is a bile duct cancer that is usually diagnosed too late for surgery, and this review examines the roles of surgical resection and liver transplantation in its management. Resection offers the best survival but is limited by high recurrence rates and the need for adequate remaining liver; liver transplantation is emerging as a curative option for select patients with unresectable disease, particularly those who respond to neoadjuvant therapy. Patient selection, tumor biology, and a multidisciplinary treatment protocol are the key determinants of success.

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This porcine laboratory study tested whether oxygenating a portable machine perfusion pump before transport — a technique called oxygen pre-charge — could substitute for the continuous oxygen supply normally required for hypothermic oxygenated perfusion. Pre-charged livers maintained higher oxygen levels than non-oxygenated pumps and showed significantly lower markers of cell injury compared to cold storage. This technique could enable portable hypothermic oxygenated perfusion on standard transport runs without specialized oxygen equipment.

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This brief review contrasts the two main ex-vivo machine perfusion approaches for liver preservation: hypothermic perfusion, which focuses on protecting mitochondria during a short window before implantation, and normothermic perfusion, which mimics physiological conditions to sustain organs for longer periods. Results from two major randomized trials were awaited at the time of publication, with both techniques showing early promise for increasing the number of viable donor livers. The review situates both strategies within the evolving clinical landscape of organ preservation.

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Cholangiocarcinoma — cancer of the bile ducts — is rarely curable by surgery alone, and this review examines indications for liver transplantation across the three anatomic subtypes. While early-stage perihilar cholangiocarcinoma after neoadjuvant treatment is an established transplant indication with good outcomes, intrahepatic cholangiocarcinoma remains investigational. Improvements in chemotherapy and molecular targeting are expected to expand the pool of patients who can be downstaged to transplant candidacy.

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The Milan criteria — defining the maximum tumor size and number for liver transplant candidacy in hepatocellular carcinoma — have been standard since 1996, but many centers believe they are too restrictive. This review examines expanded criteria and downstaging protocols that incorporate tumor biology markers like alpha-fetoprotein and treatment response, which appear to be more accurate predictors of recurrence than size alone. The field is moving toward individualized selection that rewards tumors showing stable behavior over time.

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This analysis of 2,107 donation-after-circulatory-death liver transplants from the national registry found that donor warm ischemia times up to 40 minutes did not increase graft loss or hospital readmissions, contrary to common practice guidelines. Cold ischemia time — the time the organ spends on ice during transport — was the stronger predictor of poor outcomes, with any cold ischemia beyond four hours associated with increased graft loss. These findings suggest current warm ischemia cutoffs may be overly conservative, potentially causing unnecessary discard of viable livers.

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This single-center report describes 51 fully laparoscopic living donor liver resections performed since 2009, including 20 full lobe donations — the largest North American laparoscopic living donor experience at the time. Outcomes including donor complications, recipient survival at one year, and graft survival were comparable to open surgery, with conversion rates and bile leak rates both at 4%. The series provides evidence that laparoscopic donor hepatectomy can be safely adopted at experienced centers, with less surgical impact on donors.

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A 12-year-old liver transplant recipient presented 11 years after transplant with obstruction and intestinal ischemia caused by a stone (enterolith) that had formed in the Roux limb of his bile duct reconstruction. Emergency surgery found dead bowel, requiring resection and revision of the biliary anastomosis, and the child recovered. This rare complication should be considered in transplant patients presenting with bowel obstruction or cholangitis years after surgery.

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This review covers liver transplantation for acute liver failure, a rapidly fatal condition where the liver fails suddenly in a previously healthy person. Transplant has dramatically improved survival — now 79-84% at one year — but identifying which patients will recover spontaneously versus which urgently need transplant remains the central clinical challenge. Early transfer to a transplant center is critical, as the window for listing and receiving a donor organ is narrow.

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This review summarizes the clinical experience with hypothermic machine perfusion for human liver transplantation, noting that multiple single-center studies showed reduced biliary complications, less early dysfunction, and better patient survival compared to cold storage. Mechanistically, HMP limits the mitochondrial damage that drives reperfusion injury when a cold-stored liver is implanted. The authors anticipate broader clinical adoption once regulatory, cost, and logistical barriers are addressed.

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This study analyzed national transplant registry data to assess how elderly donor livers (age over 70) are utilized across the US, finding that use is concentrated in two regions and that overall recipient survival is worse than with younger grafts. However, when elderly livers were matched to lower-risk recipients, survival was actually better than for recipients of younger livers — demonstrating that the problem is suboptimal matching, not intrinsic graft quality. The authors argue that removing regulatory disincentives and using better recipient-matching criteria could dramatically increase the number of usable elderly donor livers.

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This single-center review of 2,050 liver transplants examined outcomes when nearly half of recipients received marginal grafts — from elderly donors, donors with hepatitis C, donation-after-cardiac-death donors, high-steatosis livers, or organs turned down elsewhere. Survival for marginal graft recipients was equivalent to those receiving standard grafts, and the center's waitlist mortality was significantly lower than the national average. The findings demonstrate that liberal but selective use of marginal livers at experienced centers can expand access without sacrificing outcomes.

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Using a prospective cohort of 339 patients transplanted for hepatocellular carcinoma, researchers developed the MORAL score, which predicts recurrence based on neutrophil-to-lymphocyte ratio, alpha-fetoprotein, and tumor size before transplant — and additionally on grade and vascular invasion afterward. MORAL outperformed the Milan criteria substantially in discriminating who would and would not recur (c-statistic 0.82-0.91 vs. 0.63). The score provides a practical, biologically-grounded tool for selecting HCC candidates and for post-transplant surveillance planning.

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This prospective multicenter study of 172 living liver donors found that postoperative pain was poorly managed, with only 9-49% of donors receiving care consistent with expert pain management guidelines. Female donors and those with pre-existing medical concerns reported worse pain scores and more adverse effects from pain medications, while receiving information about pain options improved satisfaction. Standardized pain protocols tailored to donors' behavioral and psychological characteristics are needed to improve the donation experience.

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This series of 214 living donor liver transplants at a single center compared outcomes for 56 recipients of the smaller left lobe versus 158 recipients of the right lobe. Despite significantly lower graft-to-recipient weight ratios in left lobe recipients — raising concern for small-for-size syndrome — patient survival, graft survival, and complication rates were statistically identical between groups. Left lobe grafts can safely expand the living donor pool, and concerns about their use appear to be overstated.