K J Halazun

Plain English
This study looked at the effectiveness of living donor liver transplants for patients with liver cancer, specifically hepatocellular carcinoma (HCC). It found that living donor transplants offer similar or even better survival rates compared to deceased donor transplants, especially for patients whose cancer meets certain criteria. This is important because using living donors can reduce the waitlist time for transplants and help more patients get the treatment they need.

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This international study of nearly 1,000 critically ill patients who received a deceased donor liver transplant examined which patients died within three months or during their hospital stay, calling those outcomes "futile." Being 65 or older, severely underweight, on a ventilator, requiring prolonged kidney dialysis, or spending two or more weeks in the ICU before transplant were the strongest predictors of a futile outcome. The study produced a practical scoring tool that clinicians can use to decide whether a very sick patient is too sick to benefit from transplant.

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Liver transplantation is increasingly being used to treat cancers that originate in or spread to the liver, including colorectal metastases, bile duct cancers, liver cancer, and rare tumors. This review summarizes who qualifies for transplant under current evidence, how to handle the shortage of donor organs through living donation and machine perfusion, and how tools like tumor genetics and imaging analysis are beginning to improve patient selection. Cancer-related transplants are now an established part of practice and selection criteria will keep evolving as the science improves.

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After a 2020 policy change that gave exception-point patients (those with conditions like liver cancer or bile duct cancer that make their disease severity hard to measure with the standard MELD score) priority equivalent to the regional median transplant score, this study found that liver cancer patients actually received transplants at a lower rate than standard patients, yet their risk of dying on the waitlist was similar. However, patients with pulmonary complications of cirrhosis or bile duct cancer had significantly higher waitlist mortality and may need even higher priority under this system.

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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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A single surgical center reviewed 260 patients who underwent liver removal and compared outcomes between those who had open versus minimally invasive surgery, with minimally invasive used as the preferred first approach for all patients. The minimally invasive group had shorter operative times, less blood loss, shorter hospital stays, and fewer major complications, with no difference in cancer clearance margins. The study supports making minimally invasive liver surgery the default approach rather than reserving it for select cases.

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This study examined whether liver cancer patients with fatty liver disease (NAFLD) had worse outcomes after transplant compared to those with other liver diseases. NAFLD patients were older, heavier, more diabetic, and more likely to have unsuspected cancer discovered only at surgery, yet their cancer recurrence rates and recurrence-free survival after transplant were identical to non-NAFLD patients. As NAFLD becomes the most common reason for transplant, the findings are reassuring but highlight the need for better early cancer detection in this population.

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Using data from nearly 5,000 liver cancer transplant patients at 20 U.S. centers, researchers developed the RELAPSE score to predict which patients are most likely to have their cancer return after transplant. The score combines pre-surgery AFP levels, an immune marker called neutrophil-lymphocyte ratio, and findings from the removed liver such as tumor size, vascular invasion, and tumor grade, achieving better predictive accuracy than existing tools. When validated in a separate European cohort, the score held up well and could guide post-transplant surveillance and decisions about immunosuppression and preventive therapy.

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Five high-volume centers compared robotic liver removal to traditional open surgery for liver cancer in 398 patients. Robotic patients had shorter hospital stays, fewer ICU admissions, and lower rates of post-operative liver failure, while cancer recurrence rates were equivalent. This is the largest Western study confirming that robotic liver resection for liver cancer is safe, reproducible, and oncologically effective.

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Donor livers from people aged 70 and older are frequently declined, and this study found that whether a transplant center accepts these "older donor" organs varies enormously — a patient could be three times more likely to receive such a liver simply by being listed at a different hospital. Centers that accepted more older-donor organs had higher transplant rates and lower waitlist mortality for their patients, with no significant difference in post-transplant survival. Standardizing and improving the use of older-donor livers could meaningfully reduce waitlist deaths.

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This 17-center study found that liver transplant recipients who took low-dose aspirin had significantly lower rates of acute rejection and hepatic artery blockage in the first year after transplant compared to those who did not take aspirin. The protective effect appears to stem from aspirin's anti-inflammatory properties in addition to its well-known blood-thinning effects. The findings suggest that low-dose aspirin should be routinely prescribed after liver transplant.

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Researchers analyzed 20 years of national data on living liver donors and found that the demographic profile has changed very little: donors remain predominantly young, White, employed, and college-educated, with a recent rise in female donors. The narrow socioeconomic and racial profile of donors likely reflects structural barriers to donation rather than medical exclusions. Addressing financial and social obstacles to donation is essential to diversify the donor pool.

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Looking at nearly 5,000 liver cancer transplant recipients, this study found that while older patients (especially those over 70) had significantly worse long-term survival, their cancer was not the main cause: older recipients died more often from new cancers and other non-cancer causes driven by the side effects of lifelong immunosuppression. Each additional five years of age above 50 increased the mortality rate by about 8%. The findings suggest that in elderly transplant recipients, reducing immunosuppression and screening more aggressively for new cancers could improve survival.

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This study tested two imaging methods — the LI-RADS treatment response algorithm and modified RECIST — for detecting surviving tumor in liver cancer patients who had arterial chemotherapy before transplant. Both methods showed high specificity but low sensitivity, meaning they were good at confirming complete tumor kill when present but missed a substantial portion of tumors that still had living cancer cells. Neither method was clearly superior to the other, pointing to the need for better imaging tools in this setting.

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An international expert panel developed consensus guidelines for using liver transplantation to treat colorectal cancer that has spread to the liver and cannot be surgically removed. The guidelines cover how to select patients, assess tumor behavior before transplant, choose appropriate donor organs, manage patients during the wait, and treat recurrence, arriving at 44 agreed-upon statements. This framework gives transplant teams a structured approach to a rapidly growing field where demand for evidence-based practice is outpacing available data.

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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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Using national death and transplant registry data from 2014 to 2018, researchers found that Black patients with end-stage liver disease are placed on the transplant waiting list at a significantly lower rate relative to deaths than White patients, despite having similar transplant success rates once listed. This gap existed in every state analyzed and persisted after adjusting for other factors. The findings reveal a systemic barrier to transplant access for Black patients before they ever reach the waitlist.

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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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In a study of over 3,400 liver cancer transplant patients, those whose tumor was completely killed by pre-transplant treatment (complete pathologic response) had a five-year recurrence rate of just 5% versus 16% in those without complete response. Younger age, lower tumor markers, smaller tumors within standard criteria, and fewer treatment sessions predicted who would achieve complete response. These findings argue for using complete tumor kill as a benchmark to guide treatment strategy and patient selection.

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Among nearly 800 liver cancer transplant patients whose tumors initially exceeded the Milan criteria, those who successfully shrank their tumors with locoregional treatment before transplant had far lower recurrence rates and better survival than those who did not respond. AFP response to treatment and waiting time of more than 12 months were the strongest predictors of successful downstaging, and patients who failed treatment had higher recurrence than untreated patients, suggesting that persistent treatment failure signals aggressive tumor biology. Successful downstaging justifies expanding transplant eligibility for these patients.

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This nationwide database study of patients with liver scarring (cirrhosis) who underwent coronary artery stenting found their 90-day outcomes were dramatically worse than those of patients without cirrhosis. Mortality was more than four times higher, readmissions nearly doubled, and complications including gastrointestinal bleeding and kidney injury were far more common. These findings highlight the need for careful risk counseling and close follow-up when considering heart procedures in patients with liver disease.

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Written from a New York liver transplant program during the peak of the city's COVID-19 outbreak in spring 2020, this short piece argues that patients with severe liver disease must not be forgotten as healthcare resources are redirected to COVID-19. It calls on the medical community to maintain care pathways for liver failure patients who have no treatment alternative to transplant. The piece serves as a real-time record of the ethical and practical pressures faced by transplant teams during the pandemic.

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The supply of standard-quality donor livers falls far short of the number of patients waiting for transplant, causing thousands of deaths each year. This review examines strategies to use "marginal" livers — from older donors, donors with fatty livers, donors after cardiac death, or split liver grafts — more frequently and safely. Better organ preservation techniques and careful recipient selection are key to making these livers viable and closing the supply gap.

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During the early months of the COVID-19 pandemic in 2020, this 17-center international study documented how transplant programs across four continents responded to the strain on intensive care resources. Some centers stopped or sharply limited transplants to free up ICU beds while others continued routine activity to prevent waitlist deaths. The paper introduces a "quadripartite equipoise" framework that weighs recipient benefit, donor safety, waitlist mortality, and available healthcare resources as a tool for making ethically defensible decisions during resource crises.

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This review traces the growth of robotic liver surgery from an experimental technique to an increasingly viable alternative to open and laparoscopic approaches. Existing evidence shows comparable cancer control outcomes for liver cancer and colorectal metastases, with particular advantages for patients with cirrhosis or those needing repeat surgery. Broader adoption requires dedicated training in both liver surgery and robotic technique to safely climb the learning curve.

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The Milan criteria — which limit liver transplant eligibility to patients with small, limited liver tumors — were designed in 1996 and have remained dominant worldwide, but many groups have since shown that patients with larger or more numerous tumors can achieve comparable outcomes. This review summarizes the evidence for expanding transplant selection beyond Milan, focusing on scoring systems that add biological markers such as AFP and dynamic responses to pre-transplant treatments. These approaches allow more patients to be transplanted without worsening outcomes or organ utilization.

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An analysis of over 111,000 liver transplant recipients from 1987 to 2016 found that while one-year survival has improved dramatically, long-term survival among those who make it past the first year has not improved at all over three decades. The main causes of late death are cancers and infections caused by long-term immunosuppression, not organ rejection. The results indicate that improving liver transplant outcomes now requires better management of immunosuppression side effects rather than preventing rejection.

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This review examines the emerging evidence for transplanting patients whose colon cancer has spread to the liver and cannot be removed surgically. Early European results, mostly from a single Norwegian center, showed a survival advantage over chemotherapy alone, but recurrence remains common and patient selection criteria are not yet well defined. In North America, organ shortages make it difficult to pursue this approach without clear selection criteria, though living donor transplant and marginal organ strategies may offer a path forward.

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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 single-center study tracked how donor livers change in size as pediatric transplant recipients grow over 10 years. Liver volume grew by 59% by five years and 170% by 10 years post-transplant, closely matching expected liver size for the child's height and weight by year five. The findings confirm that transplanted livers in children adapt appropriately to the recipient's growth, which has practical implications for graft sizing decisions at the time of transplant.

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Using data from over 72,000 deceased donors, this study developed the Discard Risk Index (DSRI) to predict at the time of initial organ offer whether a donor liver will ultimately be discarded rather than transplanted. High bilirubin levels, donation after cardiac death, and several other factors were the strongest predictors of discard. The DSRI achieves 80% accuracy and could be used to route marginal livers preferentially to centers experienced in using difficult organs, reducing waste.

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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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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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This national study of over 11,000 children on the kidney transplant waiting list found that children listed at low-volume centers — those performing fewer than three transplants per year — received a transplant only 49% of the time, versus 88% at high-volume centers, and faced a fourfold higher risk of dying on the waitlist. Volume at the transplant center was the dominant predictor of waitlist outcomes, not the child's medical characteristics. The findings argue for concentrating pediatric transplant activity at experienced centers.

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This 20-center study of over 3,600 liver cancer transplant patients within the Milan criteria found that pre-transplant locoregional therapy (such as chemoembolization or ablation) did not improve post-transplant cancer recurrence or survival in the majority of patients who did not achieve complete tumor kill. Patients who needed three or more treatments or whose AFP did not fall with treatment had higher recurrence rates, signaling poor tumor biology. The results suggest that treatment response, not the act of treating, is what predicts outcomes.

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Using national transplant registry data on over 73,000 adult liver transplant recipients, this study developed the LOS (Length of Stay) Index, a 22-factor scoring tool that predicts which patients will require more than 30 days in the hospital after transplant. ICU admission before transplant and prior transplant history were the strongest predictors of a prolonged stay. The index gives clinicians a way to anticipate resource needs and may help identify patients who would benefit from pre-transplant optimization.

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This review summarizes how inflammatory blood markers — particularly the neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and AFP — have been combined into scoring systems that better predict liver cancer recurrence after transplant than the Milan criteria alone. Because the Milan criteria measure only tumor size and number without any biological information, they miss many patients who will recur despite meeting criteria and exclude others with good biology who would do well. Adding inflammatory markers to selection tools provides a more complete picture of tumor aggressiveness.

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The Milan criteria determine which liver cancer patients qualify for a transplant, but they don't capture tumor biology. This study built the MORAL score, combining AFP, neutrophil-to-lymphocyte ratio, and tumor size, to better predict which patients will have cancer recurrence after transplant. The model outperforms Milan criteria alone and could guide fairer organ allocation.

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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.

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The Share 35 policy, introduced in 2013, gave patients with MELD scores above 35 first access to livers within a broader geographic area. This study found that nationally, survival after transplant was unchanged, but two specific regions saw significantly worse outcomes after the policy took effect. The findings reveal that a one-size-fits-all national policy can have uneven effects depending on regional organ supply, recipient illness severity, and center capabilities.

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Most adult living-donor liver transplants use the larger right lobe because of worries that the smaller left lobe won't provide enough liver mass to the recipient. This largest North American report on left lobe adult-to-adult living donor transplants showed comparable outcomes to right lobe grafts when donors and recipients were well selected. Left lobe donation is safer for donors and more feasible than commonly assumed.