Justin A. Steggerda

Background: Liver transplantation (LT) is curative for hepatocellular carcinoma (HCC) but requires timely referral. Comprehensive data on factors impacting LT referral and outcomes for HCC are limited. We evaluated social, system, and clinical factors associated with listing, LT, mortality, HCC stage at referral, and time from HCC diagnosis to referral. Methods: The California Liver Network is a consortium of 6 LT centers comprising >75% of adult LTs in California. Demographic, clinical, psychosocial, and social determinants of health and outcome data were collected for adults referred for LT. Multivariable regression identified factors associated with outcomes. Results: Of 9987 adults referred, 1573 (15.7%) had HCC. Median age was 63.3 years; 73% males, 40% Hispanic, and 26.1% Medicaid insurance. Median MELD was 12.7 (IQR 8–16), and median time from HCC diagnosis to LT referral was 124 days (IQR 32–410). In all, 10% were T1 and 70.5% were T2 at referral. Alpha-fetoprotein (AFP) (OR 0.99), HCC stage, Medicaid insurance (OR 0.55), LT site, and marital status (OR 1.90) were associated with listing. Transplantation was associated with HCC stage (OR 0.42) and LT site. Mortality was associated with MELD (OR 1.02), hypertension (OR 1.44), dialysis (OR 2.48), hepatic encephalopathy (OR 1.54), and portal vein thrombosis (OR 1.44). Referral at more advanced HCC stage was associated with male sex (OR 1.55), AFP (OR 1.01), Medicaid insurance (OR 1.40), primary language (OR 0.70), and prior HCC treatment type. Longer time to referral was associated with HCV/alcohol liver disease and prior HCC treatment type. Conclusions: In this multicenter study of adults with HCC, Medicaid insurance, LT site, HCC treatment history, and psychosocial factors were key determinants of HCC care cascade progression, identifying targets to improve LT access.

Background.: Hypothermic oxygenated perfusion (HOPE) supplies oxygen to kidney allografts for resuscitation before transplantation and may improve graft recovery. This study represents the first U.S.-based comparative analysis evaluating the impact of HOPE on kidney transplant (KT) outcomes. Methods.: A retrospective, single-center study of adult, deceased-donor, kidney-only transplants performed between December 1, 2023, and March 31, 2025. Transplants were grouped according to preservation method: HOPE, static cold storage (SCS), or hypothermic machine perfusion (HMP) without oxygen alone. The primary outcome was 12-mo estimated glomerular filtration rate (eGFR). Subgroup analyses were performed, including donation after circulatory death (DCD) and long cold ischemic time (>18 h) KT. A matched cohort analysis was performed for DCD-KT. Kruskal-Wallis rank-sum and pairwise comparisons were used. P -values of P < 0.001). At 12 mo post-KT, HOPE demonstrated higher median eGFR compared with HMP (63 versus 53 mL/min; P = 0.019) and similar to SCS (63 versus 62 mL/min; P = 0.96). In a matched DCD-KT analysis, HOPE outperformed HMP (67 versus 48 mL/min; P = 0.034). HOPE also showed improved eGFR compared with HMP for KT with cold preservation times >18 h (64 versus 52 mL/min; P = 0.011). Conclusions.: HOPE preservation is associated with improved long-term graft function compared with HMP while maintaining outcomes compared with SCS despite longer preservation times, with notable benefits in DCD-KT.

Background: Hepatocellular carcinoma (HCC) has a poor long-term prognosis due to high recurrence and cirrhosis-related mortality, even after potentially curative treatments such as liver transplantation (LT), surgical resection, or ablation. This study aimed to identify factors associated with ≥10-year survival in HCC patients. Methods: A retrospective cohort study was conducted among HCC patients diagnosed between 2004 and 2022 using the National Cancer Database. Multivariable Cox regression was used to identify predictors of overall survival, and logistic regression was used to identify predictors of ≥10-year survival. Results: Among 249,600 HCC patients, 177,585 (71.2%) died within 5 years, 8613 (3.5%) died at 5–10 years, 54,988 (22.0%) were alive with Export

Background: Metabolic dysfunction-Associated Steatotic Liver Disease (MASLD) is becoming a leading indication for liver transplantation in the United States. In this growing recipient population, the combined effects of underlying liver disease etiology and associated comorbidities on the evaluation pathway to transplantation warrant closer examination of patient outcomes. Methods: We analyzed adult liver transplant referrals (n = 9981) from the California Liver Network, a multi-center retrospective cohort spanning six high-volume California transplant centers between 2018 and 2020. A total of 6709 patients who underwent formal evaluation were included. Patients were stratified by MASLD vs. non-MASLD etiology and compared for demographics, comorbidities, transplant evaluation timelines, listing rates, and outcomes. Results: MASLD patients (n = 1477) were older, had higher BMI, and had greater prevalence of metabolic comorbidities than non-MASLD patients (n = 5232; p < 0.001 for all). Compared to non-MASLD candidates, MASLD patients were more likely to be waitlisted (OR 1.52, 95% CI 1.33–1.74; p < 0.001). However, MASLD and non-MASLD patients had no statistically significant difference in the rate of transplant (p = 0.182), with clinically similar but statistically inferior post-transplant survival outcomes at 5 years post-transplant (88% vs. 83%; p = 0.014). Competing-risk analysis showed that MASLD candidates had higher cumulative incidence of death on the waitlist (p < 0.001), although MASLD was not independently associated with waitlist mortality when adjusting for covariates (p = 0.300). MASLD patients demonstrated increased mortality following waitlist removal (HR 1.64, 95% CI 1.14–2.35; p = 0.008), primarily among those removed for clinical deterioration (HR 1.50, 95% CI 1.01–2.23; p = 0.044). Conclusions: MASLD patients face unique challenges in liver transplant evaluation. MASLD patients are associated with higher comorbidities, increased incidence of waitlist mortality, and significantly higher mortality rate following waitlist removal. However, transplantation provides significant survival benefit with comparable outcomes to non-MASLD recipients; thus, early access to transplant may optimize outcomes for MASLD liver transplant candidates.

Background Sex disparity has been highlighted in personalized medicine for various human diseases including acute/chronic liver diseases. In the transplant community, greater graft failure risk in female-to-male liver transplantation (LT) has been repeatedly reported, and a recent study in living donor LT reported that the inferiority of female-to-male LT is shown only when donor age is ≤40 y. We aimed to analyze the United Network for Organ Sharing (UNOS) database to test if the poorer outcome of female-to-male LT changes by donor age of 40 y in deceased donor LT, as shown in living donor LT. Methods In this retrospective cohort study, 11,752 adult patients in the UNOS registry who underwent deceased donor LT between 2000–2023 were analyzed. Multivariable analysis was performed to adjust the effects from transplant years, graft ischemia time, disease severity, and others. The primary outcome was graft failure. Results Within the subgroup of recipients with ≤40 y donors, graft failure risk was significantly greater in female-to-male LT than others (vs. female-to-female, HR = 1.43 [1.16–1.76], p < 0.001; vs. male-to-female, HR = 1.46 [1.18–1.81], p < 0.001; vs. male-to-male, HR = 1.26 [1.16–1.49], p = 0.009). In contrast, within the subgroup of recipients with >40 y donors, the risk was comparable between female-to-male LT and other donor-recipient sex groups (vs. female-to-female, p = 0.907; vs. male-to-female, p = 0.781; vs. male-to-male, p = 0.937). We tested various cutoff donor ages and determined that 40 y is the best cutoff value to define the risk subgroup in female-to-male LT. Conclusions In the current study, we found that the sex disparity shown in living donor LT is also observed in deceased donor LT. That is, post-transplant graft failure risk was greater in female-to-male LT than other donor–recipient sex groups only when donor age was ≤40 y. In contrast, graft failure risk was comparable irrespective of donor-recipient sex combinations when donor age was >40 y.

Background: Current kidney transplant (KT) policies offer advantages in waiting time and organ allocation priority to pediatric patients waitlisted before 18 years old. This study evaluates the effects of this policy for patients who are on dialysis before, but not waitlisted until after, age 18.Methods: Patients aged 11–25 years and waitlisted between 2001 and 2022 for KT were identified in the OPTN STAR data file for analysis. Cohorts were defined by age and dialysis status at time of listing: Peds if < 18 yo, young adult (YA) if ≥ 18 yo; NYOD—not yet on dialysis or OD—on dialysis at time of listing, with YA groups further segregated by age at dialysis initiation. Cumulative incidence of transplant was calculated for waitlisted patients. Graft survival was assessed using Kaplan–Meier analysis and multivariable Cox proportional hazards modeling. p values < 0.01 were significant.Results: Amongst 35 764 KT registrations, candidates who initiated dialysis as pediatric patients but were not waitlisted until after turning 18 years old (YA + OD < 18) have the highest rate of nontransplantation (33.5%) and longest time on dialysis (median: 2103 days) before deceased donor (DD) KT. YA + OD < 18 patients were sixfold less likely than Peds + OD patients to undergo DDKT at 5 years after listing. YA + OD < 18 recipients had the worst post‐KT graft survival of all groups at 5 years with adjusted hazard ratio of 1.477 (95% confidence interval: 1.218–1.792) compared to Peds‐NYOD (p < 0.001).Conclusions: Current allocation policies significantly disadvantage candidates who initiate dialysis before, but are not listed until after age 18, and should be re‐examined to address these inequities.

Background.: Adoption of machine perfusion (MP) technology has rapidly expanded in liver transplantation without real-world data on utilization and outcomes, which are critical to understand the appropriate application of MP technology. Methods.: The Organ Procurement and Transplant Network/Standard Transplant Analysis and Research database was used to identify all deceased donor livers procured with intent for transplant between October 27, 2015 (date of first recorded MP) and June 30, 2023 (n = 67 795). Liver allografts were cohorted by donation after brain death (DBD; n = 59 957) or circulatory death (DCD; n = 7873) and analyzed by static cold storage (SCS) or MP preservation method. Donor demographics, organ utilization, and graft survival were evaluated. Results.: By 2023, 12.5% of all livers and 37.2% of DCD livers underwent MP preservation (82.6% normothermic, 6.7% hypothermic, and 10.8% other/unknown). Compared with SCS, MP liver donors were older (DBD: 48 versus 40 y [P < 0.001]; DCD: 43 versus 38 y [P < 0.001]) with higher body mass index (DBD: 28.8 versus 26.9 kg/m² [P < 0.001]; DCD: 27.7 versus 26.9 kg/m² [P = 0.004]). Donor livers had similar levels of macrosteatosis (median 5%). Graft utilization was higher for MP than SCS after DBD (96.4% versus 93.0%, P < 0.001) and DCD (91.4% versus 70.3%, P < 0.001) donation. Graft survival was similar between MP and SCS livers from DBD donors (P = 0.516), whereas MP-preserved grafts had superior survival from DCD donors at 1 and 3 y posttransplant (P = 0.013 and 0.037). Patient survival was similar across all groups at 3 y (P = 0.322). Conclusions.: The use of MP in liver transplantation increased rates of liver utilization and improved graft survival after DCD. Further monitoring of MP outcomes is required to understand long-term benefits.