W. Kenneth Washburn

Objective: To report real-world data on hypothermic oxygenated perfusion (HOPE) and normothermic machine perfusion (NMP) in liver transplantation (LT). Summary Background Data: Real-world comparisons between HOPE and NMP are limited and methodologically challenging due to heterogeneity in donor and recipient risk profiles and regional differences in practice patterns. Methods: This international cohort study analyzed consecutive NMP-preserved LTs performed at 15 predominantly North American centers between 2021 and 2025. Outcomes were compared with the European HOPE-REAL cohort, comprising HOPE-treated LTs from 22 centers between 2012 and 2021. Risk-adjusted analyses were performed, stratified by graft type and risk category. Imbalances in baseline characteristics were addressed using entropy balancing. Results: A total of 954 NMP-treated and 1202 HOPE-treated grafts were analyzed, revealing substantial differences in donor risk. Extended-criteria DBD grafts accounted for 30% versus 64%, and futile DCD grafts for 10% versus 30%, in the NMP and HOPE cohorts, respectively. In the NMP cohort, death-censored graft survival at 1, 2, and 3 years exceeded 96% for DBD grafts and 94% for DCD grafts. Comparable outcomes were observed in the HOPE cohort, with 93% survival in DBD and 87% in DCD grafts at up to 3 years, despite significantly higher donor risk in the HOPE-DCD cohort. After risk adjustment, death-censored graft survival remained similar between both modalities across graft types and risk categories. Conclusions: Real-world data on HOPE-treated and NMP-treated LT demonstrate excellent outcomes. Nevertheless, compared with HOPE, further high-quality evidence and longer preservation time is needed to substantiate the clinical benefits of NMP in high-risk grafts.

Aim: Post‐liver transplant (LT) alcohol relapse complicates long‐term outcomes and organ allocation. The traditional “six‐month abstinence rule” remains widely used, but relapse risk is also shaped by psychosocial, socioeconomic, and psychiatric factors. We examined the impact of pre‐LT abstinence duration on post‐LT alcohol relapse and developed a multivariable risk model integrating abstinence, psychosocial assessment, and socioeconomic status. Methods: In this single‐center retrospective study, 383 adults undergoing LT for alcohol‐related liver disease were included. Results: Any post‐LT alcohol relapse occurred in 20.9% ( n = 80). Relapse phenotypes were non‐mutually exclusive: sustained alcohol use (77.5%), harmful drinking (68.8%), and recurrent ALD (46.3%). On multivariable analysis, shorter pre‐LT abstinence, higher Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT) scores, and higher educational attainment were independently associated with relapse. Each additional month of abstinence reduced relapse odds by 4%, whereas each one‐point increase in SIPAT increased relapse odds by 3%. Cumulative risk curves demonstrated a non‐linear relationship between abstinence duration and relapse, with risk peaking around 9 months and declining thereafter across all relapse phenotypes. A prediction model combining abstinence duration, SIPAT score, and education achieved an area under the receiver operating characteristic curve (AUC) of 0.70, with consistent performance on fivefold cross‐validation. Conclusion: These findings support a multifactorial approach to relapse risk stratification that goes beyond a fixed 6‐month abstinence rule. Incorporating abstinence duration together with structured psychosocial assessment and education level may better inform both transplant listing decisions and the intensity of post‐LT addiction care for patients.

Introduction: Most studies on socioeconomic factors in liver transplantation (LT) rely on national databases without considering regional characteristics. This study uniquely investigated how educational attainment, income, and insurance status simultaneously impact early readmission and graft survival among LT recipients at a single center in Ohio, accounting for county‐level characteristics. Methods: This retrospective observational cohort study included 782 adult primary orthotopic LT recipients at Ohio State University Wexner Medical Center (2016–2023). Educational attainment was stratified into high, intermediate, and low levels. Income was estimated from county‐level census data. Insurance status was categorized as private or public. Graft survival (GS) and 30‐day readmission were analyzed using Kaplan–Meier methodology and multivariate regression. Results: Higher education correlated with higher income ( p < 0.001) and lower BMI ( p = 0.04). Three‐year GS rates were 92.7%, 88.6%, and 86.0% for high, intermediate, and low educational groups, respectively (high vs. low, p = 0.01). Private insurance showed superior GS compared to public insurance (90.2% vs. 83.5%, p = 0.02). Multivariate analysis identified low education (HR: 1.61, 95% CI: 1.01–2.59, p = 0.047 with high educational level as reference) as an independent risk factor for graft failure. The high educational group had significantly lower 30‐day readmission rates compared to the intermediate group (27.4% vs. 37.0%, p = 0.047). Conclusion: By focusing exclusively on Ohio's population and comprehensively analyzing multiple socioeconomic factors simultaneously, this study demonstrates that educational attainment independently influences post‐LT outcomes. Patients with lower educational backgrounds may benefit from enhanced post‐discharge education and more intensive follow‐up.

Background.: The widespread use of normothermic machine perfusion (NMP) has enabled greater utilization of donation after circulatory death (DCD) liver grafts for transplantation. Use of NMP can cost an additional $40 000–$100 000 The aim of our study was to see whether the use of NMP would lower postoperative costs after DCD liver transplantation (LT). Methods.: Retrospective data of all DCD LTs performed at our center between August 19, 2022, and May 31, 2024, were analyzed. The OrganOx metra device, back-to-base, was used for NMP at our center. United Network for Organ Sharing data were used to present national DCD LT volumes and waitlist outcomes. Results.: Sixty-seven NMP and 44 static cold storage transplants were performed. In the NMP group, donors were older (50 versus 45 y, P = 0.0260), were at increased risk (US donor risk index 2.43 versus 2.12, P = 0.006), incidence of early allograft dysfunction (42% versus 75%, P = 0.0008) and postreperfusion syndrome (25% versus 48%, P = 0.0239) was lower, and recipients had better native kidney function at 3 mo (estimated glomerular filtration rate 73 versus 62 mL/min/1.73 m², P = 0.0205). Use of NMP did not decrease postoperative direct costs. On multivariate analysis, an additional 56 min of cold ischemic time and the presence of postreperfusion syndrome increased postoperative direct costs by $14 700 and $23 100, respectively. Conclusions.: Use of NMP does not decrease postoperative direct costs after DCD LT. However, with the use of NMP, a greater number of DCD liver grafts can be used, from a broader range of donors, wait time to transplant can be reduced, and waitlist survival can be improved while improving relevant clinical outcomes. The overall cost savings achieved by transplanting patients quickly at low Model for End-stage Liver Disease scores and improving waitlist morbidity should be further explored.

Background and Aim: Advances in immunosuppression and surgical techniques in liver transplantation (LT) have significantly improved patient outcomes, but donor utilization and access to LT remain a challenge. The past decade has seen significant strides in donor pool expansion with acceptable clinical outcomes, while improved patient selection and advances in the management of chronic liver disease and post-LT complications have promoted better allograft health. This document aims to provide an evidence-based guideline on the management of graft complications, immunosuppression, graft rejection and recurrent disease in adult LT recipients. Methods: A multidisciplinary writing group of experts (transplant hepatologists, surgeons, pathologist, and psychiatrist) was tasked to formulate clinical questions (in PICO format) that arise during routine management of adult LT recipients. The writing group 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 group categorized the strength of recommendations based on the level of evidence, risk -benefit ratio, and patient preferences. Conclusion: While robust clinical trial data provide strong guidance on some aspects of graft management in LT such as machine perfusion and immunosuppression efficacy and safety, a significant component of graft management is derived from retrospective cohort data, extrapolation of data from other solid organ transplants, or expert opinion, including the treatment of antibody-mediated rejection. Finally, further investigation is needed to truly optimize the management of the liver allograft, including the prevention of recurrent alcohol-associated, metabolic dysfunction-associated steatotic and immune-mediated liver diseases.

Kidney allograft torsion (KAT) is a rare but critical complication of kidney transplantation that can lead to graft loss due to acute ischemia. This report presents a case of KAT resulting in graft loss 9 months following intraperitoneal simultaneous pancreas and kidney (SPK) transplant and reviews previous reports to identify potential high‐risk features. A 38‐year‐old female with end‐stage renal disease secondary to Type 1 diabetes mellitus underwent an intraperitoneal enteric drained SPK transplant. Nine months post‐transplantation, she presented with nausea, vomiting, severe abdominal pain, decreased urine output, and diarrhea. An ultrasound showed moderate hydronephrosis and no blood flow to the renal hilum. Exploratory laparotomy revealed a necrotic renal allograft twisted 360° counterclockwise on its vascular pedicles. Despite detorsion, the graft showed no signs of viability, necessitating transplant nephrectomy. This case highlights the rarity and severity of KAT, particularly in intraperitoneal kidney transplants. The patient’s low body mass index (BMI) (23.4 kg/m ² ), female sex (wider pelvis), and minimal intra‐abdominal adhesions may have contributed to increased graft mobility, predisposing to KAT. Other potential risk factors include elongated vascular pedicle and immunosuppression‐related reduced adhesion formation. The nonspecific presentation of KAT emphasizes the need for high clinical suspicion and prompt ultrasonographic evaluation in cases of graft abnormalities. This report underscores the importance of considering patient‐ and graft‐specific factors in assessing KAT risk and the critical nature of early detection and intervention to prevent graft loss.

Background. Variation in donation after circulatory death (DCD) organ recovery and liver transplant practices exist among transplant centers. This study aimed to evaluate these practices among centers in the United States. Methods. Scientific Registry of Transplant Recipients data were accessed to identify centers that performed liver transplantation in 2021 and 2022. Surveys were sent to transplant centers that consistently performed ≥5 DCD liver transplants per year. Results. DCD liver transplants were performed by 95 centers (65.1%) of the 146 liver transplant centers in the United States. Survey results were recorded from 42 centers that consistently performed ≥5 DCD liver transplants per year, with a 59.5% response rate. Withdrawal-to-asystole and agonal time were used to define donor warm ischemia time (WIT) in 16% and 84% centers, respectively. Fifty-six percent of the centers did not use oxygen saturation to define donor WIT. Systolic blood pressure cutoffs used to define agonal time varied between 50 and 80 mm Hg, donor age cutoffs ranged between 55 and 75 y, and cold ischemia times varied between 4 and 10 h. Seventy-six percent of centers used normothermic machine perfusion for DCD liver transplantation. Conclusions. This study highlights the wide variation in use, recovery, and definition of donor WIT. Using national data to rigorously define best practices will encourage greater utilization of this important donor resource. Export

Transplant oncology is a relatively new field in which transplantation is used to treat patients who would otherwise be unresectable. New anticancer treatment paradigms using tumor and transplant immunology and cancer immunogenomics are emerging. In turn, liver transplantation (LT) has become a potential therapy for certain patients with colorectal cancer (CRC) with liver metastasis, hepatocellular (HCC), cholangiocarcinoma (CCA), and metastatic neuroendocrine tumor (NET) of the liver. Although there are established criteria for LT in HCC, evidence regarding LT as a treatment modality for certain gastrointestinal malignancies is still debated. The aim of this review is to highlight updates in the role of LT for certain malignancies, including HCC, metastatic CRC, hilar CCA, and neuroendocrine tumor (NET), as well as contextualize LT use and discuss controversies in transplant oncology.