John Paul Roberts

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Building on models developed for recipients of deceased donor liver transplant, a modified early allograft dysfunction score of bilirubin>10 or INR>1.6 at postoperative day 7 has been applied to patients undergoing living donor liver transplant. However, this score has never been validated in the living donor liver transplant population or separately analyzed in patients receiving left lobe (LL) grafts. A multicenter cohort of patients (Adult-to-Adult Living Donor Liver Transplantation Cohort Study [A2ALL]) and a single-center cohort University of California, San Francisco (UCSF) were combined. Kaplan-Meier estimates were computed for graft loss (GL), and Cox proportional hazards models were used to evaluate lab values from 1-week post-transplant. Separate multivariable risk scores for GL in recipients of right lobe (RL) and LL were created and bootstrap-validated, and their risk associations compared to modified early allograft dysfunction. In total, 724 and 156 patients with RL and LL grafts, respectively, were included in this analysis. GL occurred in 7.5% of patients with RL and 7.8% patients with LL. Recipients of RL who scored above the RL score cut-point and recipients of LL who scored above the LL score cut-point had a significantly higher risk of GL (RL: HR 6.00, 95% CI: 3.15–11.4, p p p p =0.24). We developed and validated separate risk scores for recipients of RL and LL, which may allow for earlier and more accurate identification of patients at high risk of GL and early intervention to protect the graft.

Background: Arterial conduits are effective when normal graft arterialization is not feasible in liver transplantation (LT), but long‐term outcomes for both patient and graft survival are variable across studies. Most studies combine primary and re‐transplant recipients, are limited by small sample sizes, and do not include propensity‐matched controls. Methods: We included adults undergoing primary LT at a quaternary academic center between 1/1998 and 8/2025 with iliac artery conduits. Conduit patients were propensity matched using a full matching approach. Kaplan–Meier and Cox regression evaluated the effect of arterial conduits on post‐transplant patient and graft survival and hepatic artery thrombosis (HAT). Results: Compared with controls ( n = 2695), LT recipients with iliac artery conduits ( n = 100) had similar patient and graft survival at 20 years post‐transplant. However, conduit recipients had a greater risk of early (HR 6.07, 95% CI 2.09–17.57, p = 0.001) and late HAT (HR 4.34, 95% CI 1.45–13.05, p = 0.009). Even following re‐transplantation for HAT, iliac artery conduit recipients had decreased 5‐year survival compared with controls. Conduit length, placement, and reasons for graft use were not predictive of overall HAT incidence, death, or graft failure. Conclusion: Compared with matched controls, patients with iliac artery conduits have comparable 20‐year graft and patient survival. Although conduit use may not increase mortality risk, it may identify patients with vascular susceptibility, who face high risk of HAT in both the early post‐transplant period and across long‐term follow‐up. For patients with iliac artery conduits, long‐term survival may be optimized through routine, extended follow‐up with vascular imaging to detect and manage late HAT.

Introduction: Among liver transplant recipients, Roux-en-Y gastric bypass (RYGB) may lead to postoperative malnutrition and nutrient deficiencies. Procedures such as the endoscopic ultrasound-directed transgastric ERCP (EDGE) can result in advantageous weight gain for liver transplant recipients with prior RYGB who do not respond to enteral or parenteral nutritional interventions. Methods: We present three patients who underwent EDGE for post-transplant malnutrition and weight loss. Results: EDGE resulted in weight gain across all patients. Liver transplant recipients with a history of RYGB may be at significant nutritional risk following transplant due to fat malabsorption, underestimation of resting energy expenditure, and appetite suppression mediated by neurohormonal signals. Conclusion: When traditional nutritional interventions are unsuccessful, the EDGE procedure may be an effective alternative to promote post-transplant weight gain in this unique population.

Introduction: In the USA, patients with diabetes and end-stage renal disease are less likely to undergo deceased donor kidney transplantation (DDKT) or living donor kidney transplantation (LDKT). We explored the survival benefit of DDKT and LDKT among patients with diabetes. Research design and methods: We used the United Network for Organ Sharing Standard Transplant Analysis and Research file to identify adults placed on the kidney waiting list between January 2014 and January 2024. Waitlist failure was evaluated with Fine and Gray analysis; life-years from transplant, equal survival (ES), and equal risk (ER) were extrapolated using lognormal survival regression; and life-years gained was quantified via restricted mean survival over 10 years. Results: Patients with diabetes were more likely to experience 10-year waitlist failure (subdistribution HR 2.27, 95% CI 2.23 to 2.32) and receive inferior DDKT grafts (Kidney Donor Profile Index 49% vs 35%, p<0.001) compared with patients without diabetes. For patients with diabetes, LDKT, compared with DDKT, offered more life-years from transplant (18.2 years vs 14.1 years), resulted in more life-years gained (29% vs 24% relative increase over 10 years, p<0.001) and decreased ES by 19 months and ER by 30 months. Conclusions: Proceeding to transplantation offers significant survival benefit for end-stage renal disease patients with diabetes, with LDKT offering superior survival compared with DDKT. By reducing time on the waiting list and providing superior grafts, the benefit of LDKT is particularly enhanced among patients with diabetes, and targeted efforts should be made to expand living donor access for this population.

The TransMet trial and Norwegian studies have shown excellent outcomes in highly selected patients undergoing liver transplant (LT) for unresectable colorectal liver metastases (uCRLM). Our aim is to provide an updated analysis of the current state of LT for uCRLM in the United States. Adult patients with a diagnosis of uCRLM listed for LT between December 2017 and March 2025 were identified from the United Network for Organ Sharing database and analyzed. An analysis of living donor LT (LDLT) and deceased donor LT (DDLT) was performed. During this period, 222 patients were listed, and 158 received an LT across 33 centers. Of these, 76 (48.1%) underwent LDLT, and 82 patients (51.9%) underwent DDLT. Of the 82 deceased donors, 56 (68.2%) were out-of-sequence offers. Overall, the 3-year survival and disease-free survival rates were 66.7% and 44.0%, respectively. The 3-year survival for LDLT and DDLT was 74.1% and 57.3% ( p =0.04), respectively. While these results have not yet reached the acceptable threshold established for other LT indications, they have improved and are expected to continue improving after the implementation of prioritization points. Given the potential variability of oncologic selection criteria and graft quality, we call for the standardization of nationally accepted selection criteria for listing patients for LT with uCRLM and for providing early access to high-quality organs. To achieve this, it is imperative to create, update, and maintain national databases that allow for the collection of more granular oncological variables.

Background: Some right lobe (RL) and many left lobe (LL) grafts provide multiple arterial branches that require reconstruction when arterialized back‐bleeding is not present. Reconstruction on the back table provides optimal operative conditions while use of the recipient hepatic arterial system for reconstruction provides choices of size‐matched branches.Methods: Between 2001 and 2022, we performed back table reconstruction using the recipient hepatic arterial tree on 29 of 379 (7.7%) of patients who underwent living donor liver transplantation (LDLT) at our center. All reconstructed arterial trees were anastomosed in situ using a gastroduodenal branch patch to a corresponding patch in the recipient.Results: Cold ischemia times were significantly longer in back table reconstruction patients (n = 29) compared to patients at our center with anomalous arterial anatomy and sufficient back bleeding who did not require reconstruction (n = 8, p < 0.001). One back table reconstruction patient developed hepatic artery thrombosis (HAT) 6 days after reconstruction of a two artery LL, requiring re‐transplantation. A second back table reconstruction patient developed HAT 114 days after reconstruction of a four artery RL but the graft had adequate collateral circulation and survived. HAT rates did not differ significantly between back table reconstruction patients and all other LDLT patients at our center. The 1‐ and 5‐year survival rate for patients who underwent back table reconstruction were 89.6% and 82.6%, respectively.Conclusion: Back table reconstruction of complex arterial anatomy is an option when arterialized back‐bleeding is not present and can be successfully performed utilizing the recipient hepatic tree in LDLT.

Introduction: Donor safety is of paramount importance in live donor hepatectomy, and acute pain is the most frequent complaint reported by donors. There are various approaches to managing peri- and postoperative pain following live donor hepatectomy. These include the administration of opioid and non-opioid analgesics and neuraxial-, regional- and local anesthesia. However, there is limited data on the practice patterns of pain management for live donor hepatectomy, particularly when comparing left and right lobe hepatectomies. Methods: A national electronic survey was administered to active live donor liver transplant centers in the United States, identified via the Organ Procurement and Transplantation Network directory. The Survey focused on demographics, peri- and postoperative pain management strategies, and differences in pain management practices based on left vs. right lobe hepatectomies and surgical approach. Results: We received responses from 37 centers (86%). The majority of centers (67.6%) performed both right and left live donor hepatectomies. Most centers had protocolized peri- (78.4%) and postoperative (83.8%) pain management guidelines. Perioperatively, most centers utilized a multimodal approach, based on intravenous fentanyl and/or hydromorphone combined with non-opioid adjuncts. Acetaminophen was the most common postoperative analgesic for both right (75.7%) and left (80%) lobe donors. Transversus abdominis plane blocks were the most frequently used regional anesthesia technique for both right (43.2%) and left (48%) lobe donors. Epidural catheters were placed more frequently in left (40%) than in right (32.4%) lobe donors. Conclusion: We observed a significant variation in peri- and postoperative pain management strategies after live donor hepatectomy between centers. Some centers adapt analgesic techniques based on the surgical technique (e.g., open vs. laparoscopic/robotic, and right vs left lobe hepatectomy). Export

This research study introduces a decision support model for split liver transplantation (SLT). SLT is a procedure that can save two lives with one donated liver, thereby increasing the total benefit derived from the limited number of donated livers available. SLT may also improve equity by giving transplant candidates who are physically smaller, including children, increased access to liver transplants. However, SLT is rarely used in the United States. To help quantify the benefits of increased SLT utilization and provide decision support tools, this research presents a deceased-donor liver allocation model that incorporates both efficiency and fairness objectives. We formulate the liver waitlists as a multiqueue fluid system, incorporating specifics of donor-recipient size matching and patients’ dynamically changing health conditions. Leveraging a novel decomposition result, the study finds the exact optimal matching procedure, enabling policy makers to benchmark the performance of different allocation policies against the theoretical optimal. Numerical results, utilizing data from the Organ Procurement and Transplantation Network, show that increased utilization of SLT can significantly reduce patient deaths, increase total quality-adjusted life years, and improve fairness among different patient groups.