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INTRODUCTION: Living kidney donor evaluation is a lengthy and complex process requiring in-person visits. Access to transplant centers, travel costs, lost wages, and dependent care arrangements are barriers to willing donors initiating evaluation. Telemedicine can help streamline and epedite the evaluation process. We aimed to deeply understand donor experiences and preferences using hybrid telemedicine video/in-person visits to ease access to donor evaluation or counseling. METHODS: We conducted in-depth, semistructured interviews with donors or donor candidates who completed their evaluation through telemedicine/in-person, or in-person only visits at a tertiary transplant center between November 27, 2019 and March 1, 2021. Enrollment continued until data saturation was reached (interviews with 20 participants) when no new information emerged from additional interviews. Transcripts were analyzed using inductive thematic analysis. RESULTS: Eight themes were identified as follows: (i) reducing financial and logistical burdens (minimizing travel time and travel-related expenses), (ii) enhancing flexibility with scheduling (less time off work and child or family caregiver arrangements), (iii) importance of a walkthrough and establishing shared understanding, (iv) supporting information with technology and visual aids, (v) key role of the coordinator, (vi) preferred visit by provider role (meeting donor surgeon in-person to create rapport and engaging primary care provider in donor evaluation/follow-up), (vii) comparing modality differences in human connection, and (viii) opportunity for family and support network engagement (allowing loved ones to be involved in telemedicine visits irrespective of geographic locations and pandemic restrictions). CONCLUSION: Telemedicine/in-person hybrid model can make donor evaluation more accessible and convenient. Our findings help inform about determinants that influence the adoption of telemedicine to initiate donor evaluation to motivate willing donors. In addition, our results call for policy and legislation that support telemedicine services for living donor kidney transplantation across states.

BACKGROUND: Residence in rural areas is often a barrier to health care access. To date, differences in access to kidney transplantation among children who reside in rural and micropolitan areas of the US have not been explored. METHODS: A retrospective cohort study of children

BACKGROUND: Kidney transplant (KT) candidates with HIV face higher mortality on the waitlist compared with candidates without HIV. Because the HIV Organ Policy Equity (HOPE) Act has expanded the donor pool to allow donors with HIV (D + ), it is crucial to understand whether this has impacted transplant rates for this population. METHODS: Using a linkage between the HOPE in Action trial (NCT03500315) and Scientific Registry of Transplant Recipients, we identified 324 candidates listed for D + kidneys (HOPE) compared with 46 025 candidates not listed for D + kidneys (non-HOPE) at the same centers between April 26, 2018, and May 24, 2022. We characterized KT rate, KT type (D + , false-positive [FP; donor with false-positive HIV testing], D - [donor without HIV], living donor [LD]) and quantified the association between HOPE enrollment and KT rate using multivariable Cox regression with center-level clustering; HOPE was a time-varying exposure. RESULTS: HOPE candidates were more likely male individuals (79% versus 62%), Black (73% versus 35%), and publicly insured (71% versus 52%; P

Objective: Obesity stands as a risk factor for the chronic kidney disease. The objective of this study was to investigate the relationship between early renal function following kidney donation and the measurements of body fat components. Methods: In total, 86 donors followed up for at least 6 months postoperatively were included. Height and weight measurements and results of laboratory analysis of all donors were recorded retrospectively. Visceral adipose tissue (VAT), subcutaneous adipose tissue (SAT), hepatic fat (HF), pancreatic fat (PF) and splenic fat (SF) measurements were performed, and pancreatic splenic fat fraction difference (P−S) and pancreatic splenic fat fraction ratio (P/S) were calculated by a radiologist using the records of preoperative computed tomography scans of donors. Results: The estimated glomerular filtration rate (eGFR), serum creatinine and spot urinary microalbumin/creatinine ratio values of the donors at the sixth month postoperatively were statistically different from those of the preoperative values (p < 0.001). In addition, the individuals were divided into two categories based on the postoperative eGFR: ⩾ 60 mL/min/1.73 m2 and < 60 mL/min/1.73 m2. Age, low-density lipoprotein (LDL) level and VAT/SAT ratio were lower in group eGFR: ⩾ 60 (p < 0.001, p = 0.03, p = 0.007, respectively). Age and VAT/SAT ratio were the parameters found to be affecting the eGFR significantly, and VAT/SAT ratio (0.729, 95% CI: 0.602–0.856, p = 0.007) had higher predictive value in receiver operating characteristic curve (ROC). Conclusion: Preoperative measurements of body fat components may provide significant information to predict postoperative renal functions of kidney donor candidates. Level of evidence: Not applicable. [ABSTRACT FROM AUTHOR]

Background: There is limited information on the ethical issues encountered in living donor organ transplants performed on refugees and asylum seekers. This study investigates the ethical challenges faced by Syrian refugees under temporary protection in Türkiye who engage in living donor organ transplants. Methods: From April to July 2022 in Istanbul, the research employed a qualitative design involving semi-structured, in-depth interviews with 27 participants, including organ donors and recipients. The analysis utilized a thematic analytic method. Results: The findings elucidate two principal themes related to ethical concerns: justice and autonomy. Under the justice theme, several sub-themes emerged, highlighting the multifaceted challenges Syrian refugees face in accessing healthcare services. These include migration and language barriers, significantly impeding their ability to understand medical procedures and rights. Financial difficulties and restricted movement within the country further complicate their access to necessary healthcare. Despite these hurdles, refugees benefit from free access to organ transplantation services and medications, a policy underscoring Türkiye's commitment to healthcare equity for protected populations. The autonomy theme addresses the ethical handling of donor consent and motivation. The results indicate that Syrian refugees undergo a transplantation process free from coercion, with rigorous oversight by organ transplant ethics committees ensuring the prevention of donor abuse. However, despite these protective measures, challenges persist in the informed consent process, primarily due to language barriers that hinder effective communication between healthcare providers and patients. While the efforts of healthcare professionals to assist are recognized as alleviating some difficulties, the broader issues of access to comprehensive health services remain a significant concern. These barriers suggest a need for enhanced linguistic and financial support to improve healthcare accessibility for refugees. Conclusions: This study posits that the healthcare framework provided by Türkiye to Syrians under temporary protection can serve as a model for international human rights and social justice. However, it also emphasizes the importance of addressing the persistent obstacles that limit healthcare access for asylum seekers. Recommendations for policy enhancements focus on improving language services, increasing financial support, and expanding the accessibility of comprehensive health services to ensure equitable health outcomes for refugees. [ABSTRACT FROM AUTHOR]

Introduction: Living liver donation improves survival of end‐stage liver disease (ESLD) patients. Yet, it continues to represent a small proportion of United States (U.S.) liver transplantation with existing racial disparities. We investigated the interplay of donor–recipient relationship and donor race to understand donor subgroups with no significant increase. Methods: We studied 4407 living liver donors in the U.S. from January 1, 2012, to December 31, 2022 (median age = 36 years, and 59% were biologically related to the recipient). We quantified the change in the number of donors per 3‐year increment using negative binomial regression (incidence rate ratio [IRR]), stratified by donor–recipient relationship and race/ethnicity. Results: Among biologically related donors, the observed annual number of White donors increased from 146 to 253, Hispanic donors from 18 to 53, and Black donors decreased from 11 to 10. Among unrelated donors, White donors increased from 65 to 221, Hispanic donors from 4 to 25, and Black donors from 3 to 11. For the IRR of biologically related donors aged <40 and ≥40 years, White donors increased by 18% and 22%; Hispanic donors increased by 25% and 54%; and Black donors did not change. Likewise, the IRR of unrelated donors aged <40 and ≥40 years, White donors increased by 48% and 55%; Hispanic donors increased by 52% and 65%; and Black donors did not change. Conclusions: While biologically related donors represent the majority of donors, unrelated donors have substantially risen in recent years, primarily driven by White donors. Although the rate of unrelated donations increased among Hispanic donors, the absolute number remains very small (≤25 donors/year). Interventions are needed to increase education among Hispanic and Black communities to grow unrelated living liver donations across race/ethnicity. [ABSTRACT FROM AUTHOR]

Abstract Background There is limited information on the ethical issues encountered in living donor organ transplants performed on refugees and asylum seekers. This study investigates the ethical challenges faced by Syrian refugees under temporary protection in Türkiye who engage in living donor organ transplants. Methods From April to July 2022 in Istanbul, the research employed a qualitative design involving semi-structured, in-depth interviews with 27 participants, including organ donors and recipients. The analysis utilized a thematic analytic method. Results The findings elucidate two principal themes related to ethical concerns: justice and autonomy. Under the justice theme, several sub-themes emerged, highlighting the multifaceted challenges Syrian refugees face in accessing healthcare services. These include migration and language barriers, significantly impeding their ability to understand medical procedures and rights. Financial difficulties and restricted movement within the country further complicate their access to necessary healthcare. Despite these hurdles, refugees benefit from free access to organ transplantation services and medications, a policy underscoring Türkiye’s commitment to healthcare equity for protected populations. The autonomy theme addresses the ethical handling of donor consent and motivation. The results indicate that Syrian refugees undergo a transplantation process free from coercion, with rigorous oversight by organ transplant ethics committees ensuring the prevention of donor abuse. However, despite these protective measures, challenges persist in the informed consent process, primarily due to language barriers that hinder effective communication between healthcare providers and patients. While the efforts of healthcare professionals to assist are recognized as alleviating some difficulties, the broader issues of access to comprehensive health services remain a significant concern. These barriers suggest a need for enhanced linguistic and financial support to improve healthcare accessibility for refugees. Conclusions This study posits that the healthcare framework provided by Türkiye to Syrians under temporary protection can serve as a model for international human rights and social justice. However, it also emphasizes the importance of addressing the persistent obstacles that limit healthcare access for asylum seekers. Recommendations for policy enhancements focus on improving language services, increasing financial support, and expanding the accessibility of comprehensive health services to ensure equitable health outcomes for refugees.

BACKGROUND & AIMS: Carcinoembryonic antigen-related cell adhesion molecule 1 (CC1) acts through homophilic and heterophilic interactions with T cell immunoglobulin domain and mucin domain-containing protein 3 (TIM-3), which regulates innate immune activation in orthotopic liver transplantation (OLT). We investigated whether cluster of differentiation (CD) 4+ T cell-dependent CC1-TIM-3 crosstalk may affect OLT outcomes in mice and humans. METHODS: Wild-type (WT) and CC1-deficient (CC1 knock-out [KO]) mouse livers were transplanted into WT, CC1KO, or T-cell TIM-3 transgenic (TIM-3Tg)/CC1KO double-mutant recipients. CD4+ T cells were adoptively transferred into T/B cell-deficient recombination activating gene 2 protein (Rag2) KO recipients, followed by OLT. The perioperative liver-associated CC1 increase was analyzed in 50 OLT patients. RESULTS: OLT injury in WT livers deteriorated in CC1KO compared with CC1-proficient (WT) recipients. The frequency of TIM-3+CD4+ T cells was higher in WT than CC1KO hosts. Reconstitution of Rag2KO mice with CC1KO-T cells increased nuclear factor (NF)-κB phosphorylation and OLT damage compared with recipients repopulated with WT T cells. T-cell TIM-3 enhancement in CC1KO recipients (WT → TIM3Tg/CC1KO) suppressed NF-κB phosphorylation in Kupffer cells and mitigated OLT injury. However, TIM-3-mediated protection was lost by pharmacologic TIM-3 blockade or an absence of CC1 in the donor liver (CC1KO → TIM-3Tg/CC1KO). The perioperative CC1 increase in human OLT reduced hepatocellular injury, early allograft dysfunction, and the cumulative rejection rate. CONCLUSIONS: This translational study identifies T cell-specific CC1 signaling as a therapeutic means to alleviate OLT injury by promoting T cell-intrinsic TIM-3, which in turn interacts with liver-associated CC1 to suppress NF-κB in Kupffer cells. By suppressing peritransplant liver damage, promoting T-cell homeostasis, and improving OLT outcomes, recipient CC1 signaling serves as a novel cytoprotective sentinel.

IntroductionCatecholamine vasopressors such as norepinephrine are the standard drugs used to maintain mean arterial pressure during liver transplantation. At high doses, catecholamines may impair organ perfusion. Angiotensin II is a peptide vasoconstrictor that may improve renal perfusion pressure and glomerular filtration rate, a haemodynamic profile that could reduce acute kidney injury. Angiotensin II is approved for vasodilatory shock but has not been rigorously evaluated for treatment of hypotension during liver transplantation. The objective is to assess the efficacy of angiotensin II as a second-line vasopressor infusion during liver transplantation. This trial will establish the efficacy of angiotensin II in decreasing the dose of norepinephrine to maintain adequate blood pressure. Completion of this study will allow design of a follow-up, multicentre trial powered to detect a reduction of organ injury in liver transplantation.Methods and analysisThis is a double-blind, randomised clinical trial. Eligible subjects are adults with a Model for End-Stage Liver Disease Sodium Score ≥25 undergoing deceased donor liver transplantation. Subjects are randomised 1:1 to receive angiotensin II or saline placebo as the second-line vasopressor infusion. The study drug infusion is initiated on reaching a norepinephrine dose of 0.05 µg kg-1 min-1 and titrated per protocol. The primary outcome is the dose of norepinephrine required to maintain a mean arterial pressure ≥65 mm Hg. Secondary outcomes include vasopressin or epinephrine requirement and duration of hypotension. Safety outcomes include incidence of thromboembolism within 48 hours of the end of surgery and severe hypertension. An intention-to-treat analysis will be performed for all randomised subjects receiving the study drug. The total dose of norepinephrine will be compared between the two arms by a one-tailed Mann-Whitney U test.Ethics and disseminationThe trial protocol was approved by the local Institutional Review Board (#20-30948). Results will be posted on ClinicalTrials.gov and published in a peer-reviewed journal.Trial registration numberClinicalTrials.govNCT04901169.

Background : Living donor liver transplantation (LDLT) is an effective treatment for patients with end-stage liver disease. This study was performed to evaluate the outcomes of the initial series of LDLT procedures performed in the Republic of Uzbekistan and to demonstrate that liver transplantation is viable under the conditions in this country. Methods : Between October 2021 and December 2023, we performed 40 LDLTs. We evaluated both immediate and long-term outcomes. Results : Thrombosis of the hepatic artery developed in one case (2.5%). Arterial anastomotic stenoses were diagnosed in three cases (7.5%) and were successfully treated with endovascular balloon vasodilation. Splenic artery steal syndrome arose in three patients (7.5%) and was managed with endovascular embolization of the splenic artery. One patient (2.5%) developed portal vein thrombosis. Portal vein stenosis occurred in two patients (5%) at 10 months posttransplantation and was addressed with endovascular balloon angioplasty, yielding good clinical outcomes. Biliary complications were observed in 45% of the cases, with bile leakages accounting for 89% of these issues and strictures of the biliary anastomoses for 11%. The in-hospital mortality rate was 12.5%. Conclusions: Our research findings and analysis of complications align with the international literature, and the results are deemed acceptable during this implementation phase of the liver transplantation program. Accordingly, liver transplantation is feasible in the Republic of Uzbekistan; however, improvements in surgical and therapeutic methods are necessary to minimize the development of both early and late postoperative complications.

Key points The study found a higher incidence of chronic rhinosinusitis (CRS) and recalcitrant CRS in cadaveric organ transplant recipients compared to those receiving living donor transplants. Recipients of cadaveric transplants were 1.32 times more likely to develop CRS and 1.68 times more likely to develop medically recalcitrant CRS. Living kidney transplants significantly reduced the risk of developing CRS (OR = 0.12) and recalcitrant CRS (OR = 0.11), highlighting a potentially protective effect against these conditions. In contrast, cadaveric liver transplants were associated with an increased risk of CRS and medically recalcitrant CRS. Kaplan–Meier survival analysis indicated a significant difference in time to CRS onset between cadaveric and living donor transplants. Median time to CRS onset was longer for living donor recipients (21.1 months) compared to cadaveric recipients (15.6 months). This study underscores the need for transplant teams and otolaryngologist to consider donor type during transplant follow‐up due to differing risks of CRS development. [ABSTRACT FROM AUTHOR]

Background: Fresh osteochondral allograft transplantation is a good treatment option of cartilage defects. However, this treatment option is not available in all countries due to limited graft availability and tissue banks limitations. The purpose of this study is to assess the short term functional and imaging outcomes of fresh osteochondral allograft transplantation in the knee using the femoral head of living donors. Hypothesis: Fresh osteochondral allografts from the femoral heads of living donors is a valid graft source for management of distal Femur cartilage defects. This technique can improve functional knee scores with good radiological outcomes. Study Design: Prospective case series. Methods: Fifteen patients with full thickness cartilage defects of the distal femur underwent osteochondral allograft transplantation from the femoral heads of living donors. Grafts were transplanted by both shell and multiple dowels techniques. The average follow up duration was 18.3 months (range, 12–25 months). Patients were evaluated by Lysholm and International Knee Documentation Committee (IKDC) scores, radiography and MR imaging using Osteochondral Allograft MRI Scoring System (OCAMRISS). Results: There was a statistically significant improvement (P < 0.001) in both Lysholm and IKDC average scores at 6 months and 12 months postoperative. Postoperative MRI was done at an average 6.8 months (range, 5–11 months) postoperative. The mean total OCAMRISS score was 3.4 (range, 1–7). A second look arthroscopy was done in four patients and showed intact articular cartilage in all three patients. Conclusion: Femoral head of living donors is a valid new source for fresh osteochondral allograft transplantation of knee osteochondral lesions. Short term results showed improvement in clinical assessment scores. Follow up imaging showed graft incorporation and good MRI scores. Key message: What is known about the subject: Fresh osteochondral allograft transplantation is a successful treatment option for full thickness cartilage lesions in the knee. Osteochondral allografts are harvested from the knee of young deceased donors. There are limitations regarding the graft availability and postmortem tissue banks. What this study adds to existing knowledge: In our study, we used fresh osteochondral allografts from the femoral heads of living donors. The donor population is the non-arthritic patients who undergo hip replacement for traumatic neck femur fractures. This will provide a new source for fresh osteochondral allografts in countries who lack postmortem tissue banks. Even with available tissue banks, this provides an additional stable source of grafts which may expand the indications for osteochondral allografts and facilitate preoperative scheduling. To our knowledge, this is the first clinical study that used the femoral head of living donors as a source of fresh osteochondral allografts in the knee. [ABSTRACT FROM AUTHOR]

Background: Living donor liver transplantation (LDLT) is the best option for end-stage liver disease patients. Older potential donors are increasingly requesting donation. This study aims to systematically assess the differences in donor perioperative and postoperative complications, mortality, and quality of life (QoL) between younger and older living liver donors. Materials and AXmethods: Embase, Medline, and Cochrane were searched for studies published between 2002 and 2 June 2023. Donor complications, major complications, biliary complications, mortality, and QoL were systematically reviewed, including metaanalyses. Donors aged >50 years were considered older. The methodological quality of the studies was assessed using the Newcastle-Ottawa quality assessment Scale. Results: The search yielded 8320 studies, of which 17 were included. The risk ratio (RR) for complications in younger donors was 1.08 [0.90-1.31] (P= 0.41). RRs for major complications in younger donors were 0.98 [0.64, 1.48] and 0.89 [0.50, 1.57] using Clavien-Dindo =III and = IIIb as major complication. RR for biliary complications in younger donors was 1.59 [1.05-2.42] (P= 0.03). Mortality rate in younger donors was 47/13 238 (0.4%) and in older donors 13/989 (1.3%). Physical component summary (PCS) in younger donors was 51.87 and in older donors 51.29. Mental component summary (MCS) in younger donors was 52.93 and in older donors 55.40. Conclusion: Older donors do not have a higher complication or mortality rate than younger donors after LDLT. They may have a lower rate of biliary complications. Additionally, older donors have a similar QoL after LDLT. With careful selection, older donors can be included in screening programs for living liver donation to expand the donor pool. [ABSTRACT FROM AUTHOR]

Background Validating the expanded criteria for living donor liver transplantation for hepatocellular carcinoma using national data is highly significant. The aim of this study was to evaluate the validity of the new Japanese criteria for living donor liver transplantation for hepatocellular carcinoma patients and identify factors associated with a poor prognosis using the Japanese national data set. Methods The study population comprised patients who underwent living donor liver transplantation for hepatocellular carcinoma at 37 centres in Japan between 2010 and 2018. In a nationwide survey, the overall survival and recurrence-free survival rates were evaluated based on the new Japanese criteria for applying the 5-5-500 rule when extending the indication beyond the Milan criteria. Prognostic factors within the Japanese criteria were determined using the Cox proportional hazards model. Results Patients within (485 patients) and beyond (31 patients) the Japanese criteria exhibited 5-year overall survival rates of 81% and 58% and 5-year recurrence-free survival rates of 77% and 48% respectively. Patients who met the Milan criteria, but not the 5-5-500 rule, had poorer outcomes. Multivariate analysis for 474 patients identified a neutrophil-to-lymphocyte ratio greater than or equal to 5 and a history of hepatectomy as independent risk factors. Conclusion This nationwide survey confirms the validity of the Japanese criteria. The poor prognostic factors within the Japanese criteria include a neutrophil-to-lymphocyte ratio greater than or equal to 5 and previous hepatectomy. [ABSTRACT FROM AUTHOR]

Background: Organ transplantation is a critical, life-saving technique for individuals suffering from end-stage organ failure. Human organs are obtained from brain dead donors following the pronouncement of cardiac death, or from living donors. Among the numerous kinds of organ transplants, living donor liver transplantation stands out. Objective: To evaluate living donors' cognitive distortion regarding perioperative anesthetic concerns and anesthesiologists. Patients and Methods: A cross-sectional study included 120 living donors and was carried out at the National Liver Institute Hospital, during the period of the study. Results: There was significant relation among knowledge of donor regarding types of anesthesia with sex, operative history, job, education, marital status, the relation of the donor to recipient, the reason for donation, donor concern regarding problem in anesthesia, knowledge of donor about years or faculty of anesthetist, donor concern regarding preference of male-female anesthetist, fear of long hospital stay, fear of anesthesia and surgery, intraoperative awareness, disclosing personal matter, attendance of the anesthetist of the whole operation, fear of needles, fear of nausea and vomiting, knowledge of donor about the importance of preoperative visit, and donor concern if the liver will grow again (p<0.05). Conclusion: Although most donors made the decision to donate by themselves, and they looked strong and committed in their decision, a large proportion of donors were concerned about potential problems of organ donation and the implications on their life afterward. A specific and rigorous psychosocial evaluation methodology is required to assist and safeguard their decision before and after donation. [ABSTRACT FROM AUTHOR]

Background: De novo malignancies (DNMs) are a major adverse event after solid organ transplantation; however, their characteristics and recent trends after living‐donor liver transplantation (LDLT) remain unclear. Methods: We retrospectively reviewed 1781 primary LDLT recipients (1990–2020) and annually calculated standardized incidence ratios (SIRs) of DNMs compared to the age‐adjusted Japanese general population. Results: After 21 845 person‐years follow‐up, 153 DNM lesions (8.6%) were identified in 131 patients (7.4%). The incidence was 0.007 person‐years. DNMs included 81 post‐transplant lymphoproliferative disorders (PTLDs), 14 colorectal, 12 lung, and 12 gastric cancers, and so on. Comorbid DNMs significantly worsened recipient survival than those without (p <.001). The 5‐ and 10‐year recipient survival after DNM diagnosis were 65% and 58%, respectively. Notably, SIR1993–1995: 8.12 (95% CI: 3.71–15.4, p <.001) and SIR1996–1998: 3.11 (1.34–6.12, p =.01) were significantly high, but had decreased time‐dependently to SIR2005–2007: 1.31 (0.68–2.29, p =.42) and SIR2008–2010: 1.34 (0.75–2.20, p =.33), indicating no longer significant difference in DNMs development. Currently, however, SIR2014–2016: 2.27 (1.54–3.22, p <.001) and SIR2017–2019: 2.07 (1.40–2.96, p <.001) have become significantly higher again, reflecting recent aging of recipients (>50 years) and resultant increases in non‐PTLD DNMs. Furthermore, characteristically in LDLT, the fewer the donor‐recipient HLA‐mismatches, the less the post‐transplant DNMs development. Conclusion: DNM development after LDLT was significantly higher than in the general population due to higher PTLD incidence (1993‐1998), but once became equivalent (2005‐2013), then significantly increased again (2014‐2019) due to recent recipient aging and resultant increase in solid cancers. [ABSTRACT FROM AUTHOR]

Introduction: Intrahepatic cholangiocarcinoma (iCC) is the liver's second most common neoplasm. Until now, surgery is the only curative option, but only 35% of the cases are considered resectable at the diagnosis, with a post-resection survival of around 30%. Advancements in surgical techniques and perioperative care related to liver transplantation (LT) have facilitated the expansion of indications for hepatic neoplasms. Method: This study is a comprehensive review of the global experience in living donor LT (LDLT) for treating iCC and describes our first case of LDLT for an unresectable iCC. Results: While exploring LT for intrahepatic cholangiocarcinoma dates to the 1990s, the initial outcomes were discouraging, marked by poor survival and high recurrence rates. Nevertheless, contemporary perspectives underscore a reinvigorated emphasis on extending the frontiers of LT indications within the context of the "oncologic era." The insights gleaned from examining explants, wherein incidental iCC was categorized as hepatocellular carcinoma in the preoperative period, have demonstrated comparable survival rates to small hepatocellular carcinoma. These findings substantiate the potential viability of LT as a curative alternative for iCC. Another investigated scenario pertains to "unresectable tumors with favorable biological behavior," LT presents a theoretical advantage by providing free margins without the concern of a small future liver remnant. The constraint of organ shortage persists, particularly in nations with low donation rates. LDLT emerges as a viable and secure alternative for treating iCC. Conclusion: LDLT is an excellent option for augmenting the graft pool, particularly in carefully selected patients. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To examine whether body mass index (BMI) changes modify the association between kidney donation and incident hypertension. BACKGROUND: Obesity increases hypertension risk in both general and living kidney donor (LKD) populations. Donation-attributable risk in the context of obesity, and whether weight change modifies that risk, is unknown. METHODS: Nested case-control study among 1558 adult LKDs (1976-2020) with obesity (median follow-up: 3.6 years; interquartile range: 2.0-9.4) and 3783 adults with obesity in the Coronary Artery Risk Development in Young Adults (CARDIA) and Atherosclerosis Risk in Communities (ARIC) studies (9.2 y; interquartile range: 5.3-15.8). Hypertension incidence was compared by donor status using conditional logistic regression, with BMI change investigated for effect modification. RESULTS: Overall, LKDs and nondonors had similar hypertension incidence [incidence rate ratio (IRR): 1.16, 95% confidence interval (95% CI): 0.94-1.43, P =0.16], even after adjusting for BMI change (IRR: 1.25, 95% CI: 0.99-1.58, P =0.05). Although LKDs and nondonors who lost >5% BMI had comparable hypertension incidence (IRR: 0.78, 95% CI: 0.46-1.34, P =0.36), there was a significant interaction between donor and >5% BMI gain (multiplicative interaction IRR: 1.62, 95% CI: 1.15-2.29, P =0.006; relative excess risk due to interaction: 0.90, 95% CI: 0.24-1.56, P =0.007), such that LKDs who gained weight had higher hypertension incidence than similar nondonors (IRR: 1.83, 95% CI: 1.32-2.53, P 5% saw increased hypertension incidence versus similar nondonors, providing support for counseling potential LKDs with obesity on weight management postdonation.

ABSTRACT BACKGROUND: Chile presents one of the lowest organ donation rates, resulting in pediatric liver waitlist mortality rates up to 38.1%. Live donor liver transplantation is one of the main alternatives to decrease waitlist mortality, mostly utilized in our country for small children up to 20 kg. AIMS: The aim of this study was to report a three-case series of adult-to-pediatric living donor liver transplantation using a full left lobe graft. METHODS: We report three cases of children with more than 20 kg who received complete left hemi-grafts in different clinical scenarios. The indications and techniques adopted are discussed. RESULTS: Three children, two girls and one boy, aged 11, 7, and 3 years, were transplanted. The indications for transplant were fulminant hepatitis of autoimmune etiology, hepatoblastoma, and chronic liver failure due to autoimmune hepatitis, respectively. The evolution was satisfactory in all three children, and to date, all are well, approximately 12–24 months after the transplant. CONCLUSIONS: The use of a living donor left lateral segment (segments 2 and 3) has been successfully employed in pediatric liver transplantation. However, it is only suitable for infants and low-weight children. This approach using the whole left hemi-liver graft contributes to the reduction of small-for-size syndrome, mortality rate, and waiting times associated with deceased donors.

BACKGROUND: The Scientific Registry of Transplant Recipients (SRTR) Living Donor Collective (LDC), the first effort to create a lifetime registry for living donor candidates in the United States, requires transplant programs to register donor candidates while the SRTR conducts follow-up. METHODS: To better understand facilitators and barriers to program participation, we conducted a brief electronic survey of U.S. transplant program staff from October 26, 2021 to December 17, 2021. RESULTS: We received 132 responses, with at least one response from 87 living donor programs (46 kidney programs, 33 kidney and liver programs, and eight liver programs alone). We found 86% of program representatives strongly agreed or agreed that funding adequate to cover the cost of data collection would facilitate LDC participation, 92% agreed or strongly agreed with importance of electronic data submission options, and 74% reported that elimination of requirements to submit duplicative pre-operative information to the Organ Procurement and Transplantation Network (OPTN) would be helpful. Other potentially enabling factors include reduction in duration of OPTN postdonation follow-up requirements, ease-of-use, protection from data use for regulation, adequate data security, and equity in data access. CONCLUSION: This survey identifies potential targets to strengthen participation in the effort to create a national living donor registry in the United States. Collaboration and investment to overcome barriers to LDC participation among transplant programs are vital to generate long-term data on living donation for donor candidates, donors, and patients in need of transplant.

Aims: Innate and adaptive immune responses regulate hepatic ischemia-reperfusion injury (IRI) in orthotopic liver transplantation (OLT). While the mechanism of how nuclear factor erythroid 2-related factor 2 (NRF2) plays a role in liver IRI has been studied, the contribution of T cell-specific NRF2 in OLT remains unknown. In the current translational study, we investigated whether and how CD4+ T cell-specific NRF2 signaling affects liver transplant outcomes in mice and humans. Results: In the experimental arm, cold-stored (4°C/18 h) wild-type (WT) mouse livers transplanted to NRF2-deficient (NRF2-knockout [NRF2-KO]) recipients experienced greater hepatocellular damage than those in Nrf2-proficient (WT) counterparts, evidenced by Suzukis histological scores, frequency of TdT-mediated dUTP nick end labeling (TUNEL)+ cells, and elevated serum aspartate aminotransferase/alanine aminotransferase (AST/ALT) levels. In vitro studies showed that NRF2 signaling suppressed CD4+ T cell differentiation to a proinflammatory phenotype (Th1, Th17) while promoting the regulatory (Foxp3+) T cell lineage. Furthermore, OLT injury deteriorated in immune-compromised RAG2-KO test recipients repopulated with CD4+ T cells from NRF2-KO compared with WT donor mice. In the clinical arm of 45 human liver transplant patients, the perioperative increase of NRF2 expression in donor livers negatively regulated innate and adaptive immune activation, resulting in reduced hepatocellular injury in NRF2-proficient OLT. Innovation and Conclusion: CD4+ T cell population expressing NRF2 attenuated ischemia and reperfusion (IR)-triggered hepatocellular damage in a clinically relevant mouse model of extended donor liver cold storage, followed by OLT, whereas the perioperative increase of NRF2 expression reduced hepatic injury in human liver transplant recipients. Thus, CD4+ T cell NRF2 may be a novel cytoprotective sentinel against IR stress in OLT recipients. Antioxid. Redox Signal. 38, 670-683.

Polytetrafluoroethylene (PTFE) grafts are artificial vascular grafts commonly utilized for reconstructing the middle hepatic vein during living donor liver transplantation. In this report, we present three cases of expanded PTFE (ePTFE) graft migration into the gastrointestinal tract. These migrations were incidentally discovered and later migrated grafts were successfully removed endoscopically. The first case involved a patient presenting with epigastric discomfort, with a migrated ePTFE graft observed in the duodenal lumen during esophagogastroduodenoscopy (EGD). In the second case, a patient who visited the emergency room with hematochezia was found to have a migrated ePTFE graft in the colonic lumen on colonoscopy. The third case involved a patient undergoing regular EGD after endoscopic submucosal dissection for early gastric cancer; graft migration into the duodenal lumen was documented over time through sequential surveillance EGDs. The graft was endoscopically removed after complete migration. Contrary to previous reports, the three cases presented here did not exhibit serious clinical symptoms, and they were successfully treated through endoscopic foreign body removal without complications. We believe these occasions were possible due to the slow migration of the graft and the concurrent spontaneous closure of the fistula tract.

BACKGROUND: Solid organ transplantation is the therapy of choice for many patients with end-stage organ failure; however, recipients must remain on lifelong immunosuppression, leaving them susceptible to infections and cancer. The study of transplant tolerance to prolong graft survival in the absence of immunosuppression has been restricted to recipients of living donor allografts; however, deceased donors significantly outnumber living donors. Mobilization of hematopoietic stem cells (HSCs) from the bone marrow to peripheral blood (PB) could allow PB-HSCs to be used to induce tolerance in deceased donor kidney recipients; however, a major concern is the well-known concomitant mobilization of immune cells into the liver. METHODS: We mobilized HSCs to the PD using a protocol of 2 doses of granulocyte colony-stimulating factor and 1 dose of plerixafor, followed by the collection of mobilized cells via apheresis in 3 deceased donors. The physiological, laboratory, and radiographic parameters were monitored throughout the procedure. Longitudinal biopsies were performed to assess the potential for ectopic liver mobilization. RESULTS: The use of both agents led to the successful mobilization of peripheral blood CD34+ cells, demonstrating the potential for use in transplant tolerance protocols. Increased immune cell trafficking into the liver was not observed, and apheresis of mobilized cells resulted in a uniform decrease in all liver leukocyte subsets. CONCLUSIONS: HSCs can be mobilized and collected from the PB of brain-dead donors. This new approach may facilitate the dissemination of immune tolerance trials beyond living-donor kidney transplantation to deceased-donor transplantation, without sacrificing the transplantability of the liver.

Decreased postdonation eGFR is associated with a higher risk of ESRD after living kidney donation, even when accounting for predonation characteristics. The Toulouse-Rangueil model (TRM) estimates 12 month postdonation eGFR (eGFR12) to inform counseling of candidates for living donation. The TRM was validated in several single-center European cohorts but has not been validated in US donors. We assessed the TRM in living kidney donors in the US using SRTR data 1/2000-6/2021. We compared the 2021 CKD-EPI equation eGFR12 observed estimates to the TRM eGFR12 predictions. Median (IQR) bias was -3.4 (-9.3, 3.4) mL/min/1.73 m2. Bias was higher for males vs. females (bias [IQR] -4.4 [-9.9, 1.8] vs. -2.9 [-8.8, 4.1]) and younger (31-40) vs. older donors (>50) (bias -4.9 [-10.6, 3.0] vs. -2.1 [-7.5, 4.0]). Bias was also larger for Black vs. White donors (bias (-6.7 [-12.1, -0.3], p < 0.001) vs. (-3.4 [-9.1, 3.1], p < 0.001)). Overall correlation was 0.71. In a sensitivity analysis using the 2009 CKD-EPI equation, results were generally consistent with exception to a higher overall bias (bias -4.2 [-9.8, 2.4]). The TRM overestimates postdonation renal function among US donors. Overestimation was greatest for those at higher risk for postdonation ESRD including male, Black, and younger donors. A new equation is needed to estimate postdonation renal function.

Chronic kidney disease is a progressive and irreversible condition characterized by the slow loss of kidney function, which leads the patient to renal replacement therapy (RRT). Kidney transplantation is one of the available RRT modalities that can occur through a living or deceased donor and is considered the best option because it offers a better quality of life to patients. In cases of living transplants, the physical and psychological aspects of donors and recipients must be evaluated. Because it involves family relationships, it is common for expectations to arise when carrying out the procedure, some of which are focused on changes in the relationship between the donor and recipient pair after the procedure. Therefore, through a qualitative approach, this study aimed to understand the relationship dynamics between donors and recipients after undergoing kidney transplantation. Semi-structured interviews were conducted with 16 participants, eight of whom were transplant patients and their eight respective donors. Bardin's thematic content analysis was used to assess the data. The results highlighted two categories: feelings that influenced the motivation for donation and feelings that had repercussions after donation. It was found that the emotional impact of the recipient's suffering on the donor and the family, the hope of improving the quality of life of the sick relative, altruism, and the role of the donor's kinship were some of the reasons attributed to the decision to donate. Gratitude and the meaning of love given to the organ received were feelings aroused after the kidney transplant. It is concluded that feelings involved in this process had an impact on the emotional dynamics between donor and recipient in the post-transplant period in such a way as to strengthen the bond in a relationship that was already stable. The results contribute to improving the assistance provided based on comprehensive care for these subjects. [ABSTRACT FROM AUTHOR]

Sufficient liver regeneration after a right hepatectomy is important in living donors for preventing postoperative hepatic insufficiency; however, it differs for each living donor so we investigated the clinical factors affecting the rate of liver regeneration after hepatic resection. This retrospective case–control study investigated fifty-four living donors who underwent a right hepatectomy from July 2015 to March 2023. Patients were classified into 2 groups by the remnant/total volume ratio (RTVR): Group A (RTVR < 30%, n = 9) and Group B (RTVR ≥ 30%, n = 45). The peak postoperative level of total bilirubin was more elevated in Group A than in Group B (3.0 ± 1.1 mg/dL vs. 2.3 ± 0.8 mg/dL, p = 0.046); however, no patients had hepatic insufficiency or major complications. The rates of residual liver volume (RLV) growth at Postoperative Week 1 (89.1 ± 26.2% vs. 53.5 ± 23.7%, p < 0.001) were significantly greater in Group A, and its significant predictors were RTVR (β = −0.478, p < 0.001, variance inflation factor (VIF) = 1.188) and intraoperative blood loss (β = 0.247, p = 0.038, VIF = 1.182). In conclusion, as the RLV decreases, compensatory liver regeneration after hepatic resection becomes more prominent, resulting in comparable operative outcomes. Further studies are required to investigate the relationship between hematopoiesis and the rate of liver regeneration. [ABSTRACT FROM AUTHOR]

Purpose: This study aimed to identify research topics and trends on living liver donors over time through text network analysis and topic modeling. Methods: Five electronic databases (PubMed, CINAHL, Embase, Web of Science, and PsycINFO) were reviewed for studies published through September 2023, and 392 studies were included. Text network analysis was used to identify the basic characteristics and centrality of the network. The topics were named after extracting meaningful topics through topic modeling using latent Dirichlet allocation. Results: A total of 1,111 keywords were extracted from the abstracts of 392 selected studies, among which "length of stay," "morbidity," "mortality," "pain," and "quality of life" showed high frequency and centrality. Through topic modeling analysis, the following four topics were derived: objective health indicators (topic 1), subjective health indicators (topic 2), hepatobiliary-related indicators (topic 3), and early health indicators (topic 4). An analysis of trends in these topics over time showed that the proportion of topics 1, 3, and 4 increased or remained stable. In contrast, there was no significant change in topic 2, representing subjective health indicators. Conclusion: This study explored research trends on living liver donors using text network analysis and topic modeling. Based on the main topics derived, research on postoperative outcomes for living liver donors has focused on objective health indicators, hepatobiliary-related indicators, and early health indicators compared to subjective health indicators. We suggest that future studies utilize integrated indicators of physical and psychosocial aspects. [ABSTRACT FROM AUTHOR]

Rationale & Objective: The effect of apolipoprotein L1(APOL1) genotype on future risk of kidney disease among middle-aged individuals with good kidney function is not well established. Study Design: Longitudinal cohort study. Setting & Participants: In total, 5,886 healthy individuals (45-64 years old) enrolled in the Atherosclerosis Risk in Communities study with creatinine-based estimated glomerular filtration rate ≥ 80 mL/min who would be suitable kidney donors. Exposures: Race and APOL1 genotype. Outcomes: Creatinine- and cystatin C-based estimated glomerular filtration rate (eGFRcr-cys) using the CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) 2021 equation, urinary albumin-creatinine ratio (UACR), proportion with chronic kidney disease (CKD) 3a or worse, end-stage kidney disease (ESKD), and death. Analytical Approach: Participants grouped based on race and APOL1 genotype. Compared eGFRcr-cys and UACR across groups. Multinomial logistic regression models were used compare odds of CKD. Kaplan–Meier survival curves were created to compare rates of ESKD and death at last follow-up. Results: There were 5,075 Whites (86%), 701 Blacks carrying the low-risk APOL1 genotype (12%), and 110 Blacks carrying the high-risk APOL1 genotype (2%). The mean age at baseline was 53 ± 6 years. At 10 years, White participants had lower eGFRcr-cys than low-risk and high-risk groups (89 ± 16 vs 91 ± 16 and 92 ± 15 mL/min/1.73 m2, respectively; P

Promoting immune tolerance to transplanted organs can minimize the amount of immunosuppressive drugs that patients need to take, reducing lifetime risks of mortality and morbidity. Regulatory T cells (Tregs) are essential for immune tolerance, and preclinical studies have shown their therapeutic efficacy in inducing transplantation tolerance. Here, we report the results of a phase 1/2 trial (ARTEMIS, NCT02474199) of autologous donor alloantigen-reactive Treg (darTreg) therapy in individuals 2 to 6 years after receiving a living donor liver transplant. The primary efficacy endpoint was calcineurin inhibitor dose reduction by 75% with stable liver function tests for at least 12 weeks. Among 10 individuals who initiated immunosuppression withdrawal, 1 experienced rejection before planned darTreg infusion, 5 received darTregs, and 4 were not infused because of failure to manufacture the minimal infusible dose of 100 × 106 cells. darTreg infusion was not associated with adverse events. Two darTreg-infused participants reached the primary endpoint, but an insufficient number of recipients were treated for assessing the efficacy of darTregs. Mechanistic studies revealed generalized Treg activation, senescence, and selective reduction of donor reactivity after liver transplantation. Overall, the ARTEMIS trial features a design concept for evaluating the efficacy of Treg therapy in transplantation. The mechanistic insight gained from the study may help guide the design of future trials.

Background: Quadriceps muscle layer thickness (QMLT), which is measured using ultrasound, is an emerging strategy to identify sarcopenia. Purpose: The purpose of the study was to assess whether pre-operative QMLT values are associated with a prolonged length of stay (LOS; defined as >14 days) following a renal transplant. Methods: Between March 2019 and January 2020, we performed a prospective study among patients undergoing renal transplantation. Physical Frailty scores and QMLT measurements were performed pre-operatively. The primary outcome was a greater LOS following transplant. Secondary outcomes included complications and renal function. Statistical analysis: Percentiles divided patients into two categories of QMLT (low and high). Continuous outcomes were compared using a two-sided t-test or Mann–Whitney U test, and Chi-square analysis and Fisher exact testing were used for nominal variables. Results: Of 79 patients, the frailty prevalence was 16%. Among patients with low and higher QMLTs, LOS of >14 days were 21% vs. 3% [p = 0.04], respectively. Demographically, there was a higher percentage of patients with living donors in the high- vs. low-QMLT groups (40 vs. 7%). However, in a subgroup analysis excluding living-donor recipients, the difference between groups was preserved (23% vs. 0%, p = 0.01). No differences in secondary outcomes were seen between groups. Conclusions: Low quadriceps muscle layer thickness may be associated with a prolonged length of stay for renal recipients. Further research is needed to confirm our findings.

Detailed characterization of human pancreatic islets is key to elucidating the pathophysiology of all forms of diabetes, especially type 2 diabetes. However, access to human pancreatic islets is limited. Pancreatic tissue for islet retrieval can be obtained from brain-dead organ donors or from individuals undergoing pancreatectomy, often referred to as living donors. Different protocols for human islet procurement can substantially impact islet function. This variability, coupled with heterogeneity between individuals and islets, results in analytical challenges to separate genuine disease pathology or differences between human donors from experimental noise. There are currently no international guidelines for human donor phenotyping, islet procurement and functional characterization. This lack of standardization means that substantial investments from multiple international efforts towards improved understanding of diabetes pathology cannot be fully leveraged. In this Perspective, we overview the status of the field of human islet research, highlight the challenges and propose actions that could accelerate research progress and increase understanding of type 2 diabetes to slow its pandemic spreading.

Individuals considering living kidney donation face geographic, financial, and logistical challenges. Telemedicine can facilitate healthcare access/care coordination. Yet difficulties exist in telemedicine implementation and sustainability. We sought to examine centers practices and providers attitudes toward telemedicine to improve services for donors. We surveyed multidisciplinary providers from 194 active adult US living donor kidney transplant centers; 293 providers from 128 unique centers responded to the survey (center representation rate = 66.0%), reflecting 83.9% of practice by donor volume and 91.5% of US states/territories. Most centers (70.3%) plan to continue using telemedicine beyond the pandemic for donor evaluation/follow-up. Video was mostly used by nephrologists, surgeons, and psychiatrists/psychologists. Telephone and video were mostly used by social workers, while video or telephone was equally used by coordinators. Half of respondent nephrologists and surgeons were willing to accept a remote completion of physical exam; 68.3% of respondent psychiatrists/psychologists and social workers were willing to accept a remote completion of mental status exam. Providers strongly agreed that telemedicine was convenient for donors and would improve the likelihood of completing donor evaluation. However, providers (65.5%) perceived out-of-state licensing as a key policy/regulatory barrier. These findings help inform practice and underscore the instigation of policies to remove barriers using telemedicine to increase living kidney donation.

ObjectiveTo raise awareness that patients with proximal ureteral stricture who elect for nephrectomy can consider donating the kidney. We present a series of patients undergoing therapeutic living donor nephrectomy (TLDN), a scenario in which a patient undergoing nephrectomy for an underlying medical problem donates the kidney to a person with end-stage renal disease. This practice is underutilized, and only a single TLDN with proximal ureteral stricture has been previously described. We aim to help define the indications, risks, and benefits for patients.MethodsThis is a retrospective case series of seven therapeutic donors with proximal ureteral pathology and stone disease. Patient characteristics, donor work up, operative details, and donor and recipient outcome were collected.ResultsAll seven donors had proximal ureteral pathology, and six of the seven had nephrolithiasis or ureterolithiasis. After electing for nephrectomy, the mean time to TLDN was 57.9 days. No recipients experienced delayed graft function . Mean follow up was 40.1 months (range 8-131), and the most recent follow-up mean creatinine was 1.08 (mg/dL). Graft and recipient survival is 100%. No recipients developed recurrence of ureteral stricture or stones.ConclusionThis is the first series demonstrating patients with proximal ureteral stricture, even with concomitant stone disease, may donate kidneys for transplantation. Recipient outcomes suggest this practice is safe, and appropriately selected patients that have already elected for nephrectomy should receive counseling about this opportunity. Importantly, patients who donate a kidney receive waiting list priority if they ever need a kidney transplant in the future.

We conducted a systematic review to assess outcomes in Hispanic donors and explore how Hispanic ethnicity was characterized. We searched PubMed, EMBASE, and Scopus through October 2021. Two reviewers independently screened study titles, abstracts, and full texts; they also qualitatively synthesized results and independently assessed quality of included studies. Eighteen studies met our inclusion criteria. Study sample sizes ranged from 4007 to 143,750 donors and mean age ranged from 37 to 54 years. Maximum follow-up time of studies varied from a perioperative donor nephrectomy period to 30 years post-donation. Hispanic donors ranged between 6% and 21% of the donor populations across studies. Most studies reported Hispanic ethnicity under race or a combined race and ethnicity category. Compared to non-Hispanic White donors, Hispanic donors were not at increased risk for post-donation mortality, end-stage kidney disease, cardiovascular disease, non-pregnancy-related hospitalizations, or overall perioperative surgical complications. Compared to non-Hispanic White donors, most studies showed Hispanic donors were at higher risk for diabetes mellitus following nephrectomy; however, mixed findings were seen regarding the risk for post-donation chronic kidney disease and hypertension. Future studies should evaluate cultural, socioeconomic, and geographic differences within the heterogeneous Hispanic donor population, which may further explain variation in health outcomes.

This retrospective review of the largest United States kidney exchange reports characteristics, utilization, and recipient outcomes of kidneys with simple compared to complex anatomy and extrapolates reluctance to accept these kidneys. Of 3105 transplants performed, only 12.8% were right kidneys and 23.1% had multiple renal arteries. 59.3% of centers used fewer right kidneys than expected and 12.1% transplanted zero right kidneys or kidneys with more than 1 artery. Five centers transplanted a third of these kidneys (35.8% of right kidneys and 36.7% of kidneys with multiple renal arteries). 22.5% and 25.5% of centers currently will not entertain a match offer for a left or right kidney with more than one artery, respectively. There were no significant differences in all-cause graft failure or death-censored graft loss for kidneys with multiple arteries, and a very small increased risk of graft failure for right kidneys versus left of limited clinical relevance for most recipients. Kidneys with complex anatomy can be used with excellent outcomes at many centers. Variation in use (lack of demand) for these kidneys reduces the number of transplants, so systems to facilitate use could increase demand. We cannot know how many donors are turned away because perceived demand is limited.

Living donor liver transplantation (LDLT) is an attractive option to decrease waitlist dropout, particularly for patients with hepatocellular carcinoma (HCC) who face lengthening waiting times. Using the United Network for Organ Sharing (UNOS) national database, trends in LDLT utilization for patients with HCC were evaluated, and post-LT outcomes for LDLT versus deceased donor liver transplantation (DDLT) were compared. From 1998 to 2018, LT was performed in 20,161 patients with HCC including 726 (3.6%) who received LDLT. The highest LDLT utilization was prior to the 2002 HCC Model for End-Stage Liver Disease (MELD) exception policy (17.5%) and dropped thereafter (3.1%) with a slight increase following the 6-month wait policy in 2015 (3.8%). LDLT was more common in patients from long-wait UNOS regions with blood type O, in those with larger total tumor diameter (2.3 vs. 2.1 cm, p = 0.02), and higher alpha-fetoprotein at LT (11.5 vs. 9.0 ng/ml, p = 0.04). The 5-year post-LT survival (LDLT 77% vs. DDLT 75%), graft survival (72% vs. 72%), and HCC recurrence (11% vs. 13%) were similar between groups (all p > 0.20). In conclusion, LDLT utilization for HCC has remained low since 2002 with only a slight increase after the 6-month wait policy introduction in 2015. Given the excellent post-LT survival, LDLT appears to be an underutilized but valuable option for patients with HCC, especially those at high risk for waitlist dropout.

There are limited data on the degree of variability in practices surrounding prioritization of referrals for transplant evaluation and criteria for transplant candidacy and their association with transplantation rates. We surveyed transplant programs across the United States between January 2020 and May 2020 to determine current pre-transplantation practices. We examined the relation between these reported practices and the outcomes of waitlisted patients at responding programs between January 2015 and March 2021 using Scientific Registry of Transplant Recipients data. We used adjusted Cox models with random effects to accommodate clustering by program. Primary outcomes included living or deceased donor transplantation. Of 172 surveyed programs, 90 participated. Substantial variations were noted in when the candidacy evaluation began (13% reported when eGFR was

Living donor liver transplantation has expanded in recent years, particularly in North America. As experience with this procedure has matured over the last 25 years, centers are increasingly faced with potential living donors who are more medically complex. As donors move through the evaluation process, completing the informed consent process continues to be challenged by a paucity of granular data demonstrating long-term outcomes and overall safety specifically in the otherwise "healthy" living liver donor population. Two recently published studies examined long-term outcomes post-living liver donation using Korean registry data and reported similar results, with excellent overall survival when compared to appropriately matched controls. However, the authors of these studies were presented differently, with one reporting an alarmist view based on one aspect of a suboptimal analysis approach using an inappropriate comparator group. Herein, the North American Living Liver Donor Innovation Group (NALLDIG) consortium discusses these two studies and their potential impact on living liver donation in North America, ultimately highlighting the importance of scientific integrity in data presentation and dissemination when using transplant registry data.

Introduction: Living donor kidney evaluation has substantial time variations with significant intercenter variation. One‐day donor evaluation has shown to be clinically efficient and improve transplant rates. However, patients' perception of 1‐day evaluation is unknown. We hypothesized that 1 day LKD evaluation will improve patient satisfaction and improve living donation rates. Methods: All interested LD candidates from April 2018 to May 2020 were enrolled in the study. Non‐directed donors, donors greater than 60 years old, and recipients with more than three donors underwent multi‐day evaluation (control group) while the rest underwent 1‐day evaluation (intervention group). An anonymous survey was filled by both groups to assess their perceptions on different areas including time, communication, experience, information provided, and their preferences on living donor evaluation. Results: Donor candidates in the 1‐day evaluation group selected that the time from the questionnaire to clinic evaluation took "under 1 month" or "less than 3 months" (62.5% vs. 15.8%, p =.002), with "excellent" for both scheduling process (65% vs. 31.6%, p =.03) and communication (82.5% vs. 57.9%, p =.09) when compared to candidates in the multiple‐days evaluation group. One‐day candidates felt "very satisfied" with the overall experience (95% vs. 68.4%, p =.02) and felt "extremely well" with the information provided regarding the living donor process (87.5% vs. 47.4%, p =.003) when compared to multiple‐day evaluation group. Regardless of the group, 53 (89.8%) patients preferred 1‐day evaluation. Conclusion: We demonstrate 1‐day living donor evaluation is efficient, patient preferred, and adds value through improved communication, and better overall patient satisfaction. [ABSTRACT FROM AUTHOR]

Background: ND2 in Ho Chi Minh City is currently the only public center that performs PLT in Southern Vietnam. In 2005, the first PLT was successfully performed, with support from Belgian experts. This study reviews the implementation of PLT at our center and evaluates the results and challenges. Methods: Implementation of PLT at ND2 required medico‐surgical team building and extensive improvement of hospital facilities. Records of 13 transplant recipients from 2005 to 2020 were studied retrospectively. Short‐ and long‐term complications, as well as the survival rates, were reported. Results: The mean follow‐up time was 8.3 ± 5.7 years. Surgical complications included one case of hepatic artery thrombosis that was successfully repaired, one case of colon perforation resulting in death from sepsis, and two cases of bile leak that were drained surgically. PTLD was observed in five patients, of whom three died. There were no cases of retransplantation. The 1‐year, 5‐year, and 10‐year patient survival rates were 84.6%, 69.2%, and 69.2%, respectively. There were no cases of complication or death among the donors. Conclusion: Living‐donor PLT was developed at ND2 for providing a life‐saving treatment to children with end‐stage liver disease. Early surgical complication rate was low, and the patient survival rate was satisfactory at 1 year. Long‐term survival decreased considerably due to PTLD. Future challenges include surgical autonomy and improvement of long‐term medical follow‐up with a particular emphasis on prevention and management of Epstein–Barr virus‐related disease. [ABSTRACT FROM AUTHOR]

Background: For patients with primary and secondary liver tumors that are functionally or technically nonresectable, liver transplantation remains the sole curative treatment option. Over the years the benefits of transplantation have also been validated for conditions other than hepatocellular carcinoma. Currently, amidst a period of organ shortage the broadening of transplantation indications is a topic of ongoing debate. Although recent studies have confirmed the long-term success of transplantation within multimodal treatment regimens, this approach has yet to become the standard treatment for many conditions. Objective: This article explores the potential of liver transplantation in individualized multimodal oncological treatment strategies. Results and conclusion: Liver transplantation has become an integral component of the treatment regimen for hepatocellular carcinoma. In Germany there is a prioritized organ allocation facilitated by the granting of a standard exception for cases with a smaller tumor burden. Over the years numerous studies have demonstrated comparable long-term results using different listing criteria. Both intrahepatic cholangiocarcinoma and perihilar cholangiocarcinoma can be curatively treated with transplantation in Germany, although this is typically within the context of clinical studies. The neoadjuvant therapy and patient selection, based on tumor burden and the response to preliminary treatment, play a crucial role in influencing long-term survival and recurrence rates. The success of transplantation for liver metastases from neuroendocrine malignancies or colorectal carcinomas, which cannot be removed by partial resection, also significantly hinges on the patient selection. The role of living donor liver transplantation is becoming increasingly more pivotal in this context. [ABSTRACT FROM AUTHOR]

Pure laparoscopic donor hepatectomy (PLDH) is an increasingly performed procedure despite its technical difficulties. This study introduced a selective liver parenchymal hanging maneuver and rubber band retraction technique for PLDH. We retrospectively reviewed perioperative data from 58 patients who underwent donor right hepatectomy (including right extended) between March 2009 and February 2021. Eighteen patients underwent open donor right hepatectomy (ODRH) and 38 patients underwent pure laparoscopic donor right hepatectomy (PLDRH). All PLDRH donors underwent the procedure without the need for open conversion. The median PLDRH operative time was 396.84 ± 72.459 min, the median PLDRH intraoperative bleeding amount was 496.05 ± 272.591 ml, and the warm ischemic time was 8.77 ± 3.062 min. Compared to ODRH, laparoscopic surgery showed further advantages in terms of postoperative hospital stay (10.94 ± 4.036 days vs. 8.03 ± 2.646 days, respectively, P = 0.01) and estimated blood loss (676.67 ± 321.046 ml vs. 496.05 ± 272.591 ml, respectively, P = 0.033). The selective liver parenchymal hanging maneuver and rubber band retraction technique is a simple and effective pure laparoscopic procedure for donor hepatectomy. Our results demonstrate the safety and feasibility of this technique. • Pure laparoscopic donor liver resection is a difficult procedure for novice liver surgeons due to the preservation of the major blood vessels required during liver parenchymal dissection. • Although many institutions are performing pure laparoscopic donor liver resection, it is not applicable to all donors. • The rubber band method and selective hanging maneuver are good methods for pure laparoscopic donor liver resection that do not require more working port or instruments. [ABSTRACT FROM AUTHOR]

Introduction: Given the global aging population, the average age of liver donors is increasing. This study aimed to evaluate the surgical outcomes of grafts from pure laparoscopic donor right hepatectomy (PLDRH) in liver donors aged > 50 years. Methods: The medical records of liver donors were retrospectively reviewed. The donors underwent conventional donor right hepatectomy (CDRH) from January 2011 to May 2019 or PLDRH from March 2016 to May 2019. We divided the donors into three groups: PLDRH donors aged ≥50 (n = 26; Group 1) and aged < 50 (n = 257; Group 2), and CDRH donors aged ≥50 years (n = 66; Group 3). Results: Operation time (p <.01) and hospital stay (p <.01) were significantly lower in Group 1 than in Group 3. Other postoperative outcomes of donors including graft anatomical variation, graft weight, graft‐to‐recipient weight ratio, and hepatic steatosis were similar among the three groups. Although no postoperative complications occurred in Groups 1 and 3, they were detected in 17 cases (6.6%) in Group 2. No postoperative complications were detected among the recipients. Conclusions: PLDRH was feasible and safe in donors aged over 50 years, with outcomes similar to those for donors aged <50 years. PLDRH should not be avoided solely based on the donor's age ≥50 years. [ABSTRACT FROM AUTHOR]

Background: Quadriceps muscle layer thickness (QMLT), which is measured using ultrasound, is an emerging strategy to identify sarcopenia. Purpose: The purpose of the study was to assess whether pre-operative QMLT values are associated with a prolonged length of stay (LOS; defined as >14 days) following a renal transplant. Methods: Between March 2019 and January 2020, we performed a prospective study among patients undergoing renal transplantation. Physical Frailty scores and QMLT measurements were performed pre-operatively. The primary outcome was a greater LOS following transplant. Secondary outcomes included complications and renal function. Statistical analysis: Percentiles divided patients into two categories of QMLT (low and high). Continuous outcomes were compared using a two-sided t-test or Mann–Whitney U test, and Chi-square analysis and Fisher exact testing were used for nominal variables. Results: Of 79 patients, the frailty prevalence was 16%. Among patients with low and higher QMLTs, LOS of >14 days were 21% vs. 3% [p = 0.04], respectively. Demographically, there was a higher percentage of patients with living donors in the high- vs. low-QMLT groups (40 vs. 7%). However, in a subgroup analysis excluding living-donor recipients, the difference between groups was preserved (23% vs. 0%, p = 0.01). No differences in secondary outcomes were seen between groups. Conclusions: Low quadriceps muscle layer thickness may be associated with a prolonged length of stay for renal recipients. Further research is needed to confirm our findings. [ABSTRACT FROM AUTHOR]

IntroductionIntrahepatic cholangiocarcinoma (iCC) is the liver’s second most common neoplasm. Until now, surgery is the only curative option, but only 35% of the cases are considered resectable at the diagnosis, with a post-resection survival of around 30%. Advancements in surgical techniques and perioperative care related to liver transplantation (LT) have facilitated the expansion of indications for hepatic neoplasms.MethodThis study is a comprehensive review of the global experience in living donor LT (LDLT) for treating iCC and describes our first case of LDLT for an unresectable iCC.ResultsWhile exploring LT for intrahepatic cholangiocarcinoma dates to the 1990s, the initial outcomes were discouraging, marked by poor survival and high recurrence rates. Nevertheless, contemporary perspectives underscore a reinvigorated emphasis on extending the frontiers of LT indications within the context of the “oncologic era.” The insights gleaned from examining explants, wherein incidental iCC was categorized as hepatocellular carcinoma in the preoperative period, have demonstrated comparable survival rates to small hepatocellular carcinoma. These findings substantiate the potential viability of LT as a curative alternative for iCC. Another investigated scenario pertains to “unresectable tumors with favorable biological behavior,” LT presents a theoretical advantage by providing free margins without the concern of a small future liver remnant. The constraint of organ shortage persists, particularly in nations with low donation rates. LDLT emerges as a viable and secure alternative for treating iCC.ConclusionLDLT is an excellent option for augmenting the graft pool, particularly in carefully selected patients.

Background. South African transplant centres are faced with significant challenges in meeting the need for liver transplantation, owing to the low and ever-decreasing number of deceased-donor organs. To increase organ utility, deceased-donor split-liver transplant (DDSLT) and living-donor liver transplant (LDLT) programmes were initiated in the Wits Transplant Unit. Objective. To evaluate outcomes of the LDLT and DDSLT programmes. Methods. A retrospective analysis of de-identified recipient and donor variables from all adult and paediatric DDSLTs and LDLTs conducted between 2013 and 2021 was performed. Comparison of categorical study variables between graft types was done with the χ2 test. Continuous variables were compared by means of the independent samples t-test. Cox proportional hazards regression was performed to examine the effect of graft type on recipient and graft survival. All comparisons were made unadjusted, and adjusted for recipient age, recipient ethnicity, donor sex, and graft-weight-to-recipient-weight ratio (GWRWR) (for the paediatric cohort); and for donor age and GWRWR (for the adult cohort). Results. A total of 181 paediatric and 48 adult liver transplants have been performed since the inception of the two programmes. Chronic liver failure, specifically intra- and extrahepatic cholestatic disease, was our main indication for liver transplantation in both cohorts. There were no significant differences between the DDSLTs and LDLTs in respect of pre- or post-discharge intervention, in-hospital mortality, length of stay, and recipient or graft survival within both the paediatric and adult groups. Our overall 1- and 3-year survival estimates (95% confidence intervals) were 77% (70% - 83%) and 71% (64% - 78%) for the paediatric cohort, and 77% (62% - 87%) and 66% (50% - 78%) for the adult cohort, respectively. Conclusion. The results of this study demonstrate comparable outcomes between DDSLT and LDLT, indicating that both methods are effective approaches to optimise organ utilisation for liver transplantation within our setting.