This personal account, written on the occasion of the fortieth anniversary of the European Liver Transplant Registry (ELTR), traces the origins of the Registry from the earliest days of liver transplantation in Europe to its present scale. Beginning with a handful of pioneering centres in the 1970s and the scepticism that surrounded the procedure, the narrative follows the events of 1983 that transformed the field, the creation of an informal registry at Paul Brousse, and its extension to a European network following a founding meeting in Hannover in October 1985. It describes the early design choices that shaped the Registry, the methodological debates that defined its core definitions, and the scientific contributions that followed, including landmark findings on patient survival and on hepatitis B recurrence after transplantation, as well as the 1993 Paris Consensus Conference on indications for liver transplantation. The account closes with the Registry’s transition to new stewardship and its present scope, spanning more than 200,000 transplants recorded across 32 countries. The history illustrates how informal, trust-based collaboration among a small number of European surgeons gave rise to one of the longest-running transplant registries in the world.
Downstaging of hepatocellular carcinoma (HCC) before liver transplantation is established mainly in the deceased donor setting, and outcomes before living donor liver transplantation (LDLT) remain unclear. We searched PubMed and Embase through April 2026 for studies reporting post-transplant outcomes in patients with HCC beyond Milan criteria who were downstaged before LDLT. A pre-specified primary analysis covered locoregional therapy targeting Milan or UCSF criteria. We pooled proportions using random-effects models and reconstructed patient-level survival from Kaplan-Meier curves. Seventeen studies with 511 downstaged LDLT recipients were included. In the primary cohort, recurrence was 22.1% (95% CI 9.7–42.6) and 5-year overall survival 75.8% (61.8–85.8). Across all studies, recurrence was 25.0% (17.4–34.5), 5-year overall survival 75.0% (63.1–84.1), and downstaging success 47.5% (36.1–59.1); reconstructed 5-year overall and recurrence-free survival were 75.7% and 75.6%. These estimates describe patients who achieved downstaging—fewer than half of those who attempted it—and then reached transplant. They do not measure the benefit of downstaging itself. The evidence remains retrospective and mostly Asian, with wide variation between studies. Prospective intention-to-treat studies are needed.
The shortage of transplantable organs remains one of the most significant unmet challenges in modern medicine. Despite advances in donor management, organ preservation, surgical techniques, and immunosuppression, organ demand continues to exceed supply worldwide. Xenotransplantation using genetically engineered porcine organs has emerged as a promising strategy to address this gap. Recent clinical pig-to-human heart and kidney transplantations have demonstrated the feasibility of clinical xenotransplantation and shifted attention from immunological barriers toward practical implementation. This review examines the logistical requirements for clinical xenotransplantation, with particular emphasis on donor herd management, biosafety, organ preservation technologies, and future distribution networks. The integration of donor production with advanced machine perfusion technologies may ultimately transform transplantation medicine from a donor-dependent emergency service into a predictable and scalable therapeutic platform.
