BACKGROUND:As the global population ages, older-aged candidates increasingly undergo living donor liver transplantation (LDLT). Outcomes and risk factors in recipients aged ≥70 y remain unclear. This study assessed graft survival and age-specific risk factors using nationwide registry data. METHODS:From the Korean Organ Transplantation Registry, 4802 adult LDLT recipients were categorized into age <70 (n = 4660) and age ≥70 (n = 142) groups. Graft survival was analyzed using Kaplan-Meier and multivariable Cox regression to evaluate real-world outcomes. Propensity score matching was additionally performed as a sensitivity analysis to confirm the robustness of the findings. Subgroup analyses were used to identify risk factors specific to the age ≥70 group. RESULTS:In unmatched analyses, recipients aged ≥70 y demonstrated significantly lower graft survival than younger recipients (5-y survival: 74.4% versus 87.2%; P  < 0.001). However, after multivariable adjustment, age ≥70 was not an independent predictor of graft loss (adjusted hazard ratio [HR], 1.24; 95% confidence interval [CI], 0.83-1.87; P  = 0.29). Similar findings were observed in the propensity-matched cohort. Subgroup analyses demonstrated that, among recipients aged ≥70 y, pretransplant hospitalization (adjusted hazard ratio [aHR], 1.94; 95% CI, 1.14-3.29), graft steatosis ≥5% (aHR, 1.74; 95% CI, 1.03-2.95), and vascular complications (aHR, 3.11; 95% CI, 1.31-7.43) were each associated with significantly elevated risk of graft failure. CONCLUSIONS:Chronological age alone did not independently predict graft failure, but age ≥70 y may amplify risk when combined with steatosis, pretransplant hospitalization, or vascular complications. Therefore, LDLT eligibility in elderly candidates may be better guided by clinical risk profiling rather than age alone.

BACKGROUNDS:Hepatocellular carcinoma (HCC) recurrence after liver transplantation remains a significant concern. This study investigated the impact of ABO blood type on HCC recurrence and overall survival in individuals after living donor liver transplantation (LDLT) using data from the Korean Organ Transplantation Registry. MATERIALS AND METHODS:A retrospective analysis of 2380 LDLT patients from the KOTRY database (2014-2021) was conducted. Clinical outcomes were compared across ABO blood types using Kaplan-Meier survival and multivariate Cox regression analyses. RESULTS:ABO blood type did not significantly affect HCC recurrence or overall survival. Multivariate analysis demonstrated that only the Milan criteria were closely associated with HCC recurrence. Overall survival was dependent on the Milan criteria and ABO incompatibility in multivariable analysis. Patients beyond the Milan criteria with ABO-incompatibility had worse recurrence-free survival and overall survival compared with other groups. CONCLUSIONS:ABO blood type does not predict HCC recurrence or overall survival. Clinical factors like beyond the Milan criteria and ABO-incompatibility remain critical in managing LDLT patients with HCC.

Background: As liver transplantation is increasingly considered for older adults with high perioperative risks, this study investigated the outcomes of living donor liver transplantation (LDLT) in older compared to younger recipients. Methods: A retrospective analysis was performed involving 908 LDLT recipients, categorized by age: <64 years (n = 862), 65-69 years (n = 80), and >= 70 years (n = 28). Graft survival and complications were compared between the age groups. Results: Older recipients (>= 65 years) exhibited a high incidence of preexisting conditions including hypertension and diabetes. Five-year graft survival was reduced in older recipients in unmatched analysis (81.8 % in <64 years vs. 75.0 % in 65-69 years vs. 69.7 % in >= 70 years, P = 0.045). However, this difference was not significant in multivariable Cox regression (hazard ratio [HR] 1.44, P = 0.156 for 65-69 years and HR 1.69, P = 0.156 for >= 70 years). In matched analyses, graft survival in the 65-69 age group (78.9 % vs. 74.5 %, P = 0.324) and the >= 70 age group (80.3 % vs. 76.0 %, P = 0.551) was not inferior to that of the <64 age group. Rejection and surgical complications within 1 year were similar between the groups. However, the incidence of pneumonia was significantly higher in the older group than that in the younger group (11.3 % vs. 20.8 % vs. 19.3 %, P = 0.019). Conclusion: LDLT in older patients demonstrated survival comparable to that in younger patients when pre-transplant characteristics were adjusted. Patient selection based on comorbidities and infection prevention strategies is critical for optimizing postoperative outcomes in this demographic group. (c) 2025 Asian Surgical Association and Taiwan Society of Coloproctology. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/ by-nc-nd/4.0/).

Liver transplantation is the definitive treatment for end-stage liver disease, but acute allograft rejection affects 15–30

Human γδ T cells are typically divided into Vγ9Vδ2 and non-Vγ9Vδ2 cells, but their detailed heterogeneity remains to be fully elucidated, especially in the liver where they are enriched. Here we analyze liver sinusoidal γδ T cells from healthy donors, with or without latent human cytomegalovirus (HCMV) infection, by performing single-cell RNA sequencing with antibody-derived tags. Vγ9Vδ2 cells are characterized by PLZF expression, and classified into type 1 and type 3 immunity-associated clusters. In contrast, non-Vγ9Vδ2 cells are characterized by Helios expression, and their clusters display naïve-to-effector differentiation processes, which are accelerated by HCMV infection. Notably, among non-Vγ9Vδ2 cells, we identify a novel liver-resident CD56hiCD161− cell population with a distinct TCR repertoire, which is markedly enriched in HCMV-seropositive donors. These cells exhibit IL-15-induced NK-like cytotoxicity, but limited responsiveness to TCR stimulation. Our findings reveal liver sinusoidal γδ T cells’ heterogeneity in the context of latent HCMV infection, and their functions. Current understanding of human γδ T cells in the liver remains limited, particularly with regard to their heterogeneity. The authors here provide a comprehensive profile of these cells and identify liver-resident CD56hiCD161⁻ γδ T cells that exhibit IL-15-induced, NK-like cytotoxicity against cytomegalovirus-infected cells and liver tumor cells.

BACKGROUND AND AIMS:Accurate assessment of advanced fibrosis and steatosis is essential for prognostication in chronic liver disease. This study aimed to evaluate the diagnostic performance of MRI in assessing liver fibrosis and steatosis in patients undergoing liver transplantation (LT). METHODS:Patients who underwent LT between January 2019 and December 2023 with pretransplant MR elastography (MRE) and MRI-based proton density fat fraction (MRI-PDFF) examinations were included. Explanted livers were assessed for fibrosis and steatosis, with cirrhosis subclassified using the Laennec system. Diagnostic performance was evaluated using area under the receiver operating characteristic curve (AUC) analysis. RESULTS:Among 187 patients (median age, 57 years), 72.2% were male. Hepatitis B virus (55%) and alcoholic liver disease (21.4%) were the most common etiologies. The median Model for End-Stage Liver Disease (MELD) score was 11. MRE detected cirrhosis (F4) with an AUC of 0.92 (95% confidence interval [CI], 0.87-0.97) and severe cirrhosis (F4c) with an AUC of 0.85 (95% CI, 0.79-0.91), at threshold values of 4.76 and 6.43 kPa, respectively. MRI-PDFF identified steatosis with an AUC of 0.83 (95% CI, 0.76-0.89) at a threshold of 2.80%. Comparisons of patients stratified by the threshold values for cirrhosis and severe cirrhosis revealed significant differences in MELD scores, history of portal hypertension-related complications, liver function parameters, and intraoperative transfusion requirements (all p < 0.05). CONCLUSIONS:MRI demonstrated high diagnostic accuracy for detecting cirrhosis and steatosis in patients with advanced fibrosis undergoing LT. MRE further stratified cirrhosis severity, suggesting clinical applicability in cirrhosis staging and risk assessment.

Hypogammaglobulinemia (HGG) is a common complication of liver transplantation (LT). However, the impact of underlying liver disease severity on post-LT immunoglobulin dynamics remains unclear. We aimed to evaluate the differences in serum immunoglobulin G (IgG) levels based on the pre-transplantation model for end-stage liver disease (MELD) scores. We collected data from patients who underwent LT between July 2016 and December 2022 at a tertiary hospital. Propensity score matching was performed between the low and high MELD groups and IgG dynamics were evaluated. The significance of peri-LT HGG on clinical outcomes was also evaluated. In a matched population (1:1 propensity score matching), the median serum IgG levels decreased significantly from 1,606.5 mg/dL pre-LT to 1,011.6 mg/dL 1-month post-LT. IgG levels before and after transplantation (1 month, 6 months, and 1 year) did not differ significantly between the groups. Overall, 36.0% of patients developed HGG within 1 year after transplantation. Multivariable Cox regression analysis showed that pre-LT HGG was independently associated with mortality. In conclusion, HGG is frequent complication in peri-LT period and pre-LT HGG is significantly associated with mortality. No significant difference in HGG according to the MELD score was observed.

Introduction and Objectives: Major depressive disorder (MDD) is a major psychiatric complication of liver transplantation (LT). Here, we aimed to analyze the impact of de novo MDD on survival post-LT and identify risk factors for this disorder among LT recipients. Materials and Methods: A retrospective analysis was conducted on 1350 LT recipients at Severance Hospital, Korea, from July 2005 to December 2022. Patients with MDD were matched 1:5 with controls using a nested case-control design to control for immortal time bias. Results: During follow-up post-LT, 58 patients (4.3 %) were newly diagnosed with MDD. The median time from LT to MDD diagnosis was 316 (interquartile range 46–920) days. Patients with MDD had significantly lower graft survival rates than controls at 1, 3, and 5 years after matching (89.5 %, 75.3 %, and 66.5 % vs. 95.5 %, 91.5 %, and 86.4 %, respectively; P = 0.003). Multivariable Cox regression identified de novo MDD as an independent risk factor for reduced graft survival (hazard ratio 2.39, 95 % confidence interval [CI] 1.15–4.98, P = 0.003). Independent risk factors for de novo MDD included female sex (odds ratio [OR] 2.29, 95 % CI 1.16–4.53, P = 0.017), alcoholic liver disease (OR 2.36, 95 % CI 1.16–4.75, P = 0.016), pre-transplant encephalopathy (OR 2.95, 95 % CI 1.49–5.79, P = 0.002), and lower hemoglobin levels (OR 0.85, 95 % CI 0.73–0.98, P = 0.025). Conclusions: In our matched population of nested case controls, de novo MDD significantly reduced the survival of LT recipients. Screening and early intervention are required for LT recipients with risk factors for MDD.

Background. Few studies have examined the long-term outcomes of recipients in minimally invasive donor hepatectomies, particularly comparing robotic and laparoscopic donor procedures. Understanding these outcomes is crucial for optimizing surgical approaches and improving the overall success of living donor liver transplantation. This study aimed to compare the feasibility and safety of robotic donor right hepatectomy (RDRH) and laparoscopic donor right hepatectomy (LDRH) by evaluating total follow-up patient outcomes. Methods. This retrospective, single-center study included 117 and 118 donors who underwent RDRH and LDRH between March 2016 and June 2023, respectively. After performing 1:1 propensity score matching, 71 donor-recipient pairs were included in each group. Donor and recipient complications were divided into early (within 90 d) and late (after 90 d) biliary and vascular complications. Results. In the matched cohort, major complication rates of donors were similar in both groups. Bile duct (BD) variation was not significantly different; however, the rates of multiple BD openings (26.8% versus 54.9%; P = 0.001) and major biliary complications in recipients were higher in the LDRH group (22.5% versus 42.3%; P = 0.012). The cumulative biliary complication rate was significantly higher in the LDRH group. Early biliary complications were not significantly different; however, the rate of late biliary complications was higher in the LDRH group (11.3% versus 23.9%; P = 0.047). Conclusions. RDRH demonstrated comparable postoperative complications to LDRH in donors but showed fewer recipient biliary complications. This could be attributed to the precision of robotic dissection and BD division, resulting in fewer multiple BD openings.

Several donor-specific factors influence the functional recovery and long-term outcomes of liver grafts. This study investigated the association between donor fasting glucose (DFG) and recipient outcomes after living donor liver transplantation (LDLT) in 950 cases at a single center. Patients were divided into two groups: low-DFG (< 85 mg/dL, n = 120) and control (≥ 85 mg/dL, n = 830). The five-year graft survival rate was significantly lower in the low-DFG group (71.5%) compared to the control group (80.0%) (P = 0.02). Multivariable Cox regression analysis showed that low DFG was independently associated with graft loss (hazard ratio 1.72, 95% CI 1.15–2.56, P = 0.008). In propensity score-matched groups, the low-DFG group also had lower survival rates (71% vs. 83.1%, P = 0.004). The presence of additional risk factors, such as low graft-to-recipient weight ratio, older donor age, and longer cold ischemic time, further reduced graft survival in the low-DFG group. A DFG level < 85 mg/dL is associated with higher risk of graft failure after LDLT, especially when combined with other risk factors. Low DFG should be considered a prognostic marker in LDLT planning, with potential to improve patient outcomes as further research clarifies the underlying pathophysiological mechanisms.

BACKGROUND Combined hepatocellular-cholangiocarcinoma (cHCC-CC) is a rare primary liver tumor with poor prognosis. This retrospective study aimed to evaluate the outcomes and prognostic factors of 40 patients who underwent liver transplantation (LT) for cHCC-CC using data from the Korean Organ Transplant Registry (KOTRY). MATERIAL AND METHODS A cohort of 40 LT recipients diagnosed with cHCC-CC was selected from the KOTRY database between 2014 and 2019. Survival analyses were performed according to key clinicopathological variables, and risk factor analyses were conducted for overall survival (OS) and recurrence-free survival (RFS). RESULTS During a median follow-up of 21.4 months, 10 patients (25.0%) died and 9 patients (22.5%) experienced tumor recurrence. The 1-, 2-, and 3-year OS rates were 91.8%, 76.2%, and 59.3%, respectively, and the corresponding RFS rates were 88.8%, 70.5%, and 50.2%. Patients with a MELD score <20 (P=0.017) and a single tumor <3 cm (P=0.046) showed significantly better OS. On multivariate analysis, MELD score ≥20 (P=0.04), perineural invasion (P=0.04), and portal vein tumor thrombosis (P=0.005) were independent risk factors for poor OS, whereas microvascular invasion (P=0.01) was an independent risk factor for poor RFS. CONCLUSIONS LT can be a feasible treatment option for patients with early-stage cHCC-CC, providing favorable long-term survival. As most prognostic factors identified were pathology-related, further studies are needed to refine the selection criteria for LT candidates in this population.

Background: In the current “sickest first” allocation policy for limited deceased liver grafts, identifying patients “too sick to transplant” before transplantation is crucial to optimize outcomes. This study aimed to predict futile outcomes following deceased donor liver transplantation (DDLT) in patients with Model for End-Stage Liver Disease-Sodium (MELD-Na) scores ≥30. Methods: This international multicenter study was conducted as part of the International Society of Liver Surgeons. We collected data from patients with a MELD-Na score ≥30 who underwent DDLT. A total of 994 patients were enrolled between 2010–2021, including 654 from the Republic of Korea, 224 from the US, and 116 from other regions. Futility was defined as death within three months or during the hospital stay following a DDLT. After exclusion, 160 (16.6%) patients were classified into a futile group and 803 (83.4%) into a non-futile group. Results: The MELD-Na scores collected at three time points (listing, matching, and transplantation) were comparable between the groups (P = 0.442, P = 0.180, and P = 0.554, respectively). Regarding concomitant organ failure factors, the futile group showed a higher incidence of organ dysfunction across all measured parameters, including the use of mechanical ventilators, continuous renal replacement therapy (CRRT), pneumonia, bacteremia, and vasopressor use (all P<0.01). Independent risk factors for futile outcome were recipient age (≥65 years), body mass index (<18.5 kg/m 2 ), mechanical ventilator use, CRRT (≥1 week), and prolonged ICU stay before transplantation (≥2 weeks). The futility rate was 53.3% in patients with ≥3 risk factors (P<0.001). We developed a nomogram to predict futility after DDLT based on multivariate regression analysis, which showed a better predictive power than previous models. Conclusions: The risk factors and new nomogram, which adequately reflect concomitant organ failure before liver transplantation, could effectively predict the risk of futile outcomes after DDLT and contribute to decision-making regarding transplantation eligibility in clinical practice.