PURPOSE:Tumour oxygenation influences the radiobiological effect of yttrium-90 (Y90); thus, baseline hemoglobin (HGB) may affect treatment response. This study evaluated whether baseline HGB is associated with outcomes in patients with unresectable intrahepatic cholangiocarcinoma (ICC) treated with Y90 transarterial radioembolisation (TARE). METHODS:We retrospectively analysed 136 ICC patients treated with glass microsphere Y90 from 2004 to 2020, stratified by baseline HGB: ≥ 12 g/dL, 10-11.9 g/dL, and < 10 g/dL. Kaplan-Meier and log-rank tests assessed duration of response (DoR), overall survival (OS), and time to progression (TTP). Lesion response was evaluated by RECIST 1.1. Several clinical and radiologic parameters were evaluated in multivariate Cox models to identify independent OS predictors. RESULTS:Mean age was similar across HGB groups (~64 years, p = 0.934), and 49% of the cohort was female. Response rates differed significantly: For RECIST 1.1, responders comprised 38% (15/39) (≥ 12 g/dL), 42% (22/53) (10-11.9 g/dL), and 18% (7/39) (< 10 g/dL) (p = 0.041). Median DoR was longest for HGB ≥ 12 g/dL (15.0 months) vs. 6.5 and 6.2 months for 10-11.9 and < 10 g/dL (p = 0.041). TTP varied significantly (7.1, 5.8, and 1.7 months; p = 0.008). Median OS was 17.1, 13.8, and 6.0 months for ≥ 12, 10-11.9, and < 10 g/dL, respectively (p < 0.001). On multivariate analysis, HGB < 10 g/dL remained independently associated with poorer OS (HR 1.83, p = 0.031). CONCLUSION:Baseline HGB < 10 g/dL was a predictor of poor antitumor response, earlier progression, and worsened OS in ICC patients undergoing Y90 TARE. HGB is a low-cost, clinically available biomarker that may aid in risk stratification and treatment planning. Future work should assess if risk factor modification prior to TARE (i.e., transfusion for HGB < 10) improves clinical outcomes.

Intrahepatic cholangiocarcinoma (iCCA) represents an aggressive primary hepatic malignancy with limited non-surgical therapeutic options. This review examines the evolution of transarterial radioembolization (TARE) with Yttrium-90 microspheres from palliative intervention to curative-intent therapy, driven by advances over the past few decades. Partition-model dosimetry demonstrates superior survival compared to empiric approaches (14.9 versus 5.5 months, P < 0.001), establishing the critical importance of individualized treatment planning. In first-line settings, multimodal strategies combining TARE with systemic therapy achieve median overall survival of 32.5 months, with intensive protocols demonstrating objective response rates of 39-85

PURPOSE:To evaluate the safety and rates of bridging or downstaging following segmental transarterial radioembolization (TARE) in hepatocellular carcinoma (HCC) patients with baseline hyperbilirubinemia (total bilirubin [TBili] level, ≥2.0 mg/dL). MATERIALS AND METHODS:This single-institution retrospective study included 119 patients with HCC (median age, 64 years; interquartile range [IQR], 58-71 years) with baseline hyperbilirubinemia who underwent 129 segmental TARE procedures between 2006 and 2021. Baseline and posttreatment liver function, toxicities, overall survival (OS), and bridging/downstaging rates were analyzed. Patients were stratified by treatment intent: palliative, bridging, or downstaging. RESULTS:The median absorbed dose was 211 Gy (IQR, 157-318 Gy); treatment volume, 160 mL (IQR, 109-227 mL); whole liver volume, 1,402 mL (IQR, 1,136-1,830 mL); and percentage of liver treated, 11.0% (IQR, 8.2%-15.5%). Median baseline TBili level was 2.7 mg/dL (IQR, 2.3-3.2 mg/dL). Grade 3/4 bilirubin toxicity occurred in 1.0% at 1 and 3 months and 8.0% at 6 months. Although TBili (P = .011) and albumin (P = .047) levels changed significantly over time, post hoc testing showed no differences between timepoints, and albumin-bilirubin grade remained stable (P = .900). Median intention-to-treat OS was not reached (95% CI, 59.0 months to not calculable [NC]). The palliative group had a median OS of 22.0 months (95% CI, 18.0-NC), whereas OS was not reached in the bridging group. Among 71 bridging patients, 92.0% remained within Milan criteria, and 78.0% underwent transplantation. Of 6 downstaging patients, 67.0% were successfully downstaged, and 2 underwent transplantation. CONCLUSIONS:Segmental TARE is safe and well tolerated in patients with HCC with baseline hyperbilirubinemia, achieving high rates of successful bridging and downstaging to liver transplant with manageable toxicity.

OBJECTIVE:To compare the outcomes of fully robotic versus open left lobe donor hepatectomies, focusing on donor safety. BACKGROUND:Right lobe hepatectomies are traditionally preferred for adult liver transplants due to their larger graft size but may involve increased risks for donors. Left lobe hepatectomies are considered safer for donors but are less commonly used due to concerns about the small-for-size syndrome in adult settings. METHODS:We conducted an analysis of 339 living liver donors from a prospectively maintained registry at a single institution from November 2011 to June 2023, comparing 72 open and 267 robotic left lobe hepatectomies. Primary outcomes included donor complication rates until hospital discharge, whereas secondary outcomes focused on hospital stay and recipient complications. RESULTS:Robotic hepatectomy was associated with significantly less blood loss (mean 77 (SD: 68) vs 316 (SD: 168) mL, P <0.001), lower donor morbidity 6% vs 18%, P =0.003), and shorter hospital stay (3 vs 5 d, P <0.001). Adult recipients receiving robotically retrieved donor grafts were associated with a lower overall morbidity rate (40% vs 59%, P =0.033) compared to open. CONCLUSIONS:Robotic left donor hepatectomy significantly improves donor safety compared with the open approach, supporting its use as a less invasive and donor-centered option in living donor liver transplantation. This study, the largest known series of left lobe donor hepatectomies, demonstrates the robotic approach's superiority, potentially setting a new standard in the field of living donor liver transplantation.

Objectives To assess the safety and effectiveness of percutaneous endobiliary radiofrequency ablation (EB-RFA) in the management of refractory benign biliary strictures.Methods Percutaneous EB-RFA was performed in 15 individuals (M/F = 8/7; median age: 57 [33-84]) for benign biliary strictures resistant to traditional methods (transhepatic cholangioplasty and biliary drains). All patients underwent >= 1 unsuccessful cholangioplasty session and upsizing of their transhepatic biliary drains pre-procedure. Technical and clinical success were defined as luminal gain with enhanced flow and a lack of clinically evident recurrent stricture on follow-up after drain/stent removal, respectively.Results A total of 16 EB-RFA procedures were performed. Technical success rate was 100% (16/16). Procedure-related complications occurred in 1/16 cases (drain leakage with subsequent cellulitis). Clinical success rate was 87% (13/15) with a median follow-up of 17 (2-24) months. Drain/stent was not removed in one case (1/16) as the patient was lost to follow-up immediately post-procedure. The one-year patency rate was 100%. A significant reduction was observed in the median number of IR visits (8 [1-51] to 1 [0-9]; P = .003) and drain insertion/exchange procedures (5 [1-45] to 0 [0-6]; P = .003) pre- and post-EB-RFA with a median follow-up of 18 (0-26) months.Conclusion Percutaneous EB-RFA can safely and effectively treat refractory benign biliary strictures. However, larger prospective studies with extended follow-ups are needed to gather more robust data.Advances in knowledge This study contributes to the limited evidence on the role of EB-RFA in addressing refractory benign biliary strictures, enhancing the understanding of its clinical utility.

Background: Non-ideal donors provide acceptable allografts and may expand the donor pool. This study evaluates donor utilization across solid organs over 15-years in the United States. Methods: We analyzed the OPTN STAR database to identify potential donors across three donor eras: 2005–2009, 2010–2014, and 2015–2019. Donors were analyzed by a composite Donor Utilization Score (DUS), comprised of donor age and comorbidities. Outcomes of interest were overall and organ-specific donor utilization. Descriptive analyses and multivariable logistic regression modeling were performed. p-values < 0.01 considered significant. Results: Of 132,465 donors, 32,710 (24.7%) were identified as non-ideal donors (NID), based on a DUS ≥ 3. Compared to ideal donors (ID), NID were older (median 56 years, IQR 51–64 years vs. 35 years, 22–48 years, p < 0.001) and more frequently female (44.3% vs. 39.1%, p < 0.001), Black (22.1% vs. 14.6%, p < 0.001) and obese (60.7% vs. 19.6%, p < 0.001). The likelihood of overall DBD utilization from NID increased from Era 1 to Era 2 (OR 1.227, 95% CI 1.123–1.341, p < 0.001) and Era 3 (OR 1.504, 1.376–1.643, p < 0.001), while DCD donor utilization in NID was not statistically different across Eras. Compared to Era 1, the likelihood of DBD utilization from NID for kidney transplantation was lower in Era 2 (OR 0.882, 0.822–0.946) and Era 3 (OR 0.938, 0.876–1.004, p = 0.002). The likelihood of NID utilization increased in Era 3 compared to Era 1 for livers (OR 1.511, 1.411–1.618, p < 0.001), hearts (OR 1.623, 1.415–1.862, p < 0.001), and lungs (OR 2.251, 2.011–2.520, p < 0.001). Conclusions: Using a universal definition of NID across organs, NID donor utilization is increasing; however, use of DUS may improve resource utilization in identifying donors at highest likelihood for multi-organ donation.

Background. The availability of suitable donor organs remains a limiting factor to performing life-saving transplant operations. This study evaluates changes in the health of the donor popula-tion and its influence on organ use in the United States.Methods. A retrospective analysis was performed using the OPTN STAR data file from 2005 to 2019. Three donor eras were defined: 1) 2005 to 2009, 2) 2010 to 2014, and 3) 2015 to 2019. The primary outcome was donor use, defined as transplantation of at least one solid organ. Descriptive analyses were performed, and associations of donor use were examined with multi-variable logistic regression models. P values <.01 were considered significant.Results. The cohort included 132,783 potential donors of which 124,729 (93.9%) were used for transplantation. Donor median age was 42 years (interquartile range 26-54), 53,566 (40.3%) were female, and 88,209 (66.4%) were White, 21,834 (16.4%) were black, and 18,509 (13.9%) were Hispanic. Compared with donors from Eras 1 and 2, donors in Era 3 were younger (P < .001), had higher body mass index (BMI) (P < .001), increased rates of diabetes mellitus (DM) (P < .001), hepatitis C virus (HCV) positivity (P < .001) and more comorbidities (P < .001). Multivariable modeling found donor BMI, DM, hypertension, and HCV status as health factors significantly associated with donor use. Compared with Era 1, there was increased use in Era 3 of donors with BMI >= 30 kg/m2, DM, hypertension, HCV-positive status, and donors with >= 3 comorbidities. Conclusions. Despite an increasing prevalence of chronic health problems in the donor popu-lation, donors with multiple comorbid conditions are more likely to be used for transplantation in recent years.

Portal vein thrombosis (PVT) is a heterogeneous condition with multiple possible etiologies and to varying degrees has historically limited candidacy for liver transplant (LT) in the cirrhotic patient population due to resultant difficulties in constructing a robust portal vein anastomosis. While intraoperative approaches to managing PVT are well-described, methods which approximate normal portal physiology are not always feasible depending on the extent of PVT, and other nonphysiologic techniques are linked with substantial morbidity and poor long-term outcomes. Portal vein recanalization-transjugular intrahepatic portosystemic shunt (PVR-TIPS) creation is an efficacious method of restoring physiologic portal flow in cirrhotic patients prior to LT allowing for end-to-end PV anastomosis, and is the product of decades-long institutional expertise in TIPS/LT and the support of a multidisciplinary liver tumor board. To follow is a review of the pertinent pathophysiology of PVT in cirrhosis, the rationale leading to the development and subsequent evolution of the PVR-TIPS procedure, technical lessons learned, and a summary of outcomes to date.

Liver transplant is the definitive treatment of end-stage liver disease and early hepatocellular carcinoma. The number of liver transplant surgeries done is highly affected by the number and availability of deceased donor organs. Living donor liver transplantation has emerged as an alternative source of donors, increasing the availability of organs for transplant. Many factors must be considered when choosing living donor candidates to maintain a high level of donor safety and organ survival. To that end, potential donors undergo a rigorous pre-donation workup.

Abstract Purpose This study aimed to investigate vasculobiliary anatomical variations in living liver donors (LLDs) during pretransplant evaluation using magnetic resonance imaging (MRI). The accuracy of MRI in estimating graft weight was also evaluated. Methods Pre-operative MR imaging data of 100 LLDs were retrospectively assessed, and variations in the biliary, arterial, and venous systems were evaluated. Surgical records were used to identify discrepancies between MRI biliary findings and intra-operative cholangiograms. The image quality was classified as poor, fair, or good. The MRI-estimated weight was compared with the actual explant weight measured during surgery. Results Ninety-seven right lobe hepatectomies and 3 left lobe hepatectomies were performed, with 19 patients exhibiting classic anatomy in all three components. Pre-transplant MRI detected biliary, arterial, and venous variations in 42, 40, and 32 donors, respectively. Intra-operative cholangiograms were found to be discrepant with pre-operative MRIs in 35% of the cases. Furthermore, only 29 donors had acceptable image quality in all anatomical components. The mean estimated graft volume was 1015 ± 253 grams, while mean actual graft weight was 828 ± 204 grams. There was a linear correlation between the MRI-estimated graft weight and the actual graft weight (r: 0.83). Conclusion The utilization of pre-transplantation MRI in the evaluation of LLDs can provide valuable insights into anatomical variations. However, to avoid discrepancies between imaging and operative findings, it is important to exercise caution during graft volumetry and image interpretation. Furthermore, MRCP volumetry is another important step in ensuring that proper graft size is achieved.

BACKGROUND:Personality traits influence clinical outcomes in chronic diseases, but their impact in cirrhosis is unknown. We studied the personality of patients with cirrhosis undergoing liver transplant (LT) evaluation and determined their correlation to clinical outcomes. METHODS:A multicenter' prospective study of adult patients undergoing LT evaluation was performed from January 2018 to October 2019. The "Big Five" personality traits of conscientiousness, extraversion, openness, neuroticism, and agreeableness plus agency were assessed with the Midlife Development Inventory Personality Scale and compared with the general population. Frailty was assessed with the Liver Frailty Index. RESULTS:Two hundred sixty-three LT candidates were enrolled. Twenty-four percent had hepatitis C virus, 25% nonalcoholic steatohepatitis, and 25% ethyl alcohol (mean model for end-stage liver disease = 15.7). Compared with the general population, LT candidates had higher openness (3.1 versus 2.9; P < 0.001), extraversion (3.2 versus 3.1; P < 0.001), agreeableness (3.5 versus 3.4; P = 0.04), agency (2.9 versus 2.6; P < 0.001), neuroticism (2.2 versus 2.1; P = 0.001), and lower conscientiousness (3.3 versus 3.4; P = 0.007). Patients with higher conscientiousness were more likely to receive an LT (HR = 2.76; P = 0.003). CONCLUSIONS:Personality traits in LT candidates differ significantly from the general population, with higher conscientiousness associated with a higher likelihood of receiving a transplant.

Background: End-stage liver disease (ESLD) is not considered a risk factor for atherosclerotic cardiovascular disease (ASCVD). However, lifestyle characteristics commonly associated with increased ASCVD risk are highly prevalent in ESLD. Emerging literature shows a high burden of asymptomatic coronary artery disease (CAD) in patients with ESLD and a high ASCVD risk in liver transplantation (LT) recipients. Coronary artery calcium score (CAC) is a noninvasive test providing reliable CAD risk stratification. We implemented an LT evaluation protocol with CAC playing a central role in triaging and determining the need for further CAD assessment. Here, we inform our results from this early experience. Methods: Patients with ESLD referred for LT evaluation were prospectively studied. We compared accuracy of CAC against that of CAD risk factors/scores, troponin I, dobutamine stress echocardiogram (DSE), and single-photon emission computed tomography (SPECT) to detect coronary stenosis >= 70 (CAD >= 70) per left heart catheterization (LHC). Thirty-day post-LT cardiac outcomes were also analyzed. Results: One hundred twenty-four of 148 (84%) patients underwent CAC, 106 (72%) DSE/SPECT, and 50 (34%) LHC. CAC >= 400 was found in 35 (28%), 100 to 399 in 17 (14%), and <100 in 72 (58%). LHC identified CAD >= 70% in 8 of 29 (28%), 2 of 9 (22%), and 0 of 4, respectively. Two acute coronary syndromes occurred after LT in a patient with CAC 811 (CAD < 70%), and one with CAC 347 (CAD >= 70%). No patients with CAC < 100 presented with acute coronary syndrome after LT. When using CAD >= 70% as primary endpoint of LT evaluation, CAC >= 346 was the only test showing predictive usefulness (negative predictive value 100%). Conclusions: CAC is a promising tool to guide CAD risk stratification and need for LHC during LT evaluation. Patients with a CAC < 100 can safely undergo LT without the need for LHC or cardiac stress testing, whereas a CAC < 346 accurately rules out significant CAD stenosis (>= 70%) on LHC, outperforming other CAD risk-stratification strategies.

Background. Controlled attenuation parameter (CAP) and liver stiffness measurement (LSM) are noninvasive surrogates for hepatic steatosis and fibrosis, respectively, and could help identify extended criteria donors in liver transplantation (LT). We aimed to determine the accuracy of CAP/LSM in deceased donors along with post-LT changes. Methods. Accuracy of preprocurement CAP/LSM to grade/stage steatosis/fibrosis was determined using liver biopsy as reference. Transplant outcomes, including primary nonfunction (PNF) and early allograft dysfunction, were recorded. Recipients underwent CAP/LSM as outpatients. Areas under the receiver operating characteristic curve and regression models were constructed to analyze data. Results. We prospectively evaluated 160 allografts (138 transplanted). Same-probe paired baseline/post-LT CAP was 231 dB/m (181-277)/225 (187-261) (P = 0.61), and LSM 7.6 kPa (6.3-10.8)/5.9 (4.6-8.7) (P = 0.002), respectively. CAP reading was affected by BMI and LSM by ALT, race and bilirubin. Although CAP did not correlate with steatosis from frozen sections (rho = 0.08, P = 0.47), it correlated with steatosis from permanent sections (rho = 0.32, P < 0.001) and with oil red O histomorphometry (rho = 0.35, P = 0.001). CAP identified moderate-to-severe steatosis with an areas under the receiver operating characteristic curve curve of 0.79 (0.66-0.91), for a negative predictive value of 100% at a cutoff value of 230 dB/m. LSM correlated with fibrosis staging (rho = 0.22, P = 0.007) and it identified discarded allografts with advanced fibrosis/cirrhosis. Patients with no to minimal fibrosis had an LSM of 7.6 (6-10.1) kPa. Conclusions. Our results are proof-of-concept of the utility of CAP/LSM during organ procurement. Establishing the precise role of these noninvasive tools in the organ allocation process mandates confirmatory studies.

Introduction: Utilizing allografts from donors after cardiac death (DCD) has improved organ availability, and DCD livers comprise a growing proportion of transplantations. However, it has been suggested that DCD transplantations have worse outcomes. Research Questions: We aimed to characterize outcomes in a large cohort of DCD transplantations, identify trends in outcomes over time, and identify factors associated with the development of biliary complications. Design: We conducted an observational retrospective cohort study of patients receiving DCD liver allografts within a large academic teaching hospital with a high transplantation volume. Consecutive patients who underwent Type III DCD liver transplantation from 2006–2016 were included in our cohort. Re-transplantations and multi-organ transplant recipients were excluded. Results: Ninety-six type III DCD transplantations occurred between 2006–2016. We report a 1one-year patient survival of 90.6% (87) and a 5five-year patient survival of 69.8% (67). Twenty-nine (30.2%) patients experienced any biliary complication in the first year following discharge, with 17 (17.7%) experiencing ischemic cholangiopathy. Five-year patient (P = 0.04) and graft (P = 0.005) survival improved over time. Post-operative biliary complications experienced during index admission and prior to discharge were found to be associated with the development of biliary complications (P = 0.005) and ischemic cholangiopathy (P = 0.01) following discharge. Conclusion: Our data suggested that outcomes using DCD allografts have improved, however biliary complications remain a significant issue in DCD transplantation. Patients who experienced post-operative biliary complications during index admission may require more frequent screening to allow the initiation of earlier treatment for biliary complications.

Background. Donor liver biopsy (DLBx) in liver transplantation provides information on allograft quality; however, predicting outcomes from these allografts remains difficult. Methods. Between 2006 and 2015, 16691 transplants with DLBx were identified from the Standard Transplant Analysis and Research database. Cox proportional hazard regression analyses identified donor and recipient characteristics associated with 30-d, 90-d, 1-y, and 3-y graft survival. A composite model, the Liver Transplant After Biopsy (LTAB) score, was created. The Mini-LTAB was then derived consisting of only donor age, macrosteatosis on DLBx, recipient model for end-stage liver disease score, and cold ischemic time. Risk groups were identified for each score and graft survival was evaluated. P values <0.05 were considered significant. Results. The LTAB model used 14 variables and 5 risk groups and identified low-, mild-, moderate-, high-, and severe-risk groups. Compared with moderate-risk recipients, severe-risk recipients had increased risk of graft loss at 30 d (hazard ratio, 3.270; 95% confidence interval, 2.568-4.120) and at 1 y (2.258; 1.928-2.544). The Mini-LTAB model identified low-, moderate-, and high-risk groups. Graft survival in Mini-LTAB high-risk transplants was significantly lower than moderate- or low-risk transplants at all time points. Conclusions. The LTAB and Mini-LTAB scores represent guiding principles and provide clinically useful tools for the successful selection and utilization of marginal allografts in liver transplantation.