Background: Hepatopulmonary syndrome (HPS), defined by the presence of pulmonary vascular dilatations that cause right-to-left transpulmonary shunting of venous blood with a consequential increase in the alveolar–arterial oxygen gradient, is a relatively frequent complication of chronic liver disease. While orthotopic liver transplantation (OLT) is indicated and often curative in HPS patients with end-stage liver disease (ESLD), little is known about the peri- and post-operative-period risks of CVA in OLT recipients with HPS. Case Presentation: We report a case series of five non-consecutive OLT recipients with HPS who developed ischemic and/or hemorrhagic CVAs during or shortly after OLT, raising concern that the risks of neurological complications remain increased even after OLT. Conclusions: Our case series hopes to highlight the importance of close vigilance in this subset of patients, at a time when there may be multiple issues to be addressed in facilitating post-operative recovery.

Calcineurin inhibitors (CNIs) remain the cornerstone of immunosuppression after liver transplantation (LT) but contribute to chronic renal failure, increasing long-term morbidity and mortality. Strategies to minimize CNI exposure and preserve renal function are necessary to improve long-term outcomes in high-acuity LT recipients. We conducted a single-center, prospective, randomized trial of adult LT recipients requiring pre-LT renal replacement therapy (RRT). Patients were randomized to: (1) basiliximab induction and delayed tacrolimus starting postoperative day (POD) 5 (BAS); (2) basiliximab induction, tacrolimus starting POD5, and everolimus starting POD31, followed by tacrolimus minimization (BAS-EVR); (3) standard immunosuppression (control). RRT independence, renal function, rejection, graft and patient survival, and adverse events were assessed. Seventy patients were analyzed (BAS n=30; BAS-EVR n=28; control n=12). Median MELD was 40, and 55.7% of patients required mechanical ventilation or vasopressor support pre-LT. Overall, 68.6% of patients achieved RRT independence by 24 weeks: 73.3% (BAS), 75.0% (BAS-EVR), and 41.7% (control). Basiliximab ( p =0.04) and shorter duration of pre-LT RRT ( p =0.02) were significantly associated with RRT independence; basiliximab remained significant after adjusting for duration of pre-LT RRT [OR 3.87 (95% CI 1.01–14.74), p =0.048]. Among patients who achieved RRT independence, median eGFR trended higher in the BAS-EVR group (67 mL/min/1.73 m ² ) than in BAS (52 mL/min/1.73 m ² ) and control groups (50 mL/min/1.73 m ² ) at 24 weeks. Patient and graft survival were comparable across groups. Adverse events were similar, although diarrhea ( p =0.004) and acute kidney injury ( p =0.01) were more frequent in the BAS-EVR group. Basiliximab induction therapy with delayed tacrolimus promotes RRT independence in high-acuity LT recipients. Addition of everolimus to minimize tacrolimus may further preserve renal function without compromising graft or patient survival.

Intestine transplants are highly sensitive to ischemia-reperfusion injury (IRI). Static cold storage (SCS) is the standard for multivisceral (MVT) allograft preservation but carries known risks. While several devices have been developed for liver, lung, and heart graft preservation, there are no systems validated specifically for MVT grafts. We report the first use of the Paragonix LIVERguard® Donor Liver Transport System for hypothermic static preservation of a donation after brain death (DBD) MVT allograft, transported approximately 1363 miles. The Paragonix LIVERguard® was used to preserve a pediatric MVT graft during long-distance transport between the donor and recipient hospitals. We collected donor and recipient characteristics, ischemia intervals, lab markers of IRI, vasopressor duration, intensive care unit (ICU) and hospital length of stay, and time to enteral feeding. The graft included liver, stomach, pancreas, spleen, small intestine, and colon. Cold ischemia time (CIT) was 6.8 h. The device maintained a mean temperature of 4.5°C (range: 3.8–5.2°C). Endoscopy showed no evidence of rejection. There was rapid normalization of both enzymatic injury markers (AST/ALT) and metabolic markers (lactate). Enteral feeding began on POD 13 and advanced to the goal. She was discharged home on POD 103. This case represents the first reported use of the Paragonix LIVERguard® for MVT graft preservation and transport. The device maintained a narrow temperature range over a 6.8-hour CIT and more than 1300 miles of travel. Relative to historical institutional experience, the case demonstrated lower peak biochemical markers and faster normalization of graft function. These findings support further investigation into whether preservation strategies that maintain tighter thermal control may influence early graft recovery in MVT.

Portal vein thrombosis (PVT) is common among liver transplant candidates, affecting up to 26% of patients awaiting liver transplant. Despite the suspected negative impact of PVT on liver transplant outcomes, consensus recommendations remain lacking. Thrombus circumvention is most commonly achieved with eversion portal thromboendovenectomy or venous jump graft. We present a novel hybrid approach addressing PVT in a patient with acute hepatic decompensation and worsening clot burden extending to the superior mesenteric and splenic veins. This patient underwent a transjugular intrahepatic portosystemic shunt (TIPS) placement and endovascular thrombectomy of the splanchnic veins less than 24 h prior to undergoing an orthotopic liver transplant with the graft maintained on normothermic machine perfusion. Three‐month postoperative scans demonstrated a patent portal venous system with trace residual clot burden. This is the first reported case utilizing a hybrid approach for a portal vein thrombus extending into the superior mesenteric and splenic veins with subsequent orthotopic liver transplant.

The survival benefit of liver transplantation (LT) for hepatocellular carcinoma (HCC) varies by waitlist dropout risk, yet allocation policy applies uniform prioritization, and center practices remain poorly characterized. We performed a retrospective cohort study using the United Network for Organ Sharing database, including LT candidates with HCC between February 4, 2020, and October 1, 2024. Low-dropout-risk (LDR) HCC was defined as MELD<15, Child–Pugh A, single lesion <3 cm, and AFP≤20 ng/mL at listing; all others were standard risk. Centers were classified as low-LDR (lowest quartile) or high-LDR (highest quartile) based on the proportion of their transplants that were LDR candidates with complete radiographic response (no viable tumor) on the last pre-LT imaging. Waitlist outcomes were analyzed with adjusted Fine–Gray competing-risk models. Among 7198 candidates across 93 centers, the proportion of LDR transplants varied widely across centers (range 0%–42%). In adjusted analyses, among standard-risk candidates, listing at a high-LDR rather than low-LDR center was associated with lower transplantation (SHR 0.81, 95% CI 0.72–0.90) and higher dropout (SHR 1.39, 95% CI 1.14–1.70) (both p <0.001). Waitlist outcomes for LDR candidates and post-transplant survival did not differ by center type. These findings suggest substantial center variation exists for LDR HCC and may disadvantage access among higher-need candidates despite similar post-transplant survival.