Rates of simultaneous liver kidney (SLK) transplantation in the United States have progressively risen. On 8/10/17, the Organ Procurement and Transplantation Network implemented a policy defining criteria for SLK, with a ‘Safety Net’ to prioritize kidney allocation to liver recipients with ongoing renal failure. We performed a retrospective review of the United Network for Organ Sharing (UNOS) database to evaluate policy impact on SLK, kidney after liver (KAL) and kidney transplant alone (KTA). Rates and outcomes of SLK and KAL transplants were compared, as was utilization of high‐quality kidney allografts with Kidney Donor Profile Indices (KDPI) < 35%. Here, SLK transplants comprised 9.0% and 4.5% of total post‐policy liver and kidney transplants compared to 10.2% and 5.5% prior. Policy enactment did not affect 1‐year graft or patient survival for SLK and KAL populations. Less post‐policy SLK transplants utilized high‐quality kidney allografts; in all transplant settings, outcomes using high‐quality grafts remained stable. These findings suggest that policy implementation has reduced kidney allograft use in SLK transplantation, although both SLK and KAL rates have recently increased. Despite decreased high‐quality kidney allograft use, SLK and KAL outcomes have remained stable. Additional studies and long‐term follow‐up will ensure optimal organ access and sharing.

The recent shortage of University of Wisconsin (UW) solution prompted increased utilization of histidine-tryptophan-ketoglutarate (HTK) solution for liver graft preservation. This contemporary study analyzed deceased donor liver transplant outcomes following preservation with HTK vs. UW. Patients receiving deceased donor liver transplantations between 1/1/2019 and 6/30/2022 were retrospectively identified utilizing the Organ Procurement and Transplant Network database, stratified by preservation with HTK vs. UW, and a propensity score matching analysis was performed. Outcomes assessed included rates of primary nonfunction, graft survival, and patient survival. There were 4,447 patients in each cohort. Primary nonfunction occurred in 60 (1.35%) patients in the HTK group vs. 25 (0.54%) in the UW group (p<0.001). HTK was associated with lower 90-day graft survival (94.39% vs. 96.09%, p<0.001) and 90-day patient survival (95.97% vs. 97.38%, p=0.001). Unmatched donation after cardiac death-specific analysis of HTK vs. UW demonstrated respective rates of primary nonfunction of 1.63% vs. 0.82% (p=0.20), 90-day graft survival of 92.50% vs. 95.29% (p=0.069), and 90-day patient survival of 93.90% vs. 96.35% (p=0.077). These results suggest that HTK may not be an equivalent preservation solution for deceased donor liver transplantation.

Background: Robotic hepatectomy represents an appealing treatment modality for resectable hepatocellular carcinoma (HCC). A contemporary review of robotic hepatectomy compared to laparoscopic/open hepatectomy is necessary. Methods: We performed a literature review to identify studies between 2018–2024 comparing robotic to laparoscopic/open hepatectomy for HCC with measurable outcomes. Results: A total of 10 studies were identified, including 943 patients undergoing robotic hepatectomy compared to 1678 patients undergoing laparoscopic/open hepatectomy. Generally, while similar short/long-term survival was noted across all resection modalities, robotic hepatectomy was associated with longer operative time, shorter length of stay, and less post-operative complications. An additional 4 studies were evaluated in the context of HCC, reviewing the prognostic value of robotic hepatectomy margins, robotic hepatectomy in the context of metabolic syndrome, “huge” (>10 cm) HCCs, and robotic hepatectomy vs. microwave ablation. Conclusions: Robotic hepatectomy is a safe alternative to laparoscopic/open hepatectomy for HCC that provides similar oncological/long-term outcomes, while potentially decreasing post-operative complications and length of stay.

Liver transplantation continues to face significant organ shortages and efficient utilization of marginal donors is paramount. This study evaluates the practice patterns and outcomes in liver transplantation when utilizing allografts from marginal donors who required extracorporeal membrane oxygenation (ECMO) support. We performed a retrospective review of the Gift of Life (PA, NJ, DE) organ-procuring organization database for transplants performed using donors supported on ECMO for nondonation purposes. These were cross-referenced to the transplant recipients within the Organ Procurement and Transplantation Network database, and the outcomes of liver transplants using donors on ECMO support were compared with those not requiring ECMO. Organ use and nonuse patterns were then evaluated in ECMO-supported donors, identifying the factors associated with nonuse compared with the factors associated with graft failure. Thirty-nine of the 84 ECMO-supported donors contributing at least one intra-abdominal organ for transplant donated a liver. Graft survival and patient survival up to 5 years were comparable between transplants from ECMO and non-ECMO-supported donors, and no cases of primary nonfunction were seen in the ECMO group. ECMO support was not associated with 1-year graft failure on regression modeling. Additional regression analyses within the ECMO donor population identified bacteremia (HR: 19.81) and elevated total bilirubin at donation (HR: 2.44) as predictive of post-transplant graft failure. Livers from donors supported on ECMO before donation appear safe to use in select transplant settings. Better understanding of the impact of predonation ECMO on liver allograft function will help guide the optimal use of these scarcely used donors.

Non-alcoholic steatohepatitis (NASH)-related hepatocellular carcinoma (HCC) has become the second leading cause of HCC-related liver transplantation in the United States. This study investigated post-transplant recurrence and survival for patients transplanted for NASH-related HCC compared to non-NASH HCC etiologies. Retrospective review of the United Network for Organ Sharing (UNOS) Organ Procurement and Transplantation Network (OPTN) database identified 7,461 patients with HCC—1,405 with underlying NASH and 6,086 with non-NASH underlying diseases. After propensity score matching (PSM) to account for patient- and tumor-related confounders 1,175 remained in each group. Primary outcomes assessed were recurrence rate and recurrence-free survival. Recurrent malignancy at 5 years post-transplant was lower in NASH compared to non-NASH patients (5.80 vs. 9.41%, p = 0.01). Recurrence-free survival, however, was similar at 5 years between groups. Patients with NASH-related HCC were less likely to have post-transplant recurrence than their non-NASH counterparts, although recurrence-free survival was similar at 5 years.