Strategic leadership and financial governance in liver transplantation: Global insights from the International Liver Transplantation Society Congress 2025

Liver Transplantation in Croatia: "David Among Goliaths".

Current Opinion in Organ Transplantation was launched in 1996. It is part of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of organ transplantation is divided into 18 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Editors-in-Chief, Associate Editors and Section Editors for this issue. EDITORS-IN-CHIEF Linda S. SherLinda S. SherDr Linda Sher is Professor, Division of Hepatobiliary Surgery and Abdominal Organ Transplantation and the Chief, Division of Clinical Research in the Department of Surgery at Keck School of Medicine, University of Southern California (USC), USA. Dr Sher completed her medical school training and surgical residency at Mount Sinai School of Medicine in New York, following which she completed a fellowship training in Liver and Kidney Transplantation at the University of Pittsburgh, USA. After completing her fellowship in 1988, Dr Sher was involved in the establishment of two liver transplant programs in Los Angeles prior to joining the USC program in 2001. Dr Sher has participated in and overseen over 100 research projects and is currently very active in the development of the clinical and basic science research components of the USC Abdominal Organ Transplantation Program. She has numerous publications on immunosuppression, chronic rejection, disease recurrence, infection, and hepatobiliary surgery. Dr Sher is one of the original editors of Current Opinion in Organ Transplantation and has endeavored over the years to provide the reader with an up to date overview of the entire field of organ transplantation. ASSOCIATE EDITORS Josep M. GrinyóJosep M. GrinyóDr Josep Grinyó, MD, PhD, is Emeritus Professor of Medicine at the University of Barcelona. Dr Grinyó's research work on renal transplantation has been focused on immunosuppression, ischemia-reperfusion injury and chronic allograft damage in the clinical setting and in experimental animal models. He has hold more than 60 competitive research projects and he has authored more than 340 articles and given more than 250 invited lectures. He has acted as associate editor and reviewer in the top ranked journals in his field of expertise (AJT, CJASN, JASN, NEJM, NDT, TI, Lancet). He has been member of the councils of the scientific societies and chair of several scientific programs committees of congresses of these societies (TTS, ERA-EDTA, ESOT, ISN). He is member of several steering committees and DSMBs of international research consortiums on cell therapy, biomarker-driven immunosuppression, treatment of autoimmune nephritis and organ preservation. He is reviewer of competitive research applications for research organisations in Spain, Belgium, Germany, France (Inserm), Argentine, Austria, USA and UK (MRC, EME Experts). Jerzy Kupiec-WeglinskiJerzy Kupiec-WeglinskiDr Kupiec-Weglinski is the Director of Dumont-University of California, Los Angeles (UCLA) Transplant Research Laboratories in Los Angeles, USA. He is a Distinguished Professor of Surgery, and Vice-Chairman (Research), Department of Surgery, at the David Geffen School of Medicine at UCLA. He holds the Inaugural Paul I. Terasaki Endowed Chair in Surgery. Dr Kupiec-Weglinski's interests focus on the immunobiology of organ ischemia-reperfusion injury, host sensitization, and tolerance induction in transplant recipients. He has authored over 400 papers. His research for the last 32 years has been funded by National Institute of Health (NIH). He served as standing member of the Transplantation, Tolerance and Tumor Immunology (TTT) NIH Study Section, as member of the board of directors of American Society of Transplantation, recipient of AST/Astellas Established Investigator Award in Basic Transplant Research, as well as of The Transplantation Society (TTS) Awards for Outstanding Achievements in Basic Science; and for Mentorship or Education and Training in Transplantation. He holds the Honorary Doctorate (“Honoris Causa”) from Medical University of Warsaw, and is the Foreign Member of Polish Academy of Sciences and Polish Academy of Arts and Sciences. SECTION EDITORS Valeria R. MasValeria R. MasDr Valeria R. Mas, PhD is a molecular and cellular immunologist that serves as tenured Professor of Surgery and Division Head of the Division of Surgical Sciences at the University of Maryland. Dr. Mas was the Director of the Transplant Genomics Laboratory at Virginia Commonwealth University until 2011 and she went on to become a tenured Associate Professor of Research Surgery at the University of Virginia, where she directed the Translational Genomics Transplant Laboratory and was Co-Director of Transplant Research. She is the founder and former Director of the Transplant Research Institute that is part of the Methodist University Transplant Institute associated with University of Tennessee Health Science Center. Dr. Mas has been conducting studies in genomics and proteomics related to kidney and liver transplant recipients during the last 20 years. Her research projects are mainly focused to: (1) evaluate the molecular pathways that associate with graft fibrosis development and loss of function post-kidney transplantation, (2) test the effects of organ donor biology in short-and long-term outcomes post-transplantation, and (3) identify early biomarkers that distinguish those organs at high risk of post-transplant dysfunction. She uses integrative approaches (proteomics, epigenetics, transcriptomics, and bioinformatics) for understanding the role of immunological and non-immunological factors in transplantation outcomes. As a PI and Coinvestigator, she has been funded by NIH during the last 15 years and has more than 100 peer reviewed publications. She has received investigator awards from the American Transplant Society, from the International Liver Transplant Society, and from The Transplantation Society. She was elected Councilor of the International Liver Transplant Society and serves as an ad hoc reviewer in multiple NIH study sections and is a member of NIDDK PBKD study section. Michael L. VolkMichael L. VolkDr Michael L. Volk is the Chief of Gastroenterology and Hepatology, and Medical Director of Liver Transplantation at Loma Linda University. He is triple board certified in Transplant Hepatology, Gastroenterology, and Internal Medicine, and has been frequently selected by Best Doctors as among the top Hepatologists in the country. Prior to moving to Loma Linda, Dr Volk was Director of the Liver Tumor Program at the University of Michigan. He is a former Robert Wood Johnson Clinical Scholar, with a funded research program that focuses on management of cirrhosis and organ allocation for liver transplantation. He has published >100 research articles, reviews, and book chapters. Since moving to Loma Linda in 2015, Dr. Volk has helped quadruple the size of the liver transplant program, from 25/year to >100/year. He has grown the GI division from 8 faculty to 17 and established numerous satellite clinical locations including an academic-private partnership in an ambulatory surgery center. He has introduced numerous new clinical services and established a multidisciplinary Digestive Disease Center. In his free time, he enjoys hiking and biking with his wife Corrie and two boys Alexander and Sebastian. Uwe HeemanUwe HeemanProf. Uwe Heemann is a graduate from Bochum Medical University where he received his MD. He worked a fellow at the University Hospital Essen as well as at the Brigham Hospital in Boston. Currently he is Director of the Department of Nephrology, Klinikum rechts der Isar, Technical University Munich. Prof. Heemann is nationally and internationally recognized as leader in the field of kidney transplantation. He is a Past-President of the German Society of Transplantation, Member of the Board of Eurotransplant, Chair of the Kidney Advisory Committee of Eurotransplant and served as member of the DESCARTES group. His current activities focus on transplantation as well as the reduction of mortality in the field of dialysis. He has published more than 350 articles cited in medline as well as a multitude of monographies and books, was principal investigator in multiple international and national trials and served as advisor for various scientific groups as well as pharmaceutical companies. He has published in prestigious journals including Journal of Clinical Investigation, Kidney International, Transplantation, Circulation, Hypertension and Journal of the American Society of Nephrology. In addition, he serves on numerous international journals, lectures at universities around the world and has facilitated the careers of national and international fellows to high academic positions.

The impact of the COVID-19 outbreak on liver transplantation programs in Northern Italy.

GRADE, Grading of Recommendations Assessment, Development, and Evaluation; HCC, hepatocellular carcinoma; LDLT, living donor liver transplantation; LT, liver transplantation. In less than 30 years, liver transplantation (LT) has rapidly developed from a highly experimental and controversial procedure to one of the most successful stories in medicine. Nowadays, LT is a widely accepted treatment for select patients with hepatocellular carcinoma (HCC). Historically, HCC was a dismal disease amenable only to palliative therapies; a number of curative alternatives, including liver resection, locoregional therapies, and LT, have emerged. This evolution is associated with dramatic improvements in imaging techniques and the implementation of surveillance programs, which have facilitated the detection of many HCCs at an earlier stage when an effective treatment is feasible.1 In this context, LT is considered an optimal strategy that addresses both the underlying disease and the cancer, and HCC is currently the indication for LT in 25% and 35% of all cases in Europe and the United States, respectively.2, 3 The need to obtain the optimal benefit from the limited number of available organs has prompted the maintenance of stringent selection criteria so that only those patients with early HCC, who have the highest likelihood of achieving long-term survival after LT, are listed. The indications for LT and the allocation of donor organs are, therefore, closely scrutinized by all LT stakeholders. An international consensus conference on LT for HCC was held in Zurich, Switzerland on December 2-4, 2010. The aims of this conference were as follows: (1) establishing the state of the art for indications for LT in patients with HCC and (2) providing internationally accepted statements and guidelines for LT programs. This conference was endorsed and financially supported by 10 major international societies focusing on liver diseases or LT: the American Association for the Study of Liver Diseases, the American Society of Transplant Surgeons, the European Association for the Study of the Liver, the European-African Hepato-Pancreato-Biliary Association, the European Liver and Intestine Transplant Association, the International Hepato-Pancreato-Biliary Association, the International Liver Cancer Association, the International Liver Transplantation Society, the Transplantation Society, and the Liver and Gastrointestinal Disease Foundation. The University of Zurich also provided financial support for this conference. For this purpose, a novel format for the consensus conference, which was based on the Danish model, was developed.4 The organizing committee identified 19 specific questions, and these questions were grouped into 5 topics (Table 1). Nineteen working groups were created to address these questions; each group was composed of 4 to 6 experts from various fields of medicine, including surgery, gastroenterology, radiology, oncology, pathology, patient representation, health insurance, statistics, and ethics. These experts were selected on the basis of their scientific and clinical records, and their mission was to prepare evidence-based papers and draft recommendations. They were asked to follow the Oxford classification for levels of evidence5 (Table 2). Nine people from a variety of clinical and academic fields (not including any fields involving LT or HCC) were appointed to a jury, and this jury reviewed the submitted papers, commented on them, and made the final recommendations. As in the Danish model, the essential rule was that the final recommendations were to be drawn by the jury and not by the experts!4 Eighteen months before the conference in Zurich, the various topics and the progression of the groups' work were extensively discussed with the organizing committee and the members of the jury. For example, 3 workshops were held during 2009 and 2010 (2 at the annual meeting of the American Association for the Study of Liver Diseases in Boston and 1 at the meeting of the European Association for the Study of the Liver in Vienna); there, the chairs or representatives from each working group met with the organizing committee and the jury president or vice-president to evaluate and discuss the status of their work. Consequently, most papers, including the recommendations from the working groups, were assessed in advance by the jury. Most often, revisions were made to these papers before the conference. Approximately 300 attendees from 5 continents were present at the consensus conference in Zurich. The chair of each working group delivered a 15-minute presentation that covered each specific question, and this was followed by questions first from the jury and then from the audience. Before the conference, the members of the jury used the experts' texts to prepare some proposals for final recommendations that answered the 19 specific questions. These proposals were discussed during the conference, and they were modified at that time in response to the discussions. Afterwards, the audience was polled anonymously with an electronic voting system to determine the strength of each recommendation; the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system for decision making6 was used (Fig. 1). The jury met independently after the meeting to produce final recommendations, which were based on the papers submitted by the experts, the discussions, and the vote of the audience during the conference. GRADE system.6 The strength of each recommendation was determined by the vote of the audience and the jury. A committee was then established to write the consensus text. This writing committee was composed of the president, the vice-president, and a statistician from the jury as well as 3 members of the organizing committee. This text will be published in The Lancet Oncology.7 General considerations: diagnosis. Indications for LT. Bridging therapy, down-staging, and monitoring on the waiting list. Living donor liver transplantation (LDLT). Monitoring after LT. The first part of the conference focused on the survival goals for LT in patients with HCC and on the tools for establishing the diagnosis of HCC.8-11 Posttransplant survival was a matter of debate. The experts proposed lowering the 5-year survival rate to 50% because of patients' personal benefits from LT. However, because of the shortage of donor organs and for consistency with the statement that the results of LT within the Milan criteria are the benchmarks, the jury concluded that LT should be reserved for HCC patients who have a predicted 5-year survival rate comparable to that of non-HCC patients. For the diagnosis of HCC, the jury endorsed the algorithm of the American Association for the Study of Liver Diseases, which is based on state-of-the-art cross-sectional imaging techniques (computed tomography or magnetic resonance imaging). In the second part of the conference, the experts focused on the indications for LT and on the possible expansion of the accepted criteria for LT for HCC.12-17 Mazzaferro et al.12 provided an exhaustive review of the literature and analyzed 90 studies, which covered 15 years of experience with the Milan criteria. Germani et al.13 conducted a meta-analysis of 101 studies and assessed the effects of staging HCC with the size and number of nodules on posttransplant recurrence and survival. They concluded that the diameter of the largest nodule or the total diameter of all nodules is the best outcome predictor. This conclusion agrees with recent Organ Procurement and Transplantation Network data, which suggest that the total tumor volume and the alpha-fetoprotein level could be useful for selecting HCC patients for LT.18 Freeman's group16 addressed the issue of using extended criteria (ie, criteria beyond the Milan criteria). Although evidence has accumulated for good outcomes for some patients beyond the Milan criteria, no definitive recommendations could be made. These strategies should be considered according to the local situation of each transplant center (ie, the availability of donor organs and the mortality rate for patients on the waiting list). Treatment on the waiting list and the down-staging of larger HCCs were the topics of the third part of the conference.19-21 This group of experts supported the concept of down-staging, although the indications and the criteria for defining success still need to be standardized. Not surprisingly, none of the locoregional therapies showed any superiority. As for treatment on the waiting list, no therapy was recommended for United Network for Organ Sharing T1 tumors. For United Network for Organ Sharing T2 tumors, the experts suggested bridging strategies for patients likely to wait longer than 6 months to prevent the development of contraindications during the waiting period. All therapies were extensively discussed, and a marginal advantage was shown for radiofrequency ablation. The fourth part, which dealt with the use of LDLT for HCC patients, triggered some controversial debates among the experts, the audience, and the jury.22-24 They discussed ethical concerns with the double equipoise describing the balance between the recipient's survival benefit with or without LDLT and the risks of morbidity and mortality for the donor. Five years after the publication of the findings of the Vancouver forum,25 it is well accepted that patients with HCC within the Milan criteria should be offered LDLT as a treatment option. On the other hand, the question of offering LDLT to HCC patients beyond the accepted criteria raised many questions. There were arguments from experts in favor of donor protection and from experts who instead focused on the patient's benefit (the issue of organ sharing does not apply to LDLT). Finally, the jury decided not to make any formal recommendations about the use of LDLT for HCC patients beyond the Milan criteria. Each transplant center should determine a clear policy with rigorous safeguards and inform the community about the expected outcomes. Finally, the fifth part of the conference focused on management after LT and paid special attention to the risk of HCC recurrence after LT.26-28 The experts investigated whether immunosuppression regimens have an impact on HCC recurrence and whether they should be adapted in such an oncological context. Adjuvant therapies were also evaluated for their potential to reduce tumor recurrence post-LT and improve long-term survival. Finally, the different therapeutic options and their indications for HCC recurrence were discussed. Overall, this consensus conference format led to objective evaluations of the most controversial topics in the field of LT for HCC by an independent jury. To the best of our knowledge, this is the first time that this format has been used in this field, in which strong opinions or dogmatic beliefs are usually difficult to challenge. The results of this effort are compiled in this special issue, which provides up-to-date information for the consensus text to be published in The Lancet Oncology.7

We sought to evaluate the impact of liver transplantation (LT) programs on the prognosis of hepatocellular carcinoma (HCC) patients who underwent liver resection (LR) and noncurative intent treatment. LT programs have an array of resources and services that would positively affect the prognosis of patients with HCC. Patients who underwent LT, LR, radiotherapy (RT), or chemotherapy (CTx) for HCC between 2004 and 2018 were included in the National Cancer Database. Institutions with LT programs were defined as those that performed 1 or more LT for at least 5 years. Centers were stratified by hospital volume. The impact of LT programs was assessed after propensity score matching to achieve covariate balance. A total of 71,735 patients were identified, of which 7997 received LT (11.1%), 12,683 LR (17.7%), 15,675 RT (21.9%), and 35,380 CTx (49.3%). Among a total of 1267 distinct institutions, 94 (7.4%) were categorized as LT programs. Designation as an LT program was also associated with a high volume of LR and noncurative intent treatment (both P <0.001). After propensity score matching, LT programs were associated with better survival among LR and noncurative intent treatment patients. Although hospital volume was also associated with improved prognosis, LT programs were associated with additional survival benefits in noncurative intent treatment. On the other hand, no such benefit was noted in patients who underwent LR. The presence of an LT program was associated with a higher volume of LR and noncurative intent treatment. Furthermore, designation as an LT program had a "halo effect" on the prognosis of patients undergoing RT/CTx that went beyond the procedure-volume effect.

New years bring new beginnings, and we are happy to announce that the International Liver Transplantation Society (ILTS) will be rejoining the American Association for the Study of Liver Diseases (AASLD) as sponsors of our Journal, Liver Transplantation (LT). We are both very grateful for all the efforts from both societies that resulted in bringing the 2 groups back together after nearly a 9-year hiatus. As Editor-in-Chief of the Journal and President of the ILTS, we are both very confident this will be a significant achievement that will lead to improvements in the Journal and add value to both societies. We would like to take this opportunity to thank The Transplantation Society, the editors, and the editorial board of Transplantation for their support to ILTS and its members over the past 9 years—a testament to the power of collaboration and teamwork within the transplant community for the ultimate benefit of our patients. The AASLD and the ILTS are natural partners in their dedication to the science and clinical work in liver transplantation and end-stage liver disease. Additionally, liver transplantation has always been a collaborative effort between hepatology, surgery, anesthesia, intensive care, and many other important associated disciplines. Since its inception, our Journal, LT, has been no exception. The collaboration between medicine and surgery was no more apparent than in our Editors-in-Chief, which for the first 4 terms included a surgeon and a hepatologist partner, both working together to produce a journal that highlighted the best science in advanced liver disease and liver transplantation. We are confident this reunification will improve the quality of the Journal as well as the scientific material delivered to both of our memberships. The Journal will now publish the contents from the fantastic ILTS single-topic conferences, consensus meetings, and guidance documents. In addition to broadening our readership, this reunification will expand our editorial board and editorial leadership with its diverse membership of the ILTS by including transplant anesthesiologists, pathologists, and critical care physicians, who all will contribute greatly to the science of liver transplantation, liver failure, and liver surgery. In this issue of LT, we feature our first ILTS meeting summary, the Proceedings from the 28th annual ILTS meeting in Rotterdam. This manuscript is a fantastic summary that all our readers will enjoy, with topics ranging from machine perfusion to immunosuppression, robotic surgery, and acute liver failure. We expect future collaboration from the ILTS meetings including the recent ILTS-ILCA conference, future ILTS symposia, as well as our transplant course at the AASLD Congress. Many members of both the ILTS and the AASLD leadership worked together to make this reunification possible. We are extremely grateful to all of them and their hard work to grow our societies, enhance our educational efforts, and more importantly make our Journal better. We are very excited about this collaboration, and we are sure that you will be too. Now that we’ve shared this good news, are any of our LT readers humming these classic Peaches & Herb lyrics, “Reunited, and it feels so good”? As always, such changes evolve over time, and we welcome the input of all the members of both of our societies as to future directions this collaboration might take. We wish you all the best in this coming year as we embark on this exciting new project.

You celebrated 6000 liver transplants at UCLA in 2016. How does one build the largest liver transplant program in the world?FigureRWB: The building of our Liver Transplantation Program at UCLA, was a complex undertaking stimulated by a 20-year-old patient whom I had performed a distal splenorenal shunt for variceal bleeding. Unexpectedly, he developed liver failure 7 days postoperatively and died, before I could transfer him to Dr. Starzl in Pittsburgh for consideration of liver transplantation. As I walked out of the ICU that day, I turned to my friend and hepatology colleague, Dr. Leonard Goldstein and stated “Leonard, we need to start doing liver transplants at UCLA.” In late 1982, I told Dr. William P. Longmire, Jr., a renowned liver surgeon and Chairman at UCLA, that I would like to start a liver transplant program. He was supportive, and I assembled a team and initiated a program of porcine orthotopic liver transplantation. We performed over 50 transplants using venous-venous bypass, with excellent success. I then visited Dr. Starzl in Pittsburgh to observe clinical liver transplantation and participated in about 6 cases. Over the next several months, we put together our multidisciplinary team at UCLA despite some skepticism from hospital administration. On February 1, 1984, we performed our first liver transplant on a recipient with a hepatic schwannoma and used venous venous bypass. The patient required 17 units of blood and was discharged on postoperative day 17. We performed our 100th liver transplant at UCLA in November 1986, and reported our experience the following year at the American Surgical Association. In my closing remarks, I recognized Dr. Starzl’s contributions: “how well I remember the multiple phone conversations on our first few transplants, in which I sought your advice, encouragement and leadership and I am very grateful for that.” After our first 100 liver transplants, our program continued to grow rapidly since we were one of the first programs in the western part of the United States, and encompassed the entire spectrum of pediatric and adult liver transplantation including the sickest patients. Our team performed our 5000th liver transplant on September 9, 2010, and our 6000th on June 30, 2016, making our program one of the largest worldwide. None of this could have happened without the unfailing support of our totally dedicated multidisciplinary team of surgical and medical specialists, nurse coordinators, hospital leadership, administrators, organ procurement agency, and the supportive generosity of donor families. More than 6000 liver transplants would not go by without remembering very special cases. What is your most memorable surgery and patient? RWB: To be honest, all of my patients are memorable. Certainly, those who did not survive have influenced me in ways that resulted in improving our patient and donor selection, operative techniques and postoperative management. If we look for instance at our pediatric patients there has been a significant improvement in 15 year graft survival from 51% from 1984 to 2000 to 72% from 2001 to 2017. Although all of my patients are memorable, there is a very special 1-year-old child, who I transplanted on August 8, 1984, our fifth transplant, with a giant hepatic hemangioendothelioma who is now 34 years old, married, and living a wonderful life. She is one of over 1000 children that we have transplanted in our program. In addition to excellent clinical outcomes, you have a unique collection of clinical data. How did you built your database and what have you learnt and brought back to clinical application? RWB: From the inception of our program, each patient evaluated for liver transplantation has been registered into an IRB sanctioned transplant database, with a comprehensive list of recipient, donor, and perioperative variables maintained prospectively. Over the years, our transplant surgeons have played the leading role in extracting additional clinical, laboratory, radiologic, and pathologic information from the medical records, resulting in the continuous growth and enrichment of the database which is updated regularly. This robust research database has been integral to our research productivity over the years. With greater than 800 publications in peer-reviewed journals, the UCLA transplant program has made significant contributions to the field of liver transplantation, with leading roles in numerous randomized-controlled trials that led to the current standard of care in immunosuppression (tacrolimus), and fungal, viral, and PCP prophylaxis following LT. Furthermore, we have contributed important innovations in surgical techniques such as in situ split-liver transplantation, as well as innumerable reports of clinical outcomes examining salient issues pertaining to donor allocation, use of extended-criteria donor allografts, and transplantation for malignancies. Our clinical research program is integrated with our robust basic science and translational program focusing on hepatic ischemia/reperfusion injury, leading to several clinical trials in human liver transplantation. You have mentored many transplant surgeons who went on to take very successful leadership roles. What is the secret of your mentoring style? RWB: I truly believe that one of the most important components of my career has been my commitment to training and mentoring future leaders in transplantation. This is a multifaceted commitment, and as stated by Gary Burnison, CEO of Korn Ferry International, “to lead is to be all in, transparent and accessible, calm in the face of upset and even crisis, and always mindful that you are a steward of something bigger than yourself.” Transplantation is certainly a discipline which demands all of the above. Additionally, to be successful in training our future leaders, you must demonstrate vision, self-direction, courage to take on complex cases, and most importantly to always embody honesty and integrity. Finally, genuine, personal interaction is essential. Despite my administrative role as Chairman of our Department, I always set time aside for personal interaction and the mentoring of medical students, residents and fellows, which includes clinical rounding, one-on-one meetings, and hosting a monthly Journal Club at my house for the last 30 years. The LA Times had an interview, now almost 2 decades back in which they featured you and your efforts in finding novel ways to keep up with the demand for liver transplantation. All those attempts, at the time seemed unable to keep up with havoc caused by hepatitis C. Today, new and effective antivirals have changed the game. How have the new antivirals changed liver transplantation? RWB: Hepatitis C was clearly the most common indication for liver transplantation in most centers in the United States until the advent of effective antiviral agents over the past couple of years. However, even patients who have cleared the virus may still require liver replacement due to failing liver function. In these cases, the results of liver transplant are vastly improved due to the lack of HCV recurrence. HCV is diminishing as an indication for liver transplant, and we now have a new leader in the queue, which is nonalcoholic steatohepatitis (NASH). In many cases, these patients are more complex, more technically demanding and have additional co-morbidity. We are pushing to establish a trial to determine if sleeve gastrectomy performed with liver transplantation will improve the outcomes of these difficult patients. There has been a long debate on the timing for patients with end-stage alcohol toxic liver disease. Is it safe to transplant those patients without a minimum time of documented abstinence? RWB: Liver transplantation for alcoholic hepatitis is a very controversial topic, due to the high rate of recidivism and the limited donor pool. However, there is more data coming out which shows that early liver transplantation for severe alcoholic hepatitis in selected patients can provide very good short-term survival and equivalent rates of relapse as seen in patients who have 6 months of abstinence pretransplant. One of my former fellows, Dr. Andrew Cameron, Chief of Liver Transplantation at Johns Hopkins University, recently published the results of a 3-year pilot program comparing patients with alcoholic hepatitis after first liver decompensation versus those with the same condition that had 6 months of abstinence. The survival and incidence of alcohol relapse was the same in both groups. In an editorial that I authored for this article, I concluded that the dramatic improvement in survival in those transplanted early and the equivalent recidivism rates compared to those transplanted after 6 months sobriety justifies this approach and careful consideration should be given to implementing this policy with close scrutiny. You list more than 700 publications in PubMed. What do you consider your most important scientific contribution? Together with Dr. Jerzy Kupiec-Weglinski you have explored many novel mechanistic and therapeutic avenues addressing ischemia/reperfusion injury. What of those efforts have been or about to be translated into clinical application? RWB: I have been intensively involved in both clinical and basic science research since I was a medical student at Tulane, where I obtained my MD and MS degrees. My masters degree thesis was “The Cytological Localization of Erythropoietin Using the Fluorescent Antibody Technique”. Upon obtaining my PhD in 1975, I published one of the first articles demonstrating that steroid therapy was successful in blocking ischemia reperfusion injury in ischemic hearts. Since founding the liver transplant program in 1984, my basic research program has been focused on the prevention of ischemia reperfusion injury (IRI) of the liver. I have been continually funded from the NIH and other peer-reviewed granting agencies since 1981. In 1997, I recruited Jerzy Kupiec-Weglinski, MD, PhD, from Harvard University to lead the basic science thrust of our laboratory. I have worked very closely with Dr. Kupiec-Weglinski to specifically identify the mechanisms of (IRI) and to develop treatment modalities to prevent the injury. Indeed, our “bench-to-bedside” collaborative research on the innate—adaptive immune interface in liver transplant recipients has been recently awarded a 5-year Program Project Grant from the NIH. As there are less than 10 program project grants in the country funded by the NIH that are related to organ transplantation, this is quite an achievement. The focus of the research on liver ischemia reperfusion injury (IRI) is both basic and translational since IRI contributes to poor graft function after transplantation. Minimizing the adverse effects of IRI could increase the number of patients that may successfully undergo liver transplantation. Our research has involved studying the platelet leukocyte endothelial cell interactions which play a central role in IRI. We were the first group to document that inhibition of P-Selectin activation by blocking P-Selectin glycoprotein ligand-1 was highly successful in increasing survival in marginal liver grafts after transplantation. I have been the principal investigator of these studies since they were initiated in the mid-1990s and currently these have been expanded to the clinical arena with Phase II clinical trials utilizing P-Selectin/PSGL-1 blockade in both kidney and liver transplantation. In 2012, I was the lead author of a randomized placebo controlled phase II clinical trial comparing placebo versus selectin blockade in a series of 47 patients undergoing liver transplantation. Selectin blockade proved to be nontoxic and improved graft survival, liver function tests and biomarkers of inhibition of IRI. This study is the stimulus for a multicenter trial investigating selectin blockade as a mechanism to improve liver graft function and has applicability to other organ transplants. In addition to this basic science research, I have been the senior author on numerous seminal clinical articles which have served as benchmarks in the treatment of liver transplant patients in many areas of clinical focus including: immunosuppression, perioperative viral and fungal prophylaxis, technical modifications, use of extended criteria donors, management of infants undergoing liver transplantation, hepatocellular carcinoma, living donor organ donation, split liver transplantation, combined kidney - liver transplants, multivisceral transplants, and transplantation of patients with the highest Model for End-stage Liver Disease score, which is used to allocate organs. Many of these accomplishments were supported by NIH and other peer-reviewed funding. Looking into the future: what do you see as the main challenges for liver transplantation in the 10 years? RWB: There are indeed numerous challenges for liver transplantation that we will encounter over the next 10 years. Today, liver transplantation is considered the gold standard for treatment of patients with end-stage liver disease. However, new improved treatment strategies, as we now have for HCV and HBV, and in the possible near future for hepatocellular carcinoma will surely decrease the need for liver replacement. In certain metabolic diseases, cellular transplantation may become very effective as the preferred treatment over whole organs. Life-long immunosuppression definitely has its drawbacks. However, once our ability to induce tolerance improves, immunosuppressive drug therapy will be minimized. Furthermore, the new avenues of research such as blockade of ischemia reperfusion injury and the resuscitation of marginal grafts with novel preservation concepts will significantly increase the organ donor pool. Your energy does not seem to stop outside of the hospital walls. There are rumors that a unique collection of Italian sport cars share your home address. Moreover, you are an avid runner and have finished the new your city marathon twice. What do you enjoy outside the operating room? RWB: My career would not have developed were it not for the incredible, selfless, and loving support of my family: my wife of 50 years, JoAnn, our 2 daughters, Amber and Ashley, and my 4 grandsons. One of my passions is indeed automobiles, perhaps a genetic trait inherited from my father, who was a car dealer when I was growing up. I worked in his dealership as a teenager and attended many races including the 12 hours of Sebring, the Monte Carlo Grand Prix, and the Indianapolis 500. I personally raced in the Mille Miglia 1000-mile race in Italy 3 times. I have been playing tennis since I was a medical student, and still exercise daily with a morning or evening run depending on my OR and administrative schedule. My wife, JoAnn is an art enthusiast, collector, and docent for the Los Angeles Museum of Art, and I have enjoyed and benefited from her expertise and passion in this area for many years.

Editorial introductions

The International Liver Transplantation Society (ILTS) has placed a strong focus on achieving gender equality and equity in liver transplant (LT). We aimed to understand gender distribution in leadership positions among LT physicians around the world and within ILTS. In 2019, the ILTS Equality, Diversity, and Inclusion Committee distributed a survey to obtain granular data on gender and characteristics of transplant physicians as well as those in leadership positions in each center. Additionally, data were collected on the gender composition of the ILTS membership, council, chairpersons, and committees and from the United Network for Organ Sharing. Data were collected from 243 transplant centers. Thirty-two (13.2%) had at least 1 woman as the director of LT, chief of transplant surgery, or chief of transplant hepatology. Of the 243 centers, 133 reported the age and gender of the leadership personnel. Women physicians comprised 152 of the 833 transplant surgeons (18.2%) and 298 of the 935 hepatologists (31.9%). Among the 1331 ILTS physician members, 588 (44.2%) provided gender information in their member profiles, and 155 (26.3%) identified themselves as women. Of the 26 ILTS leadership positions, 7 (26.9%) were held by women. This analysis of worldwide gender distribution in the LT physician workforce showed notable gender disparity in LT leadership around the globe and within the ILTS. These data provide a launching point for promoting and achieving gender equality and equity in LT.

<h3>Background</h3> UK healthcare provision has been severely affected by the COVID-19 pandemic, with specific challenges in liver transplantation (LT). Here, we describe the co-ordinated response to, and impact of, the first year of COVID, across all 7 adult and 3 paediatric UK LT centres. <h3>Methods</h3> A series of national policy changes affecting the LT process were agreed. A ‘high-urgent’ (HU) category was established, prioritising for LT those with UKELD &gt;60, HCC reaching transplant criteria, and others likely to die within 90 days. Donor age restrictions and changes to offering were phased throughout the year. These changes were flexed in response to the ‘first wave’ (implemented: March–July 2020) and ‘second wave’ (implemented: Jan–April 2021). During the second wave, organ and patient ‘back-up’ arrangements were introduced, selected centres were designated ‘protected’ by NHSE and some patient care was transferred between centres, when overwhelmed critical care necessitated temporary unit closures. <h3>Results</h3> During 2020/21, there was a significant fall in the total number of annual liver donors (21%; 870 from 1088) and transplants (22% 749 from 950) compared to 5-year mean, prior to the pandemic. This was exclusively amongst adult recipients (23%; 672, vs 868), both elective (22%; 609 vs 778) and SU (30%; 63 vs 90), whilst paediatric activity was maintained (77 vs 81). The reduction in adult LT varied widely geographically (-3 to -43%). LT registrations fell (11%; 1063 vs 1208), again with wide geographic variation (0 to -24%). During the ‘first wave’, we successfully prioritised those with highest illness severity with no reduction in 90d patient (p=0.89) or graft survival (p=0.98). There was a small (5% cf 3%) but significant (p=0.0015) increase in deaths/removals from the UK LT waitlist, during this time. During the ‘second wave’, 5 adult units temporarily closed at various times, whilst 3 ‘protected’ LT centres were maintained at any time. Consequently, 25 waitlist registrants were transferred to protected centres with 10 undergoing LT outwith their original centre. <h3>Discussion</h3> A sophisticated national response has maintained a safe and effective UK LT program throughout the first year of COVID. We adapted our resources, implementing phased donor restrictions and a new category for recipient prioritisation. Patients benefitted from collaborative working, enabling those in most need to be transferred and transplanted in protected centres. Consequently, we mitigated against a significant fall in LT activity. Our collaborative response serves as an as exemplar for other specialist healthcare services.

Treatment of Recurrent Hepatitis C in Liver Transplant Recipients

Strategies for liver transplantation during the SARS-CoV-2 outbreak: Preliminary experience from a single center in France.

To evaluate the effect of a liver transplantation (LT) program on the outcomes of resectable hepatocellular carcinoma (HCC). Surgical treatment of HCC includes both hepatic resection (HR) and LT. However, the presence of cirrhosis and the possibility of recurrence make the management of this disease complex and probably different according to the presence of a LT program. Patients undergoing HR for HCC between January 2005 and December 2019 were identified from a national database of HCC. The main study outcomes were major surgical complications according to the Comprehensive Complication Index, posthepatectomy liver failure (PHLF), 90-day mortality, overall survival, and disease-free survival. Secondary outcomes were salvage liver transplantation (SLT) and postrecurrence survival. A total of 3202 patients were included from 25 hospitals over the study period. Three of 25 (12%) had an LT program. The presence of an LT program within a center was associated with a reduced probability of PHLF (odds ratio=0.38) but not with overall survival and disease-free survival. There was an increased probability of SLT when HR was performed in a transplant hospital (odds ratio=12.05). Among transplant-eligible patients, those who underwent LT had a significantly longer postrecurrence survival. This study showed that the presence of a LT program was associated with decreased PHLF rates and an increased probability to receive SLT in case of recurrence.

Introduction Liver transplantation (LT) is the complex and challenging procedure in preoperative work-up, surgical techniques, postoperative care, management of complications and out-patients follow-up. For these reasons, it is difficult to build up the liver transplantation program independently in small volume center and most cases of LT had been performed in a few high volume centers. However, many centers have been trying to launch the liver transplantation program recently for a local population who needs LT but has limited opportunity due to the cost and conditions. In here, we introduce our experiences and outcomes of 100 cases of LT as a small volume center. Method From November 2002 to July 2017, 100 patients were received LT in Keimyung University Dongsan Medical Center. On March 2014, we renewed the LT program by reinforcement of trained staff and establishment of complemented protocol. Fifty cases of LT were performed before renewal of LT program on March 2014 and 50 cases were performed after that time. We reviewed the outcomes of these 100 cases of LT retrospectively. Results Among 100 cases of LT, DDLT was performed in 60 cases and LDLT in 40 cases. The indications of LT were liver cirrhosis due to HBV in 62 patients, HCV in 7 patients, alcoholics in 30 patients, other causes in 10 patients and hepatocellular carcinoma in 34 patients. The perioperative mortality rate was 18 % before 2014, but decreased to 2 % after renewal (p<0.001). The 3-year survival rate was 74% before 2014, but improved to 95% after renewal (p<0.001). The rate of complications was also improved after renewal of LT program. After renewal of LT program, the outcomes of LT have been more improved and comparable to those of big centers. Conclusion It is challenging to establish stabilized LT program in small volume center due to complexity and difficulty in operative technique and management of complications. Small volume centers need long time to experience sufficient cases for overcoming learning-curve and stabilizing program independently due to small number of cases. The recruitment of trained and experienced member or support from big centers can be considered for establishment of comparable LT program to big centers in a short period of time and stable LT program in small volume center can provide a practical service for a local population.

The 2023 Joint International Congress of the International Liver Transplantation Society (ILTS), the European Liver and Intestine Transplant Association (ELITA), and the Liver Intensive Care Group of Europe (LICAGE) held in Rotterdam, the Netherlands, marked a significant recovery milestone for the liver transplant community after COVID-19. With 1159 participants and a surge in abstract submissions, the event focused on "Liver Disorders and Transplantation: Innovations and Evolving Indications." This conference report provides a comprehensive overview of the key themes discussed during the event, encompassing Hepatology, Anesthesia and Critical Care, Acute Liver Failure, Infectious Disease, Immunosuppression, Pediatric Liver Transplantation, Living Donor Liver Transplantation, Transplant Oncology, Surgical Approaches, and Machine Perfusion. The congress provided a platform for extensive discussions on a wide range of topics, reflecting the continuous advancements and collaborative efforts within the liver transplant community.