The 2025 International Liver Transplantation Society (ILTS) Congress, held in Singapore, brought together a global, multidisciplinary community to explore innovations and persistent challenges in liver transplantation (LT). The congress included seven pre-congress workshops, 92 scientific sessions, and featured 270 expert speakers. More than 1100 participants from 71 countries took part in the event. A new focus was the growing importance of strategic leadership and financial governance in sustaining and expanding liver transplant programs. A series of presentations, symposiums, and workshops focused on leadership and financial governance brought together clinical and administrative leaders to explore the operational frameworks and economic strategies critical to the long-term sustainability of liver transplant programs. Discussions emphasized the need for robust reimbursement models, clear cost-effectiveness frameworks, and integration of emerging technologies into diverse healthcare systems.

The objective of this study was to assess the safety and feasibility of duct-to-duct anastomosis (DDA) in pediatric liver transplantation with left-sided grafts. The Roux-en-Y hepaticojejunostomy (HJ) represents the gold standard for biliary reconstruction in pediatric liver transplantation. Nevertheless, the feasibility of DDA in pediatric liver transplantation remains a topic of contention and is a relatively limited technique. A total of 3307 pediatric recipients who underwent LT at Renji Hospital between October 2006 and October 2023 were enrolled in the study. Of these, 218 underwent DDA with high hilar dissection and patch anastomosis, in accordance with a prospective protocol. A comprehensive analysis was conducted to determine the risk factors for exclusion from DDA and the outcomes of recipients of DDA. The mean operative time was significantly shorter in the DDA group (DDA vs. HJ=6.5 h vs. 7.0 h, p<0.001). A minimum of 1 year of follow-up revealed that biliary complications occurred in 8 cases of recipients of DDA (3.7%) and 1 case of a recipient of HJ (1.6%), with no statistically significant difference (p=0.69). No significant difference was observed in mortality between the DDA and HJ groups (DDA vs. HJ=1.8% vs. 1.6%, p>0.99). The graft survival rates at 1 and 3 years after DDA were 98.2% and 96.8%, respectively. However, patients with Langerhans cell histiocytosis may be unsuitable candidates for DDA due to their elevated rates of DDA exclusion and biliary complications. Appropriate learning and decision-making processes ensure the safety and feasibility of DDA, with excellent perioperative and long-term outcomes. It is therefore recommended that DDA should be considered the first choice for biliary reconstruction in eligible pediatric patients of transplant.

Liver transplantation (LT) remains the only cure for severe polycystic liver disease (PLD). However, LT indications and strategies vary across Europe, resulting in (unwanted) practice variation and unequal access to care for patients with PLD. This study aimed to (1) identify existing PLD-specific LT criteria across European countries, (2) assess which criteria are considered relevant by specialists, and (3) map the variation in liver-kidney transplant strategies among patients with autosomal dominant polycystic kidney disease (ADPKD). National PLD-specific LT criteria were collected, and if unavailable, ERN RARE-Liver representatives from that country were asked to provide information. An online survey was conducted among hepatologists, LT surgeons, and nephrologists managing patients with PLD. The survey assessed relevant LT indications/listing requirements, clinical case evaluations, and explored preferences for liver-kidney transplantation in patients with ADPKD. Defined LT criteria for patients with PLD were available in only 8 of the 17 assessed countries and showed substantial variation. Sixty-nine clinicians (43 hepatologists, 15 surgeons, and 11 nephrologists), predominantly from LT centers (75.4%), completed the survey. Key LT indications were recurrent liver cyst infections (78.3%), significant impaired quality of life (75.4%), and severe malnutrition (75.4%). In ADPKD, simultaneous liver-kidney transplantation was preferred by 40.4% of respondents, primarily due to the favorable immunological profile (47.6%) and prevention of renal failure (33.3%). In contrast, those favoring a liver-first approach (30.8%), followed by sequential kidney transplant, highlighted the potential harm to the kidney graft during simultaneous liver-kidney transplantation (62.5%). Uniform PLD-specific LT criteria in Europe are lacking. While recurrent liver cyst infections, decreased quality of life, and malnutrition are widely recognized as crucial LT indications, they are insufficiently reflected in existing criteria, contributing to unequal access to LT. Moreover, considerable variation exists in liver-kidney transplantation for patients with ADPKD, with a current lack of evidence to support one approach over another.

Liver transplantation (LT) is a therapeutic option for patients suffering from end-stage liver disease. Recent research has probed the prognostic significance of biomarkers to predict graft function and mortality post-transplant, yet few candidates are recommended in clinical practice. We employed a pipeline that integrates meta-analysis (PRISMA 2020), followed by Kaplan–Meier (KM)-based individual patient data (IPD) analysis, aiming to identify potential novel prognostic biomarker panels for LT recipients. Ovid Medline, Embase, and Cochrane databases were searched. Twenty-one prognostic and 8 diagnostic studies were eligible, pooling 34,922 patients. Single biomarkers sampled at an early stage (≤15 d after LT) were significantly associated with graft-related outcomes (HR/OR 0.95 [0.94–0.97]) but did not predict mortality (HR/OR 1.00 [0.97–1.04]) or composite outcomes (HR/OR 1.02 [0.98–1.07]). Biomarkers in combination (GGT/bilirubin ratio, ALT+AST or ALT+AST+bilirubin+INR) predicted composite outcomes (graft failure or mortality, aHR/aOR 4.37 [2.65–7.21]). Biomarkers assessed at late stage (>15) did not show association with mortality (HR/OR 1.02 [1.00–1.04]) or composite outcomes (HR/OR 1.00 [0.99–1.01]). KM-based IPD analysis showed that coagulation factor V combined with ALT predicted graft survival (HR 2.12 [1.44–3.12]), and coagulation factor V+insulin-like growth factor 1 stratified the risk of patient survival (HR 2.97 [1.79–4.91]). Therefore, we were able to compare various scoring systems in predicting graft-related outcomes and mortality following LT. Additionally, we identified novel combinations of biomarkers that exhibited prognostic value for LT patients. Finally, we demonstrate that combined analytical tools for assessing large clinical datasets effectively evaluate multi-modal markers for risk stratification of early and late outcomes for LT.

Refractory ascites often requires therapeutic paracentesis, which is associated with potential risks and diminished quality of life. Terlipressin is a vasopressin analog that is indicated for i.v. bolus injection for hepatorenal syndrome, with the potential to reduce large-volume ascites and its complications. Continuous infusion of terlipressin is associated with fewer adverse effects than bolus dosing. The efficacy and safety of continuous infusion of a novel liquid formulation of terlipressin acetate (BIV201) were evaluated in this open-label phase 2 study. Patients with cirrhosis and refractory ascites were randomly assigned (2:1) to receive two 28-day cycles of continuous infusion BIV201 plus standard of care (SOC) separated by a ≤56-day washout (n=10), or SOC alone (n=5). Data analysis was limited by the small sample size and confounded by a potential interaction with gabapentinoids in the BIV201+SOC group. Nonetheless, there were differences in favor of BIV201+SOC versus SOC in the coprimary efficacy endpoints and several quality of life assessments. The beneficial effects of BIV201 on liver complications (mean: 90% CI; BIV201-completers=2.87: 1.51; 5.46 vs. SOC=2.38: 1.20; 4.73) and the change in cumulative ascites (mean: 90% CI; BIV201-completers=−10.76: −26.51; 5.00 vs. SOC=−4.99: −21.95; 11.97) were more pronounced versus SOC in the 5 BIV201+SOC patients who completed both treatment cycles. There were also greater improvements in exploratory quality of life assessments and the percent change in therapeutic paracenteses with BIV201+SOC (−27.94±41.80) versus SOC (−16.67±45.64). Despite the high rate of hyponatremia in the BIV201+SOC group (4/10 patients), the safety profile suggested that continuous BIV201 infusion was well tolerated. These findings support further development of BIV201 in confirmatory trials.

Due to the easier availability of transgenic mice and reagents, the mouse orthotopic liver transplantation model offers significant advantages in liver transplantation research. However, technical challenges have limited its broader application. The most challenging steps of the procedure include manual anastomosis of the suprahepatic vena cava, cuff anastomosis of the portal vein, and maintaining the anhepatic phase within 20 minutes. This study aims to provide detailed solutions to overcome these bottlenecks and introduces a modified magnetic device to facilitate safer and more efficient cuff anastomosis. We also describe the learning curve for beginners to achieve a 30-day survival rate exceeding 90% in mouse orthotopic liver transplantation. We demonstrate that mouse orthotopic liver transplantation can be mastered within 8 months of continuous practice, with 7-day and 30-day survival rates improving from 0% to 96.7% and 0% to 93.3%, respectively. The entire procedure can be completed within 80 minutes. We believe these technical improvements will provide more practical guidance for mouse liver transplantation.

Portopulmonary hypertension (POPH), pulmonary arterial hypertension that develops in the setting of portal hypertension, has long been of significant interest to the pulmonary, cardiology, and hepatology communities. Optimal management of POPH has been challenging to define due to a lack of evidence from clinical trials regarding pulmonary arterial hypertension therapies and uncertainty regarding the role of liver transplantation (LT). Initially, the high risk of intraoperative and early post-transplant death in predominantly untreated patients with POPH tempered consideration of LT. More recently, the observation that POPH can improve, and sometimes even resolve, following LT, has led to reconsideration of the role of LT in selected patients. The first International Liver Transplantation Society (ILTS) POPH and hepatopulmonary syndrome practice guideline was a multidisciplinary consensus of expert opinions based on available evidence. Since that publication, hemodynamic definitions, management approaches, and POPH MELD exception criteria have evolved, and there have been new randomized controlled trials in POPH as well as studies regarding long-term outcomes. In order to ensure the guidelines remained current and reflected recent evidence, the original writing committee of the 2016 guidelines, leaders of the ILTS Cardiovascular Special Interest Group, and colleagues active in POPH research were invited to participate in the writing committee. In this document, approved for publication by the ILTS executive council, we provide an update to the prior guidelines with expert recommendations to guide and advance POPH management. Recommendations in these guidelines are based on expert opinion and available evidence and were agreed upon by consensus.