Trenches in Transplant Surgery

NAFLD/NASH epidemic has two-fold impact on transplantation: it threatens the donor supply (steatotic grafts have higher risk) and creates a new high-risk recipient population (with metabolic complications and graft steatosis). Recent consensus and meta-analytic data emphasize using donor livers with ≤30% macrosteatosis whenever possible, careful evaluation with advanced imaging (CAP, CT) and possi...

Overall, the surgical technique of kidney transplant has evolved from its early open forms to incorporate modern minimally invasive technology, but the core principles remain: precise vascular suturing and a secure ureteral reimplantation. Major contributors include Joseph Murray (Brigham Hospital, Boston) and colleagues (first transplants), Folkert Belzer (UW solution), Lloyd Ratner (laparoscopic...

The evolution of liver transplantation techniques has shifted from the classical (conventional) approach, which involves removal of the retrohepatic inferior vena cava (IVC) and typically requires veno-venous bypass, to the piggyback technique, which preserves the recipient’s IVC and offers improved hemodynamic stability. While the classical method remains useful in complex cases (e.g., IVC thromb...

The past 5–10 years have witnessed remarkable progress in applying genomics, proteomics, and metabolomics to kidney and liver transplant medicine. Genomic tools are uncovering polymorphisms and gene expression signatures that predict rejection or identify tolerance, as well as informing tailored drug dosing. Proteomic studies have yielded noninvasive protein biomarkers (chemokines, injury molecule...

Deceased Donor Management and Evaluation Phase 3 (donor evaluation) and Phase 4 (ICU donor management) are pivotal in the deceased donation pathway, directly impacting how many and how well organs can be transplanted. Recent years have seen significant progress: standardized donor management protocols, better understanding of pathophysiology after brain death, and technological innovations all con...

This podcast presents an original article detailing a phase 1-2 clinical study called VX-880-101 FORWARD, which investigates zimislecel as an allogeneic stem cell-derived islet-cell therapy for type 1 diabetes. The research aimed to assess the safety and efficacy of this new treatment, particularly its ability to restore physiologic islet function and potentially lead to insulin independence. The...

Liver transplantation demands meticulous intraoperative management tailored to each surgical phase. By anticipating the typical hemodynamic changes in the pre-anhepatic, anhepatic, and neohepatic phases, the anesthesia and surgical teams at high-volume centers can proactively mitigate risks. In the pre-anhepatic phase, controlling bleeding (often by keeping CVP low and employing rapid transfusion...

Immunosuppression minimization and withdrawal in liver transplantation is an area where clinical practice and cutting-edge research intersect. The driving rationale is clear – mitigating the long-term deleterious effects of chronic immunosuppressive therapy – but the execution requires navigating complex immunological and ethical terrain. Over the past two decades, we have learned that operational...

Ex vivo machine perfusion has ushered in a new era where a liver graft’s viability can be tested before the irreversible step of transplantation. Both normothermic and hypothermic perfusion techniques play roles in modern liver preservation, with NMP in particular enabling real-time functional evaluation. Key viability markers – lactate clearance, perfusate pH, glucose consumption, transaminase re...

Transplant tourism sits at the troubling intersection of medical need and global inequality. On one hand, it underscores the desperation of patients willing to do anything for a life-saving organ; on the other, it exposes the plight of the poor who are driven (or coerced) to literally sell parts of their bodies. The ethical global practice of transplantation demands that life be preserved without...

A-NRP utilizes extracorporeal membrane oxygenation (ECMO) technology, including a pump, oxygenator, and heater, to maintain normothermic (37°C) blood flow to abdominal organs in situ. This process reverses warm ischemic damage, improving organ quality for transplantation. However, simultaneous procurement of thoracic organs, such as lungs, can lead to significant blood loss in the chest, compromis...

​ Elevated liver enzymes after a liver transplant can stem from various causes, including surgical complications, infections, or rejection, with no single definitive source. ​ Workup involves blood tests, imaging like ultrasounds, and sometimes biopsies to identify the cause, though outcomes can vary. ​ The evidence leans toward treatments being tailored to the specific cause, such as medications...

• Research suggests AI and deep learning are enhancing liver transplant outcomes. • It seems likely that donor-recipient matching and post-transplant predictions are improving. • The evidence leans toward AI helping with organ allocation and surgical innovations. • Challenges include data quality and validation, with ongoing efforts to address them.

​ Research suggests EBV is a significant risk post-transplant, with PTLD incidence at 4-22% in children and 1-2% in adults, higher in EBV-negative recipients. ​ It seems likely that CMV remains the most common viral infection, with varying incidence based on donor/recipient status. ​ The evidence leans toward BK virus being a major concern for kidney transplants, with no effective prophylaxis. ​ H...

• Ductopenia is mainly caused by chronic rejection, where the immune system attacks the bile ducts. Ischemic cholangiopathy, on the other hand, comes from poor blood flow, like when the hepatic artery is blocked. • Research shows ischemic cholangiopathy can lead to ductopenia by causing bile duct damage that results in their loss, but ductopenia can also happen from rejection, not just ischemia. •...

• Research suggests increasing public awareness and opt-out donation systems can boost liver donations, though effectiveness varies by region. • It seems likely that using extended criteria donors and split liver techniques can expand the donor pool, but outcomes may differ. • The evidence leans toward machine perfusion and bioengineered livers as promising innovations, though they are still exper...

• Research suggests hepatocellular carcinoma (HCC) is the most common liver tumor considered for transplantation, with specific size and spread criteria. • It seems likely that cholangiocarcinoma and colorectal liver metastases (CRLM) may be considered in select cases, but this is less common and debated. • The evidence leans toward strict criteria, like the Milan criteria, to ensure successful ou...

• Thomas Starzl is widely regarded as the father of liver transplantation, based on his pioneering work. • He performed the first human liver transplant in 1963 and the first successful one in 1967. • Starzl developed key immunosuppression techniques, like cyclosporin, improving transplant success rates. • His research on chimerism and animal-to-human transplants has shaped modern transplant medic...

• Research suggests liver transplant complications include infections, biliary issues, and rejection, with varying incidence rates. • It seems likely that infections, especially CMV, are very common early post-transplant, while biliary complications affect 15-20% of patients. • The evidence leans toward medication side effects, like high blood pressure and kidney issues, being significant long-ter...

Research suggests defatting livers during machine perfusion can improve transplant outcomes, but it’s still being studied. It seems likely that drugs like forskolin and L-carnitine help reduce liver fat, with early studies showing promise. The evidence leans toward machine perfusion, especially normothermic, being a key method for defatting, though more research is needed.

Understand the Mechanisms and Benefits: Explain the principles of machine perfusion (hypothermic and normothermic) and normothermic regional perfusion (NRP), and evaluate their roles in improving liver preservation and transplantation outcomes. Analyze Clinical Impact and Challenges: Assess the clinical benefits of machine perfusion and NRP in expanding the donor pool and reducing complications, w...