October 2023

LIVER TRANSPLANTATION: CHALLENGES AND ADVANCES IN THE 21ST CENTURY

The field of liver transplantation is at an exciting, challenging crossroad. The last two decades have seen a steady growth in numbers of patients waitlisted and transplanted; outcomes have been preserved thanks to advances in medical, surgical and multidisciplinary care.

Due to the advent of potent, safe oral antiviral therapy, viral hepatitis B and C rarely recur and no longer negatively affect our patients after transplantation. The impact of these treatments in reducing the need for initial transplants and repeat transplants has been profound.
The system used to allocate and distribute donated livers in the U.S. has improved greatly due to regional and national efforts to limit geographic disparities and promote equity and fairness.
The MELD score, adopted in 2002, changed from MELD-Sodium to MELD 3.0. Earlier models disadvantaged women and this change increases the ability of women to receive transplants.
A national review board has replaced regional review boards, enabling patients with high mortality not reflected by MELD score to have a better pathway to receiving MELD exceptions.
We are also better preserving organs through machine perfusion technology, which is increasingly available, to allow graft assessments before implantation and to increase the usability of certain organs that were not previously usable.
The field is also developing personalized approaches, using biomarkers to help predict outcomes and modify immunosuppression to improve short- and long-term outcomes.

However, several unique challenges remain, and clinicians and investigators are working to address them. In the last 20 years, our liver transplant population has gotten older with more comorbidities that need specialized diagnostic assessments and management strategies to optimize survival and quality of life pre- and post-transplant. Frailty assessments are now standard at transplant centers and aid decisions to move forward with transplantation and/or highlight the need for physical therapy, nutrition and psychological support.

Metabolic-associated steatohepatitis and alcohol-associated steatohepatitis are by far the leading causes of liver failure leading to transplantation. Both can recur after transplantation unless interventions are implemented soon after the transplant to address issues of recurrence of obesity, diabetes, other cardiovascular risks and alcohol use. While early outcomes are excellent, the long-term survival of liver transplant recipients has not changed significantly in the last 20 years, owing to the occurrence of malignancy, kidney failure, cardiovascular events, infection and recurrent graft fibrosis.
All of these issues need more attention to enhance long-term survival and quality of life for our patients. Minimizing or withdrawing immunosuppressive therapy without causing rejection may be part of the answer to limit these complications — several studies are underway to assess the risks and benefits of these interventions.

As president of the American Society of Transplantation (ATS), I am dedicated to advancing transplantation. As a hepatologist, I am dedicated to advancing the field of liver transplantation.

AST is working with other liver societies to advance the field and work together for our clinicians, patients donors and their families.

Josh Levitsky, MD, MS
Professor of Gastroenterology and Hepatology, Organ Transplantation, Medical Education
Chief, Division of Hepatology
Northwestern Medicine