30-Second Takeaway
- Simplified ischemia-free liver transplantation can minimize ischemia while maintaining outcomes, potentially extending use of high-risk grafts.
- Discrete MELD score cutoffs still create abrupt jumps in offers, transplants, and mortality risk under current U.S. policies.
- Molecular HLA mismatch integration refines dnDSA and rejection risk, enabling more tailored allocation and immunosuppression strategies.
- Center-level navigation, financial support, and paired exchange infrastructure can substantially increase living kidney transplant volumes.
- Emerging biomarkers and intragraft pathways, including perfusate small RNAs, chymase, and D-kynurenine, may individualize graft selection and immunotherapy.
Week ending February 7, 2026
Levers to expand organ use and durability: ischemia-free liver workflows, allocation thresholds, molecular matching, and new intragraft targets
Simplified ischemia-free liver transplantation preserves outcomes with less procedural burden
This protocol details a simplified ischemia-free liver transplantation technique using continuous normothermic machine perfusion throughout procurement and implantation. The method aims to minimize ischemia–reperfusion injury, particularly in extended-criteria and other high-risk donor livers. Streamlined retrieval and optimized vascular anastomosis sequencing reduce complexity and avoid the prolonged anhepatic phase of classic IFLT. Reported efficacy and safety, including complication rates and graft and patient survival, are comparable to classic IFLT. SIFLT may therefore offer a more practical path to wider ischemia-free adoption and expanded marginal liver use.
MELD cutoffs still create artificial jumps in liver transplant access and mortality
Analysis of 98,896 adult candidates showed crossing MELD-35 under Share-35 tripled offer rates and doubled transplant odds versus just below threshold. Under Acuity Circles, MELD-37 and MELD-33 still generated significant, though smaller, discontinuities in offers and transplant likelihood. Candidates remaining below MELD-37 experienced higher waitlist mortality, indicating misalignment between risk and organ access. Around thresholds, offer decline patterns and reduced marginal donor use revealed policy-driven shifts in donor-quality selection. The authors conclude rigid MELD cutoffs distort access and support transition to smoother, continuous-distribution allocation.
Integrated epitope and PIRCHE scores sharpen dnDSA and rejection prediction after kidney transplant
In 594 kidney recipients followed until 2024, 17.5% developed de novo donor-specific antibodies, predominantly against HLA-DQ. ROC analysis defined class I and II mismatch cutoffs for Epregistry, PIRCHE-T2, and PIRCHE-B to predict dnDSA. Patients with all three scores above cutoff had significantly lower dnDSA-free and ABMR-free survival than those with all scores below cutoff. PIRCHE-T2 at class I loci and overall PIRCHE-T2 were significantly associated with T cell–mediated rejection. Combining these algorithms yields a more nuanced immunologic risk profile that could guide allocation and immunosuppression intensity.
References
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Additional Reads
Optional additional studies from this edition.