Transplant Surgery

Older liver grafts disproportionately harm younger liver transplant recipients

In >57,000 US liver transplants (2011–2021), donor age strongly modified post‑LT outcomes across recipient age strata. Donor age >45 years was independently associated with higher mortality and graft failure in recipients ≤35 years. In recipients ≥65 years, outcomes were largely insensitive to donor age, even for older grafts. These data support prioritizing younger donor livers for younger adults and allocating older grafts preferentially to older recipients when feasible. 1

EDAM reclassifies many ‘high KDPI’ kidneys as intrinsically low-risk

Using 122,646 UNOS deceased-donor kidneys, investigators derived the donor-centric Equitable Donor Assessment Model (EDAM) for death‑censored graft failure. Risk factors included donor age, diabetes, hypertension, stroke death, proteinuria, CMV seropositivity, and elevated creatinine. EDAM showed good discrimination and calibration across US regions, with a graded increase in graft failure across five risk categories. Nearly half of kidneys with moderate-to-high KDPI were reclassified as low-risk by EDAM and had 10‑year graft survival matching conventional low‑KDPI kidneys. EDAM may allow more aggressive utilization of kidneys currently labeled ‘marginal’ without sacrificing long-term graft outcomes, pending external validation. 2

Expedited kidney allocation yields survival comparable to in-sequence placement

This paired-kidney study evaluated 15,602 kidneys from 8,544 deceased donors where one kidney was allocated in sequence and the other out of sequence. Use of unilateral out‑of‑sequence kidneys expanded rapidly from 2020 to 2024, involving all US OPOs. Recipients of out‑of‑sequence kidneys were more often older, male, Asian or White, privately insured, and transplanted preemptively. Despite these differences, adjusted Cox models showed no significant detriment in patient survival for unilateral out‑of‑sequence kidney transplants. These findings support broader use of expedited allocation for kidneys at risk of nonuse, without clear early outcome penalty. 3

Atezolizumab–bevacizumab downstaging enables curative LT in advanced HCC

In this phase II study, 16 patients with intermediate/advanced HCC beyond expanded LT criteria were downstaged using atezolizumab–bevacizumab before liver transplantation. Median tumor size was 6.5 cm, AFP 283 ng/mL, and half had portal vein thrombosis, reflecting high‑risk disease. After a median 4.7 months of therapy and ~2‑month washout, explants showed 10 complete and 6 partial responses. Two‑year post‑LT recurrence-free and overall survival were 90% and 94%, respectively, with one HCC recurrence observed. Acute rejection occurred in 25% but was clinically manageable, suggesting LT is feasible after immune checkpoint–based downstaging with careful timing and monitoring. 4