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Clinical Advances and Challenges in Liver Transplantation: 3rd Edition

A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Gastroenterology & Hepatopancreatobiliary Medicine".

Deadline for manuscript submissions: 20 June 2026 | Viewed by 1229

Special Issue Editor


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Guest Editor
1. Fondazione Policlinico Universitario A. Gemelli IRCCS, Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Rome, Italy
2. Dipartimento di Scienze Biotecnologiche di Base, Università Cattolica del Sacro Cuore, Cliniche Intensivologiche e Perioperatorie, Rome, Italy
Interests: geriatric anaesthesia; perioperative medicine; neuroscience (pain mechanisms; cognition) postoperative cognitive disorders; monitoring of anaesthesia depth; anaesthesia for robotic surgery; transplantation; hemodynamic monitoring
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Special Issue Information

Dear Colleagues,

This Special Issue is the third edition of “Clinical Advances and Challenges in Liver Transplantation” (Edition 1, Edition 2) and aims to further examine the rapidly changing field of liver transplantation (LT).

In recent years, transplant medicine has seen a continual expansion of donor criteria, with more frequent use of marginal grafts—such as elderly donors, steatotic livers, and donors after circulatory death (DCD). Simultaneously, recipients are being listed with more advanced diseases and complex comorbidities. This trend continues to present significant challenges related to graft function, vascular and biliary complications, and overall postoperative outcomes.

Meanwhile, new technological and diagnostic tools are changing the field. Advances in genomics, radiomics, and machine perfusion technologies provide exciting options to improve donor selection, organ preservation, and post-transplant care. In particular, machine perfusion is redefining what is considered an acceptable graft.

The selection criteria for hepatocellular carcinoma (HCC) candidates are also evolving. There is an increasing emphasis on incorporating biological and immunological markers into decision making, beyond traditional morphologic parameters, to better predict recurrence and guide immunosuppression strategies.

Anaesthesiology now plays a key role in this complex situation, as perioperative management has a direct and measurable effect on transplant outcomes. Intraoperative hemodynamic optimisation, management of coagulopathy, use of viscoelastic testing, organ protection strategies, enhanced recovery after surgery (ERAS) ,and prehabilitation protocols are becoming essential parts of transplant programmes. Additionally, anaesthesiologists are increasingly involved in preoperative risk assessment and postoperative intensive care, making their role vital to the multidisciplinary management of LT patients.

This third edition of the Special Issue welcomes hepatologists, transplant surgeons, and anaesthesiologists, aiming to promote a comprehensive and multidisciplinary discussion on the current and future challenges of liver transplantation.

Topics of interest include (but are not limited to) the following:

  • Clinical and perioperative management of marginal donors and high-risk recipients;
  • Technological advances in organ preservation and assessment (e.g., machine perfusion, imaging, omics);
  • Evolving strategies for selecting and managing HCC in the transplant setting;
  • Perioperative strategies in LT: hemodynamics, coagulation, analgesia, and ERAS/prehabilitation protocols;
  • Multidisciplinary approaches to optimising short- and long-term transplant outcomes;
  • Immunological and metabolic considerations in pre- and post-transplant care.

We welcome original research articles and reviews that offer valuable insights into the clinical, surgical, anaesthesiologic, and technological aspects of liver transplantation.

Dr. Paola Aceto
Guest Editor

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Keywords

  • liver transplantation (LT)
  • elderly donors
  • steatotic livers
  • donors after circulatory death (DCD)
  • hepatocellular carcinoma (HCC)
  • perioperative management

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Published Papers (2 papers)

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12 pages, 1227 KB  
Article
Outcomes of Liver Transplantation in Incidental Intrahepatic Cholangiocarcinoma and Combined Hepatocellular-Cholangiocarcinoma: An Exceptional Perspective from a Single-Center Experience
by Lijie Ma, Qiang Xia and Meng Sha
J. Clin. Med. 2025, 14(24), 8857; https://doi.org/10.3390/jcm14248857 - 15 Dec 2025
Cited by 1 | Viewed by 538
Abstract
Background/Objectives: Intrahepatic cholangiocarcinoma (ICC) and combined hepatocellular-cholangiocarcinoma (CHC) have historically been considered a contraindication for liver transplantation (LT) due to poor prognosis. However, incidental ICC/CHC has been reported in small amounts of patients undergoing LT. Methods: A retrospective cohort study was [...] Read more.
Background/Objectives: Intrahepatic cholangiocarcinoma (ICC) and combined hepatocellular-cholangiocarcinoma (CHC) have historically been considered a contraindication for liver transplantation (LT) due to poor prognosis. However, incidental ICC/CHC has been reported in small amounts of patients undergoing LT. Methods: A retrospective cohort study was conducted to analyze patients undergoing LT with incidental ICC/CHC at our center between January 2010 and December 2021. Results: 28 patients including 12 incidental ICCs and 16 CHCs on explant were identified. Median follow-up after LT was 63 months and 13 patients died due to tumor recurrence. The 1-, 3-, and 5-year survival rates for the whole group were 85.7%, 64.3%, and 53.3%, respectively. There was no significant difference in survival rates between the ICC and CHC groups. RFS and OS in the group with tumors less than 3 cm at 1, 3, and 5 years were 85.7%, 78.6%, and 70.7% and 92.9%, 78.6%, and 64.3%, respectively, which were significantly higher than those with tumors over 3 cm (p = 0.029 and 0.089, respectively). Additionally, patients within the Milan criteria also had a superior RFS (p = 0.032) and OS trend (p = 0.097) when compared with those beyond the Milan criteria. Conclusions: These results suggest that LT could be an option for highly selected patients with an early stage of ICC/CHC. Full article
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17 pages, 1831 KB  
Systematic Review
Can Intraoperative Anesthesiological Management Reduce the Risk of Acute Kidney Injury After Liver Transplantation? A Systematic Review
by Filippo Del Tedesco, Giovanni Punzo, Valeria Di Franco, Rita Gaspari, Teresa Sacco, Rikardo Xhemalaj, Tiziana Bove and Paola Aceto
J. Clin. Med. 2026, 15(6), 2181; https://doi.org/10.3390/jcm15062181 - 12 Mar 2026
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Abstract
Background: Acute kidney injury (AKI) is a frequent and severe complication after liver transplantation (LT), occurring in 30–60% of cases. It increases mortality, prolongs hospital stay, and increases the risk of chronic kidney disease. Intraoperative, modifiable anesthetic factors play a key preventive role. [...] Read more.
Background: Acute kidney injury (AKI) is a frequent and severe complication after liver transplantation (LT), occurring in 30–60% of cases. It increases mortality, prolongs hospital stay, and increases the risk of chronic kidney disease. Intraoperative, modifiable anesthetic factors play a key preventive role. This systematic review synthesizes the overall prevalence of AKI and examines the evidence linking intraoperative anesthetic management to AKI after LT, emphasizing modifiable factors that may inform future perioperative strategies. Methods: We conducted a systematic, computerized search on PubMed, EMBASE, Cochrane Library, and Scopus from January 2004 to November 16, 2025, following a registered protocol on PROSPERO (ID: CRD420250580749). Randomized controlled trials (RCTs) and cohort studies assessing intraoperative predictors of AKI were considered eligible for inclusion. The primary outcome was the incidence of post-LT AKI. Intraoperative factors associated with post-LT AKI, including intraoperative hypotension, fluid therapy, transfusion strategies, and the use of vasopressors and/or inotropic agents, were also assessed. Results: A total of 50 studies (8 RCTs and 42 cohort studies) involving 22,434 patients were included. The pooled incidence of post-LT AKI from observational studies was 41% (95% CI 36–46%). Across the included studies, intraoperative hemodynamic instability, excessive or unbalanced fluid administration, liberal transfusion practices, and suboptimal use of vasopressors were consistently associated with an increased risk of post-transplant AKI. Conclusions: AKI after LT is mainly influenced by modifiable perioperative factors. Prevention relies on maintaining stable hemodynamics, careful fluid and transfusion management, and avoiding intraoperative hypotension. Prompt and adequate vasopressor support appeared protective. A multimodal, personalized, kidney-protective approach is essential for improving post-transplant outcomes. Full article
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