Emergency living donor liver transplantation (LDLT) serves as a critical procedure for patients grappling with acute liver failure, acute-on-chronic liver failure, and decompensated cirrhosis. This review explores the indications, surgical techniques, challenges, and outcomes of emergency LDLT. Despite the inherent logistical and ethical complexities, carefully selected patients undergoing emergency LDLT achieve survival rates comparable to those seen in elective LDLT and deceased donor liver transplantation. Advances in surgical protocols, immunosuppression, and perioperative care continue to improve outcomes, though further research and standardized approaches are necessary to expand access and optimize results.

Advances in surgical techniques, perioperative management, and immunosuppressive therapies (ISs) have significantly improved the clinical outcomes of liver transplantation (LT). However, these advancements have also highlighted the importance of addressing non-hepatic complications, particularly cardiovascular events (CVEs), in the management of LT patients. Key risk factors for CVEs in post-LT patients include metabolic conditions such as diabetes mellitus (DM), hypertension (HTN), and dyslipidemia. The continued need for ISs contributes to the development of these metabolic complications, making their management crucial for optimizing patient outcomes. This review aims to summarize current strategies for managing metabolic complications, including DM, HTN, and dyslipidemia, in post-LT patients.

Liver transplant (LT) recipients are at high risk of infections due to both immune dysfunctions associated with liver disease and immunosuppressive therapy necessary after transplantation. Effective vaccination strategies are crucial to prevent vaccine-preventable diseases, which remain a significant cause of morbidity and mortality in this population. Vaccines should be administered as early in the pre-transplant period as possible when the likelihood of developing a protective immune response is highest and when live vaccines can be given safely. Live vaccines should be given at least 4 weeks prior to transplantation in immunocompetent patients. With rare exception, live vaccines are contraindicated in LT recipients.Post-transplantation, inactivated vaccines are generally safe, although their efficacy may be diminished. This review provides a detailed overview of current vaccination guidelines for adult LT candidates and recipients, covering key vaccines including influenza, pneumococcus, hepatitis A and B, herpes zoster, and tetanus-diphtheria.

Pregnancy in liver transplantation (LT) recipients has become an increasingly important topic in hepatology and obstetrics. Chronic liver disease, once predominantly affecting older individuals, is now more common among women of reproductive age due to rising prevalence of metabolic dysfunction-associated steatotic liver disease and alcohol-related liver disease. While cirrhosis can impact fertility through various mechanisms, many women retain or regain fertility with improved liver function. LT typically restores gonadal function, with 70%–95% of recipients experiencing menstrual normalization within a year. Pregnancy in LT recipients is considered high-risk, requiring careful management and multidisciplinary care. Most experts recommend waiting at least 1–2 years post-transplantation before conception to allow for graft stabilization and reduced immunosuppression. Pre-pregnancy management includes adjusting immunosuppressive agents, folic acid supplementation, cervical cancer screening, and appropriate vaccinations. Maternal complications in LT recipients include higher rates of pregnancy-induced hypertension, pre-eclampsia, and gestational diabetes compared to the general population. Fetal outcomes show higher rates of preterm birth and intrauterine growth restriction, though live birth rates have improved over time. The incidence of congenital abnormalities appears comparable to the general population. Postpartum management requires close monitoring of immunosuppressant levels and regular follow-ups.Breastfeeding is not absolutely contraindicated, but requires careful consideration of potential risks and benefits. This review summarizes current knowledge on fertility and pregnancy outcomes in these populations.

Replacement of the retrohepatic inferior vena cava (IVC) after concurrent resection of IVC and tumor-bearing liver is regarded as a feasible living donor liver transplantation (LDLT) technique to cope with tumors around the IVC. This method can make the resection extent of LDLT comparable to that of deceased-donor liver transplantation. We present one pediatric LDLT case with IVC replacement using an enlarged iliac vein conduit to treat advanced hepatoblastoma. The patient was a 33-monthold and 12 kg-weighing girl suffering from large multiple hepatoblastomas invading the retrohepatic IVC. At 2-month waiting after deciding LDLT, we obtained a coldstored iliac vein graft and LDLT was performed with the father’s left lateral section graft. A 1.3 cm-wide and 10 cm-long iliac vein was transformed to be a 2 cm-wide and 5 cm-long vein graft through a double-barrel unification venoplasty. The left lateral section graft was implanted along the standard procedure of LDLT. The patient recovered uneventfully and is undergoing scheduled adjuvant chemotherapy. IVC replacement with vein homograft is a feasible option for LDLT in pediatric patients with advanced liver malignancy.

Acute liver failure (ALF) is a life-threatening condition characterized by rapid hepatic deterioration, coagulopathy, and encephalopathy. While orthotopic liver transplantation (OLT) is often necessary, donor organ shortages and the unpredictable course of ALF highlight the need for alternative supportive therapies. Bioartificial liver (BAL) systems offer a potential bridge to OLT or spontaneous liver recovery by providing metabolic and synthetic liver functions. Early extracorporeal liver support efforts relied on artificial-liver devices, which primarily performed detoxification but failed to improve survival. This led to the development of BAL systems incorporating viable hepatocytes to support both metabolic detoxification and biosynthetic functions.Initial BAL studies, including the HepatAssist ® system, demonstrated improvements in biochemical parameters and hepatic encephalopathy, though survival benefits remained inconsistent. BAL devices comprise functional subunits, including filtration, detoxification, and bioreactor components housing hepatocytes. Various cell sources have been explored, including porcine hepatocytes, immortalized human cell lines, and induced pluripotent stem cell (iPSC)-derived hepatocyte-like cells.While porcine hepatocytes remain widely used due to their metabolic activity, concerns regarding immunogenicity and zoonotic transmission persist. Clinical trials of BAL devices have shown biochemical and neurologic improvements but have yet to demonstrate definitive survival benefits. Recent advances, such as hepatocyte spheroid culture and iPSC-derived hepatocytes, may enhance BAL efficacy. Further research is needed to optimize cell sources, bioreactor designs, and integration with existing liver failure management strategies. While BAL systems offer a promising approach for ALF management, their clinical efficacy remains unproven. Continued advancements in cell technology and bioreactor design are necessary to establish BAL as a viable therapeutic option.

Background: Phase angle (PA) has been proposed as a prognostic factor for evaluating postoperative outcomes across various types of surgery. In this study, we investigated whether preoperative PA measured in living liver donors is associated with postoperative recovery. Methods: Donors aged over 19 years, scheduled for elective purely laparoscopic donor hepatectomy, were included. Each donor underwent bioimpedance analysis(BIA), including PA, on the day before surgery (PA pre ) and the third postoperative day (PAPOD3 ) using the InBody S10 (InBody Co., Ltd, Seoul, Korea). Postoperativerecovery quality was assessed using the Korean version of the quality of recovery (QoR-15K). All donors completed the QoR-15K on POD3 and POD21 to evaluate their recovery following surgery and anesthesia. Results: The mean age of the participants was 38.7±13.2 years, and 24 maledonors (59%) were included. PAPOD3 significantly decreased compared to PA pre(5.42±0.97 vs. 5.99±0.76; mean difference: —0.57, p=0.004). The extracellular water ratio (ECWR) on POD3 increased compared to preoperative levels (0.391±0.011 vs.0.378±0.007; mean difference: 0.013, p<0.001). However, skeletal muscle massindex (SMI) did not significantly change over time (SMI pre : 7.5±1.1; SMI POD3 : 8.0±1.2;p=0.67). Neither PA pre nor ECWR pre was associated with QoR-15K scores on POD3.However, SMI pre was significantly associated with QoR-15K on POD3, but not onPOD21. In the logistic regression model, preoperative BIA variables were not associated with in-hospital complications. Conclusion While PA pre was not associated with postoperative recovery or com-plications, a higher SMI was identified as a significant predictor of better recovery, suggesting its potential use as a screening tool in living liver donors.

Background: Liver transplant (LT) is a well‑established therapeutic strategy for endstage liver diseases. In the absence of a biopsy diagnosis, it is a common practice to increase immunosuppression for raised liver function tests, which may prove harmful in a non-rejection setting, hence, an accurate histopathological diagnosis from liver biopsy plays a significant role in the management of transplant recipients.We aim to study the spectrum of histopathological findings in post-transplant graft biopsies performed within 3 months of LT. Methods: This was a retrospective study of 81 patients who underwent LT at Medanta-The Medicity in the year 2022 and had a liver biopsy performed within 3 months following the LT. All biopsies with T cell-mediated rejection (TCMR) and antibody-mediated rejection (AMR) were graded according to the 2016 Banff criteria by two assessors in a blinded manner. Immunohistochemistry for anti-C4d (polyclonal; BioGenex, Fremont, CA, USA), anti-cytokeratin7 (clone RM416; BioSB, Santa Barbara, CA, USA), anti-cytokeratin-19 (clone RCK108; BioGenex, Fremont, CA, USA), and anti-CMV (clone 8B1.2, 1G5.2, and 2D4.2; BioSB, Santa Barbara, CA, USA) were performed wherever required. Results: The median age of the cohort was 45.5 years with a male predominance.The main indications of LT were alcoholic liver disease (22.22%), cryptogenic cirrhosis (20.98%), non alcoholic steatohepatitis (11.11%), and hepatocellular carcinoma (7.2%). A total of 113 biopsies were performed in 81 patients. The most common histopathological findings were TCMR (n=43, 53.08%), cholestatic changes (n=19, 23.45%), cholangitis (n=16, 19.75%), and preservation/reperfusion injury (PRI) (n=13, 16.04%). Two patients who underwent ABO-incompatible LT showed AMR. Conclusion The most common pathological diagnosis was TCMR, followed by cholestasis, cholangitis, and PRI. A non-TCMR diagnosis was present in 28.39% of cases.

Postoperative adhesions following hepatic resection are a significant cause of morbidity, leading to complications such as small bowel obstruction and chronic pain. However, in the context of liver surgery, these adhesions present a unique and formidable challenge, particularly when a subsequent liver transplantation may be necessary. Adhesions from a prior resection can dramatically increase the difficulty, operative time, and blood loss associated with the transplantation procedure, thereby increasing patient morbidity. Furthermore, with the prominence of living donor liver transplantation, minimizing adhesion formation in healthy donors is an ethical and clinical imperative. This review provides a comprehensive analysis of currently available anti-adhesive agents, including films, gels, and solutions. We evaluate the evidence for their efficacy and safety in hepatic resection and, most importantly, explore their critical applications and potential benefits in the specific settings of liver transplantation recipients and living donors. Finally, we propose future research directions to establish best practices for the use of these agents to improve outcomes in the field of liver transplantation.