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Liver Transplantation
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Introduction Neuroprotection remains a central challenge in the management of acute liver failure, where cerebral oedema and intracranial hypertension are major drivers of mortality. Traditionally, invasive intracranial pressure monitoring has been used to guide management, but recent shifts in clinical practice suggest a move away from this approach. This evolving paradigm reflects a deeper understanding of the pathophysiology of brain injury in acute liver failure, where ammonia toxicity, systemic inflammation, and blood–brain barrier dysfunction act synergistically rather than independently. Summary This article highlights a significant transition in neuroprotective strategies in acute liver failure following evidence that declining use of invasive intracranial pressure monitoring has not adversely affected survival outcomes. The focus is shifting from reactive management of intracranial hypertension to proactive prevention of cerebral oedema. Blood ammonia is emphasised as a key early biomarker for identifying high-risk patients, although it is recognised as a downstream marker rather than the primary driver of injury. Increasing attention is being directed toward upstream mechanisms, particularly systemic inflammation and cytokine-mediated neurotoxicity, which may offer future therapeutic targets. The second major shift is toward non-invasive, multimodal neurological monitoring. Emerging tools such as transcranial Doppler, near-infrared spectroscopy, and continuous electroencephalography offer dynamic insights into cerebral perfusion, oxygenation, and neuronal activity, enabling a more comprehensive and individualised assessment of brain function without procedural risk. Finally, the reduction in invasive monitoring introduces a critical clinical challenge: determining irreversible brain injury and transplant eligibility. The author proposes a multimodal framework combining imaging, functional neurophysiology, and biomarkers to guide decision-making. This approach is essential to ensure appropriate use of liver transplantation while avoiding both futile interventions and missed opportunities for timely transplantation.
Introduction Primary sclerosing cholangitis is a unique indication for liver transplantation because long-term outcomes are influenced not only by graft survival, but also by the risks of acute cellular rejection, recurrent PSC, and complications related to associated inflammatory bowel disease. Although survival after transplantation is generally favorable, the ideal post-transplant immunosuppressive strategy remains uncertain. This international survey from the IPSCSG is important because it highlights how little standardization currently exists in the care of PSC patients after liver transplantation. Summary This survey of 31 transplant centers across Europe, the United States, and other regions showed marked heterogeneity in immunosuppressive practice after liver transplantation for PSC. Nearly half of centers reported using a more intensive immunosuppressive approach in PSC than in other transplant recipients, and basiliximab induction was routinely used by a similar proportion. Triple immunosuppression was common early after transplantation, but long-term practice varied substantially. Some centers tapered to tacrolimus monotherapy, most used dual therapy, and about one-quarter maintained triple therapy long term. Corticosteroid use also differed greatly, with most centers stopping prednisolone within the first year, while nearly one-third continued lifelong prednisolone. Importantly, these differences were seen even among high-volume transplant centers, suggesting that experience alone has not led to convergence in practice. Follow-up strategies also varied, including inconsistent use of imaging and protocol liver biopsies. The major message is that post-transplant care in PSC remains highly individualized and not evidence-based. This variation creates an important opportunity for comparative outcome studies to determine whether certain immunosuppressive strategies are associated with lower recurrence, better graft survival, or fewer long-term complications.
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