Trending Topics in Gastroenterology | GastroAGI

Synbiotics After Liver Transplant Show No Clinical Benefit: Liver Transplant | July 2026

Introduction: Bacterial infections remain a major cause of morbidity after liver transplantation despite advances in perioperative care. Synbiotics, combining probiotics and prebiotics, have been proposed to reduce postoperative infections by restoring gut microbiota and strengthening intestinal barrier function. Earlier studies suggested potential benefits, but their findings have not been consistently replicated in clinical practice. Why was this study needed?: . Previous studies suggested synbiotics may reduce post-transplant bacterial infections, but the evidence was inconsistent. . Synbiotic therapy has not been widely adopted in liver transplant programs. . High-quality randomized controlled data were needed to validate their effectiveness. . It remained uncertain whether postoperative synbiotics improve clinically meaningful outcomes after liver transplantation. Results: In this randomized, double-blind, placebo-controlled trial, postoperative synbiotic supplementation for 14 days did not reduce bacterial infections compared with placebo. There were no significant differences between the groups in antibiotic use, acute rejection, hospital length of stay, or short-term survival. Per-protocol analyses yielded similar findings, confirming the absence of a meaningful clinical benefit. Synbiotic therapy was well tolerated but failed to improve postoperative outcomes. Clinical Impact: This study challenges earlier reports supporting routine synbiotic supplementation after liver transplantation. The findings indicate that postoperative synbiotics should not be recommended as standard care solely to prevent bacterial infections. Future research should focus on identifying specific patient populations, alternative microbiome-based interventions, or different treatment strategies that may offer greater clinical benefit. Bottom Line: Routine postoperative synbiotic supplementation does not reduce bacterial infections or improve short-term clinical outcomes after liver transplantation and should not be incorporated into standard postoperative management based on current evidence.

Tranexamic Acid in Liver Transplantation: Liver Transplant | June 2026

Introduction: Perioperative bleeding remains a major challenge during orthotopic liver transplantation (OLT), largely due to hyperfibrinolysis and coagulation abnormalities. Although tranexamic acid (TXA) effectively reduces bleeding in several surgical settings, its routine prophylactic use during liver transplantation remains controversial because of uncertain efficacy and concerns regarding thromboembolic complications. Why was this study needed?: Current evidence supporting routine prophylactic TXA use during OLT is limited and inconsistent. It is unclear whether prophylactic TXA reduces major perioperative bleeding and transfusion requirements. Safety concerns, particularly thromboembolic complications, have limited widespread adoption. Identifying patient subgroups most likely to benefit could enable a more personalized approach to antifibrinolytic therapy. Results: In this randomized, placebo-controlled trial, prophylactic TXA did not significantly reduce the overall incidence of major perioperative bleeding during liver transplantation. However, patients receiving TXA required fewer intraoperative red blood cell transfusions and had a shorter hospital stay. Importantly, benefits were more pronounced in lower-risk recipients, including those with low MELD 3.0 scores and Child–Pugh A cirrhosis. Rates of thromboembolic events and mortality were comparable between the TXA and placebo groups, supporting an acceptable safety profile. Clinical Impact: These findings do not support routine prophylactic TXA administration for all liver transplant recipients. Instead, TXA may offer meaningful clinical benefits in carefully selected lower-risk patients by reducing transfusion requirements and accelerating postoperative recovery without increasing thromboembolic risk. The study reinforces the need to move from universal prophylaxis toward individualized antifibrinolytic strategies based on patient risk profiles. Bottom Line: Routine prophylactic tranexamic acid is not justified for all liver transplant recipients, but selected lower-risk patients may benefit through reduced blood transfusion requirements and shorter hospitalization without compromising safety. Larger trials are needed to define patient groups most likely to benefit.

Whole-Organ Donor Liver Assessment Using PS-OCT: Science Translational Medicine | July 2026

Introduction: Liver transplantation is limited by a shortage of suitable donor organs. Current viability assessment relies on needle biopsy, which samples only a small portion of the liver and may miss important regional pathology. This study evaluated polarization-sensitive optical coherence tomography (PS-OCT), a noninvasive imaging technique, for comprehensive whole-organ donor liver assessment. Why was this study needed? • Liver biopsy samples only a tiny fraction of the donor liver and may overlook heterogeneous disease. • Better methods are needed to accurately assess extended-criteria donor livers. • Inaccurate assessment can lead to unnecessary organ discard or transplantation of poor-quality grafts. • Whole-organ, noninvasive viability assessment has remained an unmet need. • Artificial intelligence may improve interpretation of advanced imaging data. Results: • PS-OCT accurately assessed steatosis, fibrosis, inflammation, and necrosis across the entire donor liver, showing excellent agreement with conventional histopathology. • PS-OCT findings closely correlated with liver function during normothermic machine perfusion and with early post-transplant clinical outcomes, supporting its clinical relevance. • By providing rapid, noninvasive whole-organ assessment, PS-OCT has the potential to reduce unnecessary organ discard while improving donor liver selection. Clinical Impact: This study represents a major advance in donor liver evaluation. PS-OCT combines high-resolution imaging with artificial intelligence to assess the entire liver rather than a small biopsy sample, potentially improving transplant decision-making and expanding the usable donor pool. Bottom Line: PS-OCT may redefine donor liver viability assessment. By providing accurate, noninvasive, whole-organ evaluation that correlates with graft function and transplant outcomes, it has the potential to reduce organ discard and safely expand liver transplantation.

Personalizing Antifibrinolytic Use in Liver Transplantation : Liver Transpl | Jul 2026

Introduction: Bleeding remains a major challenge during liver transplantation despite advances in surgical techniques, anesthesia, and perioperative care. Antifibrinolytic agents have long been used to reduce intraoperative blood loss and transfusion requirements. However, evolving transplant practices and improved understanding of coagulation have prompted re-evaluation of routine prophylactic antifibrinolytic therapy. Problem Statement: Historically, antifibrinolytics were frequently administered empirically to liver transplant recipients because of the perceived high risk of hyperfibrinolysis. However, not all patients develop clinically significant fibrinolysis, raising concerns about unnecessary treatment, thrombotic complications, and indiscriminate use of these agents. The challenge is identifying which patients are most likely to benefit from targeted antifibrinolytic therapy. Summary: This editorial discusses the transition from routine empirical antifibrinolytic administration toward a personalized approach in liver transplantation. The author highlights that contemporary perioperative management, including improved surgical techniques, restrictive transfusion practices, and widespread use of viscoelastic coagulation monitoring, has substantially changed the bleeding profile of liver transplantation. As a result, universal prophylactic antifibrinolytic therapy may no longer be appropriate for all recipients. Instead, individualized treatment based on patient-specific bleeding risk, intraoperative coagulation status, and real-time assessment of fibrinolysis is increasingly favored. Viscoelastic testing offers an opportunity to identify clinically significant hyperfibrinolysis and guide targeted administration of antifibrinolytic agents, potentially maximizing benefit while minimizing unnecessary drug exposure and thrombotic risk. The editorial emphasizes that precision-based hemostatic management aligns with the broader movement toward personalized perioperative medicine. Future research should focus on refining risk stratification models, validating biomarker- and viscoelastic-guided treatment algorithms, and defining the subgroup of liver transplant recipients who derive the greatest benefit from antifibrinolytic therapy. Overall, the article argues that the era of routine empirical prophylaxis is giving way to individualized, evidence-based coagulation management, with the goal of optimizing patient safety while preserving the hemostatic advantages of antifibrinolytic treatment in liver transplantation.

Integrating LDLT into Modern Liver Transplant Programs: Liver Transplantation | June 2026

Introduction: The demand for liver transplantation continues to exceed the availability of deceased donor organs, resulting in prolonged waiting times and preventable waitlist mortality. This perspective discusses how living donor liver transplantation (LDLT) can complement deceased donor transplantation to expand access and improve patient outcomes. Why was this article needed? Many countries continue to face a shortage of deceased donor organs. Although LDLT is an established procedure with excellent outcomes, its adoption remains limited in many adult transplant programs because of logistical, ethical, and perceived clinical barriers. What did the article show? • LDLT is an effective strategy to reduce the gap between organ demand and supply. • It can shorten waiting times and reduce waitlist mortality, particularly for patients with advanced liver disease and selected liver cancers. • Successful LDLT requires careful donor selection, rigorous recipient evaluation, and experienced multidisciplinary transplant teams. • Donor safety remains the highest priority, requiring comprehensive medical, surgical, and psychological assessment. • Ethical principles, informed consent, and independent donor advocacy are fundamental to every LDLT program. • Countries with established deceased donor programs can further improve transplant access by incorporating LDLT into routine practice. Clinical Impact: Living donor liver transplantation should be viewed as a complementary, rather than competing, strategy to deceased donor transplantation. Expanding LDLT programs can increase transplant opportunities while maintaining high standards of donor safety and recipient outcomes. Take-Home Message: Living donor liver transplantation offers a sustainable solution to the growing shortage of donor organs. With appropriate expertise, ethical safeguards, and multidisciplinary care, LDLT can significantly expand access to life-saving liver transplantation while preserving donor safety.

Post-Transplant Management in Pediatric LT: Liver Transplantation | June 2026

Introduction: Pediatric liver transplantation has achieved excellent survival rates, shifting the focus from graft survival alone to optimising long-term health, growth, neurodevelopment, and quality of life. This updated guideline provides evidence-based recommendations for comprehensive care from transplantation through transition to adult services. Why was this guideline needed? * Advances in surgical techniques and intensive care have improved survival. * Long-term complications of immunosuppression remain a major concern. * Infection prevention and vaccination strategies have evolved. * Greater emphasis is now placed on nutrition, growth, development, and psychosocial well-being. * Standardised transition from pediatric to adult care is increasingly recognised as essential. Key Recommendations: • Use individualized immunosuppression with the lowest effective dose to minimize long-term toxicity. • Monitor closely for acute and chronic graft rejection through regular clinical and laboratory surveillance. • Prevent infections with appropriate antimicrobial prophylaxis and timely immunization. • Optimize nutrition early after transplantation to support normal growth and neurodevelopment. • Regularly monitor renal function, cardiovascular risk factors, bone health, and metabolic complications. • Screen for post-transplant lymphoproliferative disorder (PTLD) and other malignancies in high-risk patients. • Assess developmental, cognitive, behavioral, and mental health outcomes during long-term follow-up. • Promote medication adherence through patient and family education. • Use a multidisciplinary team involving hepatologists, transplant surgeons, dietitians, psychologists, pharmacists, nurses, and social workers. • Initiate structured transition planning during adolescence to ensure successful transfer to adult transplant services. • Provide lifelong surveillance for graft function and late post-transplant complications. Clinical Impact: The updated guideline emphasises that successful pediatric liver transplantation extends beyond graft survival. Comprehensive multidisciplinary care, minimisation of immunosuppression-related toxicity, infection prevention, developmental support, and planned transition to adult care are essential for optimising lifelong outcomes. Take-Home Message: Modern pediatric liver transplantation focuses not only on preserving the liver graft but also on ensuring healthy growth, normal development, fewer treatment-related complications, and a smooth transition into adult care through coordinated multidisciplinary follow-up.

IBAT Inhibitor Relieves Refractory ICP After Liver Transplant : Liver Transpl | Jun 2026

Introduction: Intrahepatic cholestasis of pregnancy (ICP) is a pregnancy-specific liver disorder characterized by severe pruritus and elevated bile acids, carrying risks for both maternal well-being and fetal outcomes. Management can be particularly challenging in patients with underlying cholestatic liver diseases, even after liver transplantation. Therapeutic options for refractory ICP remain limited when conventional treatment fails to adequately control symptoms and bile acid levels. Problem Statement: Women with a history of cholestatic disorders such as Alagille syndrome may remain susceptible to severe cholestatic complications during pregnancy despite successful liver transplantation. Refractory ICP can lead to debilitating pruritus and increased obstetric risk, highlighting the need for effective alternative therapies when standard treatments prove insufficient. Summary: This report describes the use of an ileal bile acid transporter (IBAT) inhibitor in a liver-transplanted woman with Alagille syndrome who developed refractory intrahepatic cholestasis of pregnancy. The case highlights the persistent vulnerability to cholestatic dysfunction that may remain despite transplantation, particularly under the physiological stress of pregnancy. Conventional therapeutic measures were insufficient to adequately control the patient's cholestatic symptoms, prompting consideration of an IBAT inhibitor. By reducing enterohepatic bile acid recirculation, IBAT inhibition offers a mechanistically targeted approach to lowering systemic bile acid burden and alleviating cholestatic symptoms. The reported experience suggests that this strategy may provide meaningful symptomatic and biochemical improvement in highly selected patients with difficult-to-manage ICP. Beyond its immediate clinical relevance, the case raises important questions regarding the potential role of IBAT inhibitors in pregnancy-associated cholestatic disorders, particularly among women with underlying genetic cholestatic diseases or prior liver transplantation. Although conclusions are necessarily limited by the single-patient nature of the report, the findings highlight a promising therapeutic avenue in an area where treatment options remain scarce. This case contributes to the emerging evidence supporting bile acid–targeted therapies and may stimulate future studies evaluating the safety and efficacy of IBAT inhibitors in severe or refractory ICP.

Post-Transplant Infections Drive Early Readmissions : Liver Transpl | Apr 2026

Introduction: Hospital readmission within 30 days of liver transplantation is a common and costly event that reflects early postoperative morbidity and is increasingly used as a quality metric in transplant care. Early readmissions place substantial burdens on patients and healthcare systems and have been associated with worse long-term outcomes. However, predictors of readmission have varied across studies, limiting the development of effective preventive strategies. Problem Statement: Most previous studies examining post-transplant readmissions have been limited by single-center experience or administrative datasets, making it difficult to identify consistent and actionable risk factors. Understanding the causes and predictors of early readmission is essential for improving post-transplant care and reducing avoidable healthcare utilization. Summary: Using the national TransQIP registry, this study evaluated patterns and determinants of unplanned 30-day readmission after deceased donor liver transplantation. The investigators found that early readmission was common, affecting more than two-fifths of transplant recipients. Most readmissions were relatively short and were not primarily driven by procedural complications, suggesting that medical issues remain the dominant cause of rehospitalization during the early post-transplant period. The most important finding was the strong association between post-discharge infectious complications and readmission risk. Organ-space surgical site infections emerged as the strongest predictor, followed by sepsis and urinary tract infections. These observations highlight infection prevention, early detection, and prompt outpatient management as critical targets for reducing readmissions after liver transplantation. In contrast, better pre-existing functional status was independently associated with a lower likelihood of readmission, emphasizing the importance of patient conditioning and functional recovery. The study also identified distinct risk profiles for different infection types, suggesting opportunities for more personalized post-discharge monitoring strategies. Overall, these findings indicate that many early readmissions may be preventable through focused infection surveillance, optimized discharge planning, and enhanced outpatient follow-up. The results provide important national-level evidence supporting targeted interventions aimed at reducing infectious complications and improving early outcomes after liver transplantation.

Frailty at 1 Year Predicts Long-Term Mortality After Liver Transplant : Liver Transpl | June 2026

Introduction: Frailty is increasingly recognized as a key determinant of outcomes in patients with advanced liver disease and has become an important component of liver transplant evaluation. Although many patients experience functional recovery after liver transplantation, a subset remain frail or develop new frailty during the post-transplant period. The long-term consequences of persistent or newly developed frailty after transplantation have not been well defined. Problem Statement: Most studies have focused on pre-transplant frailty, yet little is known about the prognostic significance of frailty after transplantation. Identifying whether post-transplant frailty influences long-term survival and quality of life could help guide follow-up strategies and inform interventions aimed at improving outcomes in liver transplant recipients. Summary: This multicenter analysis from the Functional Assessment in Liver Transplantation (FrAILT) Study demonstrates that frailty one year after liver transplantation is a powerful predictor of long-term outcomes. Approximately one in eight transplant recipients remained frail at one year, with frailty occurring more commonly among patients with metabolic dysfunction–associated steatotic liver disease, diabetes, prior frailty, and certain vascular comorbidities. Importantly, frailty at one year was associated with substantially higher long-term mortality and significantly poorer physical health-related quality of life. Even after accounting for other clinical factors, post-transplant frailty remained an independent predictor of adverse outcomes. Particularly noteworthy was the observation that patients who transitioned from a non-frail state before transplantation to a frail state one year later experienced the greatest increase in mortality risk. These findings challenge the assumption that successful transplantation alone eliminates the prognostic impact of frailty and suggest that functional recovery should be considered a major post-transplant outcome. The study highlights the first year after liver transplantation as a critical window for ongoing frailty assessment and intervention. Structured rehabilitation, nutritional optimization, physical activity programs, and targeted management of metabolic comorbidities may represent important opportunities to improve long-term survival and quality of life. Overall, the findings support incorporating routine frailty assessment into post-transplant care and emphasize frailty as a modifiable determinant of long-term transplant success.

GLP-1RAs Aid Weight Control After Liver Transplant : Liver Transpl | June 2026

Introduction: Weight gain and metabolic dysfunction are increasingly recognized as major challenges after liver transplantation. Obesity, diabetes, dyslipidemia, and metabolic dysfunction–associated steatotic liver disease can adversely affect graft health, increase cardiovascular risk, and compromise long-term survival. As glucagon-like peptide-1 receptor agonists (GLP-1RAs) have demonstrated substantial metabolic benefits in the general population, there is growing interest in their use among liver transplant recipients. However, concerns regarding safety, drug interactions, graft function, and immunosuppression have limited widespread adoption. Problem Statement: Evidence supporting the use of GLP-1RAs after liver transplantation remains limited, with uncertainty regarding their impact on graft outcomes, rejection risk, immunosuppressant levels, and cardiovascular safety. Robust real-world data are needed to determine whether these agents can effectively manage post-transplant weight gain without compromising allograft function. Summary: This multicenter international study evaluated the safety and effectiveness of GLP-1RAs in adult liver transplant recipients and provides reassuring evidence supporting their use in post-transplant metabolic management. Treatment with GLP-1RAs resulted in meaningful reductions in body weight, body mass index, and glycemic parameters, with additional modest improvements in lipid profiles. Importantly, these benefits were achieved without evidence of adverse effects on liver graft function, kidney function, or immunosuppressive drug levels. Matched analyses further confirmed superior weight loss and glycemic control among GLP-1RA users compared with non-users. Notably, there was no increased risk of allograft dysfunction, acute cellular rejection, or major adverse cardiovascular events. Semaglutide was the most commonly prescribed agent, reflecting current clinical practice patterns. These findings are particularly relevant as metabolic complications have emerged as a major determinant of long-term outcomes after transplantation. The study suggests that GLP-1RAs may offer a valuable therapeutic strategy for addressing post-transplant obesity and diabetes while maintaining graft safety. Although the observed weight loss was moderate and treatment doses were relatively low, the overall safety profile was highly encouraging. Prospective randomized trials are now needed to define optimal dosing strategies, long-term efficacy, and their potential role in preventing post-transplant metabolic and cardiovascular complications.