Transplant physicians and candidates have become increasingly aware that donor characteristics significantly impact liver transplantation outcomes. Although the qualitative effect of individual donor variables are understood, the quantitative risk associated with combinations of characteristics are unclear. Using national data from 1998 to 2002, we developed a quantitative donor risk index. Cox regression models identified seven donor characteristics that independently predicted significantly increased risk of graft failure. Donor age over 40 years (and particularly over 60 years), donation after cardiac death (DCD), and split/partial grafts were strongly associated with graft failure, while African-American race, less height, cerebrovascular accident and 'other' causes of brain death were more modestly but still significantly associated with graft failure. Grafts with an increased donor risk index have been preferentially transplanted into older candidates (>50 years of age) with moderate disease severity (nonstatus 1 with lower model for end-stage liver disease (MELD) scores) and without hepatitis C. Quantitative assessment of the risk of donor liver graft failure using a donor risk index is useful to inform the process of organ acceptance.

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The Banff Working Group on Liver Allograft Pathology reviewed and discussed literature evidence regarding antibody-mediated liver allograft rejection at the 11th (Paris, France, June 5-10, 2011), 12th (Comandatuba, Brazil, August 19-23, 2013), and 13th (Vancouver, British Columbia, Canada, October 5-10, 2015) meetings of the Banff Conference on Allograft Pathology. Discussion continued online. The primary goal was to introduce guidelines and consensus criteria for the diagnosis of liver allograft antibody-mediated rejection and provide a comprehensive update of all Banff Schema recommendations. Included are new recommendations for complement component 4d tissue staining and interpretation, staging liver allograft fibrosis, and findings related to immunosuppression minimization. In an effort to create a single reference document, previous unchanged criteria are also included.

We aimed to determine whether frailty, a validated geriatric construct of increased vulnerability to physiologic stressors, predicts mortality in liver transplant (LT) candidates. Consecutive adult outpatients listed for LT with laboratory MELD≥12 at a single center (97% recruitment rate) underwent 4 frailty assessments: Fried Frailty, Short Physical Performance Battery (SPPB), Activities of Daily Living (ADL), and Instrumental ADL (IADL) scales. Competing risks models associated frailty with wait-list mortality (death/delisting for being too sick for LT). 294 listed LT patients with MELD≥12, median age 60y, and MELD 15 were followed for 12 months. By Fried Frailty score≥3, 17% were frail; 11/51 (22%) of the frail versus 25/243 (10%) of the not frail died/were delisted (p=0.03). Each 1-unit increase in the Fried Frailty score was associated with a 45% (95%CI, 4-202%) increased risk of wait-list mortality adjusted for MELD. Similarly, the adjusted risk of wait-list mortality associated with each 1-unit decrease (i.e., increasing frailty) in the SPPB (HR 1.19, 95%CI 1.07-1.32). Frailty is prevalent in LT candidates. It strongly predicts wait-list mortality, even after adjustment for liver disease severity demonstrating the applicability and importance of the frailty construct in this population.

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