State of the Union: Liver Transplantation Today

An interview with Tomoaki Kato, MD, Chief of Abdominal Organ Transplant and Hepatobiliary Surgery.

Liver transplantation continues to evolve, not through a single breakthrough, but through incremental shifts in technology, end-of-life decision-making, oncology care, and organ utilization. As these boundaries expand, questions of timing, eligibility, and equity remain central. In this interview, Dr. Kato reflects on how these changes are reshaping care today, and what may be ahead.

More Donations, More Time to Donate

What has changed in liver donation and preservation since we last spoke?

The biggest difference is in how people donate an organ, and that applies to any organ, not just the liver. DCD [donation after cardiac death] has increased a lot. The decision for end-of-life care is made much earlier and is becoming more and more publicly recognized. Previously, people would wait until there was a complete brain death before the family was approached for organ donation. But now if the poor prognosis is clear, families can make that decision before complete brain death. It’s a big shift that makes a big difference, actually.

And at the same time, ex vivo machine perfusion was FDA-approved and quickly gained popularity. And that’s when we can keep blood running through the organ, oxygenated outside the body. Liver quality wasn’t so good when transplanted after death, but with the machine perfusion, the quality improved a lot, and we know the quality beforehand. It’s the combination of access and preservation together.

How does machine perfusion change the timing of surgery?

It’s an interesting question because one of the biggest things is that the machine actually allows for a lot more liver transplant cases to be done during the day. In the past, they were routinely started at nighttime or went through the night because we didn’t have the luxury of time management; everything was done as quickly as possible to preserve organ function. So, we can plan better and work during the daytime. That’s one big difference.

What does machine perfusion actually do?

Besides preserving the organ, the machine gives us confirmation of the organ quality as it functions inside the machine. We call it viability testing. It gives us more assurance; we can see how viable an organ is while it’s on the machine. It’s not completely reliable for everything, but at least it’s a good way to ensure the organ quality before transplant.

Do you use perfusion for every deceased liver transplant?

Well, we can’t use it for every single case because it’s very expensive. So far, we have limited use for donation after cardiac death or to make sure a certain type of very unknown, uncertain quality organ is okay. Or sometimes an organ is coming from far away, and the expected preservation time is too long. When a transplant is expected to be very difficult, we would rather put it in the machine so we can have a relaxed time doing these cases.

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Robotic Living Liver Donation

Where does robotics fit into liver transplantation?

Robotic donor hepatectomy has been a really big change that’s allowed us to push living donation forward. Living donation used to be a big surgery, but robotics has lowered the bar for people to donate. As long as it’s a good quality robotic surgery, recovery is so much faster. So, I think it’s going to increase the number of living donors.

How does it change who might become a donor?

People want to donate to family or friends, but some people want to donate to people they don’t know. If the barrier is lower, like a smaller incision or faster recovery, there could be more of those donors. Also, many are of working age, so shorter recovery matters.

Is robotic donation now your standard?

We are doing more and more. For the donors, we use robotic surgery for the vast majority of cases. We are also working using robotics for the recipient; Dr. Jason Hawksworth does those now. If both can be robotic, it has a good chance of becoming the standard of care across the board.

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Transplant Oncology: Expanding Who Is Eligible

Cancer indications for liver transplant are changing quickly. What stands out?

Liver transplant for colorectal cancer metastasis has increased a lot. It used to not be an indication, but for selected patients, it is working really well. There are many more multi-center large studies showing very good results. So the biggest change is that colorectal cancer metastasized to the liver has become a potential target for liver transplant.

Why does living donation matter more in oncology?

Timing—you can control the timing. In order to do those cases successfully, living donation works the best because of the chemotherapy timing, and it eliminates the uncertainty and waiting for an available organ. If the cancer progresses while you’re waiting, the patient becomes ineligible. So, when the oncologist says, “Now is the time,” we can do it right away.

Are you doing more transplants for cancers that previously had no surgical option?

Yes. Those are in situations with multiple lesions scattered through the liver, so those cases are not resectable. Either your patient is on chemo forever or they will die. Giving chemo forever is not a solution, at some point it will break through. So that’s why the transplant is being offered to these patients.

The transplant outcome is still not perfect yet. A lot of them recur still, but better to recur outside than to have a liver failure. So even with the recurrence there are benefits to having liver transplant. The survival benefit is significant. Patients live longer; recurrence is not necessarily a failure.

Clinical Trials and Immunosuppression

Is tolerance–getting patients off anti-rejection medication–becoming a reality?

Not as fast as it looked. For the liver, tolerance was expected to come earlier, but the trials are slower than expected. We’re not doing a lot of tolerance trials for liver here right now.

Are there other innovations in drug therapy?

We are doing a new kind of immunosuppression. Ours is not for tolerance. Ours is immunosuppression to prevent recurrence. Especially for cancer, preventing recurrence is the main target.

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Xenotransplantation and Precision Medicine

Where does xenotransplant fit into the future of liver transplant?

Xenotransplantation is still in the stage of animal experiments for the liver. But progress is very fast. For the liver, I think the bridge use will be first — a step before full replacement. But eventually it will be primary. Maybe not too far. I don’t think it’s “10 years away” like people used to say.

Are the ethics or regulations the main barrier?

There are always issues, but mostly, the ethical framework is already there. The biggest factor is going to be who is the right patient for the early trial — oncology, metabolic, acute liver failure, pediatric? That decision is the difficult part.

What role are AI and biomarkers playing now?

AI can read pathology slides, it can predict outcomes, and it can evaluate donor livers. We are using more genetically-based biomarkers, as well as genomics, which is called cell-free DNA, to see who has more of a greater tendency to reject or not. It’s individualized immunosuppression based on the patient’s biology and seems to be working really well in terms of stratifying the patient's need for immunosuppression.

Access and Equity

How is liver transplant doing in terms of equity?

There are quite a significant number of underserved people. African American and Asian populations are underserved and have lower access. We’ve been working on it with outreach and education, and we see some improvement, but not enough. Awareness is key, and there is a lot more work to be done. Living donation can sometimes make more inequity because the decision comes from within the family or community, and there is not always an equal understanding.

What needs to change?

Translation is not enough. With kidney transplant, they started the Spanish-speaking program and are doing every part, most importantly, evaluation, in Spanish. We’re mimicking that with liver, too. But education has to be culturally appropriate, not just language appropriate. We need a community‐based understanding of what donation is.

What's Ahead

What does the next era of transplant care look like to you?

Living donor transplant with minimally invasive, robotic surgery is going to expand. But the biggest change is for cancer patients, and having much more freedom to do those cases. Oncology transplant will grow. Combining those with perfusion and individualized immunosuppression will change who can be transplanted and when. The multidisciplinary approach, chemotherapy combined with a living donor, things like that.

And longer term?

I'm really looking forward to seeing xenotransplant liver transplants becoming available. That's my next 5-year goal.

Xeno will change everything. It will expand access, especially for oncology. It will change how fast we do things, who gets a liver, and for what disease. It will change the timing. It will change the whole field.