Liver Lineup: Bridging Innovation and Practice in Liver Transplant and HCC Care

In this episode of Liver Lineup: Updates and Unfiltered Insights, hosts Kimberly Brown, MD, and Nancy Reau, MD, break down new research on liver transplantation, hepatocellular carcinoma (HCC), and the ongoing evolution of surveillance strategies in chronic liver disease. Drawing on their extensive experience as transplant hepatologists, Brown and Reau place new data into practical context, highlighting where evidence may meaningfully inform practice and where unanswered questions remain.

The conversation opens with a discussion of frailty assessment in transplant evaluation, an area of growing importance given its association with post-transplant outcomes. Brown highlights data comparing the 6-minute walk test with the Liver Frailty Index, noting that simpler, more scalable tools may perform comparably in predicting both waitlist and post-transplant outcomes. While formal frailty metrics are increasingly embedded into transplant workflows, both experts emphasize that implementation burden, staffing, and clinical actionability remain key considerations for transplant programs.

Turning to allocation policy, the duo examines real-world data on MELD 3.0, particularly its impact on transplant access for women. While early implementation suggested improved equity in organ offers, longer-term analyses indicate that these gains may not be sustained. Emerging data suggest height and body size, rather than sex alone, may continue to disadvantage certain patients, underscoring the complexity of refining allocation models that were originally designed to predict mortality, not transplant access.

A major focus of the episode is emerging global data on immune checkpoint inhibitors used for downstaging or bridging patients with HCC to liver transplantation. Reviewing outcomes from a large, international cohort, Brown outlines encouraging tumor response rates and acceptable post-transplant survival, while acknowledging a greater, but manageable, risk of rejection. Both experts stress the importance of washout timing and careful patient selection as immunotherapy becomes increasingly integrated into pre-transplant oncology care.

The discussion then shifts to the intersection of metabolic liver disease and HCC, highlighting data linking hepatic steatosis and metabolic dysfunction with more advanced tumor stage and poorer treatment response. Reau emphasizes that delayed diagnosis and suboptimal surveillance in MASLD populations may play a significant role, particularly given ongoing challenges in defining who should be screened and how best to do so.

The episode concludes with a candid discussion of HCC surveillance adherence, with data showing strikingly low rates of full guideline-concordant screening. Notably, lack of physician recommendation emerged as the most common barrier. Brown and Reau go on to explore how blood-based biomarkers and composite scores, such as GALAD, may offer more accessible and consistent screening approaches, potentially reducing patient burden and improving early detection.

Editors’ note: Relevant Disclosures for Reau include AbbVie, Gilead, Salix, Arbutus, and VIR. Relevant disclosures for Brown include Mallinckrodt Pharmaceuticals, Gilead, Salix, Intercept, Ipsen, and Madrigal.

References

1. Elshaer A, Mead-Harvey C, Carey E. Comparison of the 6-Minute Walk Test and the Liver Frailty Index in Predicting Liver Transplant Mortality. Presented at the American Association for the Study of Liver Diseases (AASLD) The Liver Meeting 2025. Washington, DC. November 7-11, 2025.

2. Tanaka T, Shane D, Lai J. MELD 3.0 Failed to Sustainably Address Sex Disparities in US Liver Transplant Allocation. Presented at the American Association for the Study of Liver Diseases (AASLD) The Liver Meeting 2025. Washington, DC. November 7-11, 2025.

3. Yang JD, Rezaee-Zavareh MS, Wang T, et al. Leveraging Immunotherapy For Transplantation in Hepatocellular Carcinoma (LIFT HCC): Analysis of 375 Patients Receiving Pre-Transplant Immune Checkpoint Inhibitors. Presented at the American Association for the Study of Liver Diseases (AASLD) The Liver Meeting 2025. Washington, DC. November 7-11, 2025.

4. Duseja A, Ashraf MU, Singh P, et al. Impact of hepatic steatosis and metabolic dysfunction on disease severity and treatment outcomes in patients with hepatocellular carcinoma. Presented at the American Association for the Study of Liver Diseases (AASLD) The Liver Meeting 2025. Washington, DC. November 7-11, 2025.

5. Shukla A, Padole V, Vaidya A. NON-ADHERENCE TO SURVEILLANCE PROTOCOL OF HEPATOCELLULAR CANCER IN PATIENTS WITH LIVER CIRRHOSIS: PREVALENCE AND REASONS. Presented at the American Association for the Study of Liver Diseases (AASLD) The Liver Meeting 2025. Washington, DC. November 7-11, 2025.

6. Demirtas C, Akin S, Karadag DY, et al. Enhancing Hepatocellular Carcinoma Surveillance: Comparative Evaluation of AFP, AFP-L3, DCP, and Composite Scoring Models in a Biobank-Based Case-Control Study. Presented at the American Association for the Study of Liver Diseases (AASLD) The Liver Meeting 2025. Washington, DC. November 7-11, 2025.