Regional and national variation in donor and recipient characteristics, transplant practice, and outcomes after liver transplantation (the IMPROVEMENT collaborative): a multicentre cohort study

Background Outcome variability in liver transplantation remains globally driven by differences in donor-recipient characteristics and in risk-mitigation strategies. Prediction models lack geographic balance and fail to account for current disease classification and advanced organ preservation methods. The IMPROVEMENT study (ClinicalTrials.gov, NCT05289609) aimed to characterise the donor-recipient risks and to develop and validate global prognostic algorithms (mortality and complication rate). Methods This non-competitive, international, cohort study involved 61 centres across Europe, Asia, North and South America, Oceania. Centres provided 83 balanced data series. 5218 patients were enroled in retrospective (2017–2019) and/or prospective (2022–2023) cohorts to avoid COVID-19 confounding. A four-step analytical hierarchy process (world maps, radar graphs, donor versus recipient risk plot, and mixed-effects generalised models) enables visualisation of risk propensity, namely, "aggressiveness", and risk-mitigation balance, namely "coverage adequacy". Outcome measures were 90-, 365-, and 730-day mortality and high complication rates. Findings Overall survival rates at 90 days, 1 year and 5 years were 93, 90 and 80, respectively. Predictors of mortality included recipient age, CAD, pre-operative complex portal thrombosis, preoperative ventilatory life support, MASLD, MELD 3.0 > 30, packed red blood transfusions (PRBC), and cold ischaemia time ≥360 min. The high complication rate resulted dependent from preoperative ventilatory life support, complex portal thrombosis, TIPS and PRBC. Notably, donor factors had a low impact on outcomes, reflecting successful donor-recipient matching and new graft perfusion modalities. Transplant at high-volume centres (>65 transplants/year) was a significant protective factor (mortality and complication rates). C-statistics of 90-day mortality and high complication rate models were 0.78 and 0.77, respectively. Interpretation The IMPROVEMENT study shows that, unlike before, recipient and system-level factors now appear to account for the largest proportion of outcome variability. Implementing risk-mitigation strategies can offset high-risk profiles. These findings provide a robust framework for equitable health resource allocation and clinical decision-making worldwide. Funding Italian Ministry of Health #RF-2021-12372422 grant.

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Journal
The Lancet Regional Health - Europe
Published
2026-10-29
DOI
https://doi.org/10.1016/j.lanepe.2026.101889
Primary Topic
Organ Transplantation Techniques and Outcomes
Type
article
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article

Regional and national variation in donor and recipient characteristics, transplant practice, and outcomes after liver transplantation (the IMPROVEMENT collaborative): a multicentre cohort study

Michele Finotti, Gonzalo Sapisochín, Stefano Di Sandro, Martín de Santibañes et al.
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The Lancet Regional Health - Europe
Organ Transplantation Techniques and Outcomes
article

Regional and national variation in donor and recipient characteristics, transplant practice, and outcomes after liver transplantation (the IMPROVEMENT collaborative): a multicentre cohort study

Michele Finotti, Gonzalo Sapisochín, Stefano Di Sandro, Martín de Santibañes, Felix Braun, Davide Ghinolfi, Giuliano Testa, Davide Chiappori, Gabriel C. Oniscu, Elaine Cristina de Ataíde, M.A. Bodyrev, Giulia Cirillo, Roberta Angelico, Eliano Bonaccorsi‐Riani, Nicola De Stefano, Marco Maria Pascale, Lorenzo Cocchi, Giovanni Vennarecci, Ilka de Fátima Santana Ferreira Boin, Kristopher P. Croome, Cristiano Quintini, Burcin Ekser, Renato Romagnoli, Fabrizio Di Benedetto, Patrizia Burra, Umberto Cillo, Đang Hai, Giammauro Berardi, Matteo Cescon, Sunhawit Junrungsee, Silvio Nadalin, Luciano Gregorio De Carlis, Mikel Gastaca, Amedeo Carraro, Marco Angelo Bongini, Massimo Arcerito, Salvatore Gruttadauria, Daniele Eliseo Dondossola, Domenico Pinelli, Madhukar S. Patel, Timuçin Taner, 邓斐文, Daniele Ferraro, Marco Vivarelli, Jessica Bronzoni, Joris Couillerot, Femke H.C. de Goeij, Wojciech Grzegorz Polak, Christopher S. Chandler, Olga Ciccarelli, Stefania Camagni, Massimo Rossi, Mickaël Lesurtel, Andrea Della Penna, Umberto Baccarani, Marcos Vinicius Perini, Paulo Ney Aguiar Martins, Giuseppe Maria Ettorre, Lucio Caccamo, Michael Crawford, Jeroen de Jonge, Louise A. Barbier, Alfonso Wolfango Avolio, Francesco Tandoi, Júlio César Wiederkehr, 胡泽民, Riccardo De Carlis, Quirino Lai, Daniela Caracciolo, Xiaoshun He, Francesca Caputo, Hiroto Egawa, Mohamed Rela, Elisa Schirra, John Hammond, Michael Fink, Petru Bucur, Ephrem Salamé, Jean Y. Mabrut, Nghia Q. Nguyen, Bunthoon Noonthasoot, Gilberto A. Mejia, Zhiyong Guo, Daniel Maluf, Brian M. Nguyen, Zhi-Jun Zhu, Michal J. Grat, Artem Monakhov, Zhishui Chen, Takashi Ito, Thamara Perera, Laura Llado, Rajesh Dey, Bo Yang, Emanuele Felli, Deniz Balci, Vincenzo Mazzaferro, Subhash Gupta, Surendran Sudhindran, Carlo Pulitano
article en

Abstract

Background Outcome variability in liver transplantation remains globally driven by differences in donor-recipient characteristics and in risk-mitigation strategies. Prediction models lack geographic balance and fail to account for current disease classification and advanced organ preservation methods. The IMPROVEMENT study (ClinicalTrials.gov, NCT05289609) aimed to characterise the donor-recipient risks and to develop and validate global prognostic algorithms (mortality and complication rate). Methods This non-competitive, international, cohort study involved 61 centres across Europe, Asia, North and South America, Oceania. Centres provided 83 balanced data series. 5218 patients were enroled in retrospective (2017–2019) and/or prospective (2022–2023) cohorts to avoid COVID-19 confounding. A four-step analytical hierarchy process (world maps, radar graphs, donor versus recipient risk plot, and mixed-effects generalised models) enables visualisation of risk propensity, namely, "aggressiveness", and risk-mitigation balance, namely "coverage adequacy". Outcome measures were 90-, 365-, and 730-day mortality and high complication rates. Findings Overall survival rates at 90 days, 1 year and 5 years were 93, 90 and 80, respectively. Predictors of mortality included recipient age, CAD, pre-operative complex portal thrombosis, preoperative ventilatory life support, MASLD, MELD 3.0 > 30, packed red blood transfusions (PRBC), and cold ischaemia time ≥360 min. The high complication rate resulted dependent from preoperative ventilatory life support, complex portal thrombosis, TIPS and PRBC. Notably, donor factors had a low impact on outcomes, reflecting successful donor-recipient matching and new graft perfusion modalities. Transplant at high-volume centres (>65 transplants/year) was a significant protective factor (mortality and complication rates). C-statistics of 90-day mortality and high complication rate models were 0.78 and 0.77, respectively. Interpretation The IMPROVEMENT study shows that, unlike before, recipient and system-level factors now appear to account for the largest proportion of outcome variability. Implementing risk-mitigation strategies can offset high-risk profiles. These findings provide a robust framework for equitable health resource allocation and clinical decision-making worldwide. Funding Italian Ministry of Health #RF-2021-12372422 grant.

The Lancet Regional Health - EuropeVol. 71
Università Cattolica del Sacro Cuore (IT), Université de Tours (FR), University of Rome Tor Vergata (IT), University of Modena and Reggio Emilia (IT), University of Maryland, Baltimore (US), Bahçeşehir University (TR), Amrita Institute of Medical Sciences and Research Centre (IN), University of Udine (IT), The University of Sydney (AU), Cliniques Universitaires Saint-Luc (BE), Cleveland Clinic (US), Mayo Clinic (US), University of Padua (IT), Chulalongkorn University (TH), University of California, Los Angeles (US), The University of Melbourne (AU), University of Massachusetts Chan Medical School (US), University of the Basque Country (ES), Universidade Estadual de Campinas (UNICAMP) (BR), Capital Medical University (CN), University of Milan (IT), Loyola University Chicago (US), Université Paris Cité (FR), Kyoto University (JP), Medical University of Warsaw (PL), Queen Elizabeth Hospital Birmingham (GB), Hôpital Beaujon (FR), Royal Prince Alfred Hospital (AU), Policlinico Umberto I (IT), Auckland City Hospital (NZ), Newcastle upon Tyne Hospitals NHS Foundation Trust (GB), Toronto General Hospital (CA), Bellvitge University Hospital (ES), Hospital Italiano de Buenos Aires (AR), Max Super Speciality Hospital (IN), MedStar Georgetown University Hospital (US), Agostino Gemelli University Polyclinic (IT), Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico (IT), Karolinska Institutet (SE), Azienda Ospedaliera Citta' della Salute e della Scienza di Torino (IT), Ospedale Antonio Cardarelli (IT), Hôpital de la Croix-Rousse (FR), National Clinical Research Center for Digestive Diseases (CN), Universitätsklinikum Tübingen (DE), Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda (IT), Azienda Ospedaliera Universitaria Integrata Verona (IT), Azienda Universitaria Ospedaliera Consorziale - Policlinico Bari (IT), Azienda Ospedaliera San Camillo-Forlanini (IT), Centre Hospitalier Universitaire de Tours (FR), Southwestern Medical Center (US), IRCCS Azienda Ospedliero-Universitaria di Bologna Policlinico di Sant'Orsola (IT), Assistance Publique – Hôpitaux de Paris (FR), Hospices Civils de Lyon (FR), First People's Hospital of Foshan (CN), Ospedale Papa Giovanni XXIII (IT), Zhongshan People's Hospital (CN), Azienda Ospedaliero Universitaria Ospedali Riuniti (IT), V.I.Shumakov Federal Research Center of Transplantology and Artificial Organs (RU), University Hospital Schleswig-Holstein (DE), Hamamatsu Rosai Hospital (JP), Mayo Clinic in Arizona (US), The First Affiliated Hospital, Sun Yat-sen University (CN), Institute of Cardiology (CO), Hospital de Cruces (ES), Mayo Clinic in Florida (US), Azienda Ospedale - Università Padova (IT), Beijing Friendship Hospital (CN), Istituti di Ricovero e Cura a Carattere Scientifico (IT), Viet Duc Hospital (VN), Fondazione IRCCS Istituto Nazionale dei Tumori (IT), Tongji Hospital (CN), Austin Health (AU), Azienda Ospedaliera Universitaria Pisana (IT), Baylor Scott & White All Saints Medical Center (US), Erasmus MC Transplant Institute (NL), Indiana University Indianapolis (US), Azienda sanitaria universitaria Friuli Centrale (IT), Huazhong University of Science and Technology (CN), Chiang Mai University (TH), Universidade Federal do Paraná (BR), Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione (IT), University of Milano-Bicocca (IT), Amrita Vishwa Vidyapeetham (IN), Sapienza University of Rome (IT), The University of Texas Southwestern Medical Center (US), University of Lübeck (DE), University of Bologna (IT)
Ministero della Salute
Good health and well-being
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Organ Transplantation Techniques and Outcomes
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