Artificial intelligence and organ transplantation: challenges and expectations

Evolving Transplant Oncology: Evolving Criteria for Better Decision-Making

Transplant oncology integrates a wide variety of fields, such as surgery, oncology, and transplant medicine, intending to increase the range of studies and treatments for hepatobiliary cancers and other liver-related malignant lesions. Liver transplantation (LT) has proven to be an effective treatment for hepatocellular carcinoma. While the Milan criteria are still the gold standard, several new, more inclusive criteria have been proposed, and hepatocellular carcinoma has become a major indication for liver transplantation. The continuous evolution of diagnostic technologies supported this with higher image quality and more accurate staging. This review describes the current applications of transplant oncology in hepatocellular carcinoma, cholangiocarcinoma, neuroendocrine tumors, and liver metastatic disease from colorectal cancer and discusses the path that led to the development of transplant oncology as an organized approach to managing gastrointestinal malignancies through transplantation. More importantly, the significance of a multidisciplinary approach and criteria in the selection of suitable candidates are discussed. In addition, newer aspects of transplant oncology, such as immunotherapy, circulating tumor DNA (ctDNA), novel surgical techniques, and the utilization of artificial intelligence, are presented. Finally, the opportunities and challenges involved in the field's future, as well as the evolution of the criteria used over the years and insightful thoughts for the future of the criteria, are discussed.

The future of liver transplantation

Over the last 50 years, liver transplantation has evolved into a procedure routinely performed in many countries worldwide. Those able to access this therapy frequently experience a miraculous risk-benefit ratio, particularly if they face the imminently life-threatening disease. Over the decades, the success of liver transplantation, with dramatic improvements in early posttransplant survival, has aggressively driven demand. However, despite the emergence of living donors to augment deceased donors as a source of organs, supply has lagged far behind demand. As a result, rationing has been an unfortunate focus in recent decades. Recent shifts in the epidemiology of liver disease combined with transformative innovations in liver preservation suggest that the underlying premise of organ shortage may erode in the foreseeable future. The focus will sharpen on improving equitable access while mitigating constraints related to workforce training, infrastructure for organ recovery and rehabilitation, and their associated costs. Research efforts in liver preservation will undoubtedly blossom with the aim of optimizing both the timing and conditions of transplantation. Coupled with advances in genetic engineering, regenerative biology, and cellular therapies, the portfolio of innovation, both broad and deep, offers the promise that, in the future, liver transplantation will not only be broadly available to those in need but also represent a highly durable life-saving therapy.

Artificial intelligence and liver transplantation: looking inside the Pandora’s box

Artificial intelligence (AI) is the discipline of computer science dedicated to processing a large amount of throughput data and is based on algorithms that can rationalize increasingly complex tasks and ultimately reproduce human intelligence. It has been speculated for clinical uses in liver transplantation (LT) for several years, but its application remains incipient worldwide. Therefore, the recent advancements of digital and robotic tools in daily medical practice make the modern environment propitious to its proper implementation. Nevertheless, it is noteworthy that this technology has significant limitations: (i) its unconditional dependence on a pre-established reliable and extensive database; (ii) the potential impact on independent medical decision-making; and (iii) a major economic and environmental burden. So, despite its seducing and flawless simplicity features, AI emerges as a new “Pandora’s box” that should be carefully understood and used under the light of ethical principles to improve clinical outcomes, promote medical and para-medical working conditions, and increase patient safety and access to medical care. The present work aims to review literature data supporting AI implementation on this basis.

BOMS: blockchain-enabled organ matching system

This work proposes a Blockchain-enabled Organ Matching System (BOMS) designed to manage the process of matching, storing, and sharing information. Biological factors are incorporated into matching and the cross-matching process is implemented into the smart contracts. Privacy is guaranteed by using patient-associated blockchain addresses, without transmitting or using patient personal records in the matching process. The matching algorithm implemented as a smart contract is verifiable by any party. Clinical records, process updates, and matching results are also stored on the blockchain, providing tamper-resistance of recipient's records and the recipients' waiting queue. The system also is capable of handling cases in which there is a donor without an immediate compatible recipient. The system is implemented on the Ethereum blockchain and several scenarios were tested. The performance of the proposed system is compared to other existing organ donation systems, and ours outperformed any existing organ matching system built on blockchain. BOMS is tested to ascertain its compatibility with public, private, and consortium blockchain networks, checks for security vulnerabilities and cross-matching efficiency. The implementation codes are available online.

Exploring the variable importance in random forests under correlations: a general concept applied to donor organ quality in post-transplant survival

Random Forests are a powerful and frequently applied Machine Learning tool. The permutation variable importance (VIMP) has been proposed to improve the explainability of such a pure prediction model. It describes the expected increase in prediction error after randomly permuting a variable and disturbing its association with the outcome. However, VIMPs measure a variable's marginal influence only, that can make its interpretation difficult or even misleading. In the present work we address the general need for improving the explainability of prediction models by exploring VIMPs in the presence of correlated variables. In particular, we propose to use a variable's residual information for investigating if its permutation importance partially or totally originates from correlated predictors. Hypotheses tests are derived by a resampling algorithm that can further support results by providing test decisions and p-values. In simulation studies we show that the proposed test controls type I error rates. When applying the methods to a Random Forest analysis of post-transplant survival after kidney transplantation, the importance of kidney donor quality for predicting post-transplant survival is shown to be high. However, the transplant allocation policy introduces correlations with other well-known predictors, which raises the concern that the importance of kidney donor quality may simply originate from these predictors. By using the proposed method, this concern is addressed and it is demonstrated that kidney donor quality plays an important role in post-transplant survival, regardless of correlations with other predictors.

Artificial Intelligence Advances in Transplant Pathology

Transplant pathology plays a critical role in ensuring that transplanted organs function properly and the immune systems of the recipients do not reject them. To improve outcomes for transplant recipients, accurate diagnosis and timely treatment are essential. Recent advances in artificial intelligence (AI)-empowered digital pathology could help monitor allograft rejection and weaning of immunosuppressive drugs. To explore the role of AI in transplant pathology, we conducted a systematic search of electronic databases from January 2010 to April 2023. The PRISMA checklist was used as a guide for screening article titles, abstracts, and full texts, and we selected articles that met our inclusion criteria. Through this search, we identified 68 articles from multiple databases. After careful screening, only 14 articles were included based on title and abstract. Our review focuses on the AI approaches applied to four transplant organs: heart, lungs, liver, and kidneys. Specifically, we found that several deep learning-based AI models have been developed to analyze digital pathology slides of biopsy specimens from transplant organs. The use of AI models could improve clinicians' decision-making capabilities and reduce diagnostic variability. In conclusion, our review highlights the advancements and limitations of AI in transplant pathology. We believe that these AI technologies have the potential to significantly improve transplant outcomes and pave the way for future advancements in this field.

Artificial Intelligence and Robotics in Transplant Surgery: Advancements and Future Directions

This editorial explores the transformative impact of artificial intelligence (AI) and robotics in transplant surgery. By merging robotic precision with AI analysis, this integration enhances organ transplantation outcomes. AI algorithms scrutinize patient data, elevating organ compatibility during allocation. Robotic systems such as the da Vinci Surgical System enable intricate operations with reduced complications and faster recovery. AI-driven post-transplant monitoring identifies early rejection signs, while tailored immunosuppressive regimens enhance patient care. Future prospects encompass predictive organ availability, telemedicine-enabled expertise dissemination, bioengineered organs, and personalized immunosuppression. Ethical considerations include privacy and algorithmic bias. In striking a balance, responsible AI and robotics application can revolutionize transplant surgery, offering a brighter future for patients in need.

Kidney transplant in the next decade: Strategies, challenges and vision of the future

Although the results of kidney transplantation (KT) have improved substantially in recent years, a chronic and inexorable loss of grafts mainly due to the death of the patient and chronic dysfunction of the KT, continues to be observed. The objectives, thus, to optimize this situation in the next decade are fundamentally focused on minimizing the rate of kidney graft loss, improving patient survival, increasing the rate of organ procurement and its distribution, promoting research and training in health professionals and the development of scientific registries providing clinical and reliable information that allow us to optimize our clinical practice in the field of KT. With this perspective, this review will deep into: (1) strategies to avoid chronic dysfunction and graft loss in the medium and long term; (2) to prolong patient survival; (3) strategies to increase the donation, maintenance and allocation of organs; (4) promote clinical and basic research and training activity in KT; and (5) the analysis of the results in KT by optimizing and merging scientific registries.

The Importance of Animal Models in Biomedical Research: Current Insights and Applications

Animal research is considered a key element in advance of biomedical science. Although its use is controversial and raises ethical challenges, the contribution of animal models in medicine is essential for understanding the physiopathology and novel treatment alternatives for several animal and human diseases. Current pandemics’ pathology, such as the 2019 Coronavirus disease, has been studied in primate, rodent, and porcine models to recognize infection routes and develop therapeutic protocols. Worldwide issues such as diabetes, obesity, neurological disorders, pain, rehabilitation medicine, and surgical techniques require studying the process in different animal species before testing them on humans. Due to their relevance, this article aims to discuss the importance of animal models in diverse lines of biomedical research by analyzing the contributions of the various species utilized in science over the past five years about key topics concerning human and animal health.

Declined Organs for Liver Transplantation: A Right Decision or a Missed Opportunity for Patients with Hepatocellular Carcinoma?

BACKGROUND

Liver transplantation is the only promising treatment for end-stage liver disease and patients with hepatocellular carcinoma. However, too many organs are rejected for transplantation.

METHODS

We analyzed the factors involved in organ allocation in our transplant center and reviewed all livers that were declined for transplantation. Reasons for declining organs for transplantation were categorized as major extended donor criteria (maEDC), size mismatch and vascular problems, medical reasons and risk of disease transmission, and other reasons. The fate of the declined organs was analyzed.

RESULTS

1086 declined organs were offered 1200 times. A total of 31% of the livers were declined because of maEDC, 35.5% because of size mismatch and vascular problems, 15.8% because of medical reasons and risk of disease transmission, and 20.7% because of other reasons. A total of 40% of the declined organs were allocated and transplanted. A total of 50% of the organs were completely discarded, and significantly more of these grafts had maEDC than grafts that were eventually allocated (37.5% vs. 17.7%, p < 0.001).

CONCLUSION

Most organs were declined because of poor organ quality. Donor-recipient matching at time of allocation and organ preservation must be improved by allocating maEDC grafts using individualized algorithms that avoid high-risk donor-recipient combinations and unnecessary organ declination.

Monitoring of Serological, Cellular and Genomic Biomarkers in Transplantation, Computational Prediction Models and Role of Cell-Free DNA in Transplant Outcome

The process and evolution of an organ transplant procedure has evolved in terms of the prevention of immunological rejection with the improvement in the determination of immune response genes. These techniques include considering more important genes, more polymorphism detection, more refinement of the response motifs, as well as the analysis of epitopes and eplets, its capacity to fix complement, the PIRCHE algorithm and post-transplant monitoring with promising new biomarkers that surpass the classic serum markers such as creatine and other similar parameters of renal function. Among these new biomarkers, we analyze new serological, urine, cellular, genomic and transcriptomic biomarkers and computational prediction, with particular attention to the analysis of donor free circulating DNA as an optimal marker of kidney damage.

"Transplantomics" for predicting allograft rejection: real-life applications and new strategies from Network Medicine

Although decades of the reductionist approach achieved great milestones in optimizing the immunosuppression therapy, traditional clinical parameters still fail in predicting both acute and chronic (mainly) rejection events leading to higher rates across all solid organ transplants. To clarify the underlying immune-related cellular and molecular mechanisms, current biomedical research is increasingly focusing on "transplantomics" which relies on a huge quantity of big data deriving from genomics, transcriptomics, epigenomics, proteomics, and metabolomics platforms. The AlloMap (gene expression) and the AlloSure (donor-derived cell-free DNA) tests represent two successful examples of how omics and liquid biopsy can really improve the precision medicine of heart and kidney transplantation. One of the major challenges in translating big data in clinically useful biomarkers is the integration and interpretation of the different layers of omics datasets. Network Medicine offers advanced bioinformatic-molecular strategies which were widely used to integrate large omics datasets and clinical information in end-stage patients to prioritize potential biomarkers and drug targets. The application of network-oriented approaches to clarify the complex nature of graft rejection is still in its infancy. Here, we briefly discuss the real-life clinical applications derived from omics datasets as well as novel opportunities for establishing predictive tests in solid organ transplantation. Also, we provide an original "graft rejection interactome" and propose network-oriented strategies which can be useful to improve precision medicine of solid organ transplantation.

AI for Anglophone Africa: Unlocking its adoption for responsible solutions in academia-private sector

In recent years, AI technologies have become indispensable in social and industrial development, yielding revolutionary results in improving labor efficiency, lowering labor costs, optimizing human resource structure, and creating new job demands. To reap the full benefits of responsible AI solutions in Africa, it is critical to investigate existing challenges and propose strategies, policies, and frameworks for overcoming and eliminating them. As a result, this study investigated the challenges of adopting responsible AI solutions in the Academia-Private sectors for Anglophone Africa through literature reviews, expert interviews, and then proposes solutions and framework for the sustainable and successful adoption of responsible AI.

"Just" accuracy? Procedural fairness demands explainability in AI-based medical resource allocations

The increasing application of artificial intelligence (AI) to healthcare raises both hope and ethical concerns. Some advanced machine learning methods provide accurate clinical predictions at the expense of a significant lack of explainability. Alex John London has defended that accuracy is a more important value than explainability in AI medicine. In this article, we locate the trade-off between accurate performance and explainable algorithms in the context of distributive justice. We acknowledge that accuracy is cardinal from outcome-oriented justice because it helps to maximize patients' benefits and optimizes limited resources. However, we claim that the opaqueness of the algorithmic black box and its absence of explainability threatens core commitments of procedural fairness such as accountability, avoidance of bias, and transparency. To illustrate this, we discuss liver transplantation as a case of critical medical resources in which the lack of explainability in AI-based allocation algorithms is procedurally unfair. Finally, we provide a number of ethical recommendations for when considering the use of unexplainable algorithms in the distribution of health-related resources.

Role of artificial intelligence in the diagnosis and treatment of hepatocellular carcinoma

Artificial intelligence (AI) evolved many years ago, but it gained much advancement in recent years for its use in the medical domain. AI with its different subsidiaries, i.e. deep learning and machine learning, examine a large amount of data and performs an essential part in decision-making in addition to conquering the limitations related to human evaluation. Deep learning tries to imitate the functioning of the human brain. It utilizes much more data and intricate algorithms. Machine learning is AI based on automated learning. It utilizes earlier given data and uses algorithms to arrange and identify models. Globally, hepatocellular carcinoma is a major cause of illness and fatality. Although with substantial progress in the whole treatment strategy for hepatocellular carcinoma, managing it is still a major issue. AI in the area of gastroenterology, especially in hepatology, is particularly useful for various investigations of hepatocellular carcinoma because it is a commonly found tumor, and has specific radiological features that enable diagnostic procedures without the requirement of the histological study. However, interpreting and analyzing the resulting images is not always easy due to change of images throughout the disease process. Further, the prognostic process and response to the treatment process could be influenced by numerous components. Currently, AI is utilized in order to diagnose, curative and prediction goals. Future investigations are essential to prevent likely bias, which might subsequently influence the analysis of images and therefore restrict the consent and utilization of such models in medical practices. Moreover, experts are required to realize the real utility of such approaches, along with their associated potencies and constraints.

Artificial intelligence and liver transplantation: Looking for the best donor-recipient pairing

Decision-making based on artificial intelligence (AI) methodology is increasingly present in all areas of modern medicine. In recent years, models based on deep-learning have begun to be used in organ transplantation. Taking into account the huge number of factors and variables involved in donor-recipient (D-R) matching, AI models may be well suited to improve organ allocation. AI-based models should provide two solutions: complement decision-making with current metrics based on logistic regression and improve their predictability. Hundreds of classifiers could be used to address this problem. However, not all of them are really useful for D-R pairing. Basically, in the decision to assign a given donor to a candidate in waiting list, a multitude of variables are handled, including donor, recipient, logistic and perioperative variables. Of these last two, some of them can be inferred indirectly from the team's previous experience. Two groups of AI models have been used in the D-R matching: artificial neural networks (ANN) and random forest (RF). The former mimics the functional architecture of neurons, with input layers and output layers. The algorithms can be uni- or multi-objective. In general, ANNs can be used with large databases, where their generalizability is improved. However, they are models that are very sensitive to the quality of the databases and, in essence, they are black-box models in which all variables are important. Unfortunately, these models do not allow to know safely the weight of each variable. On the other hand, RF builds decision trees and works well with small cohorts. In addition, they can select top variables as with logistic regression. However, they are not useful with large databases, due to the extreme number of decision trees that they would generate, making them impractical. Both ANN and RF allow a successful donor allocation in over 80% of D-R pairing, a number much higher than that obtained with the best statistical metrics such as model for end-stage liver disease, balance of risk score, and survival outcomes following liver transplantation scores. Many barriers need to be overcome before these deep-learning-based models can be included for D-R matching. The main one of them is the resistance of the clinicians to leave their own decision to autonomous computational models.

Artificial Intelligence: Present and Future Potential for Solid Organ Transplantation

Artificial intelligence (AI) refers to computer algorithms used to complete tasks that usually require human intelligence. Typical examples include complex decision-making and- image or speech analysis. AI application in healthcare is rapidly evolving and it undoubtedly holds an enormous potential for the field of solid organ transplantation. In this review, we provide an overview of AI-based approaches in solid organ transplantation. Particularly, we identified four key areas of transplantation which could be facilitated by AI: organ allocation and donor-recipient pairing, transplant oncology, real-time immunosuppression regimes, and precision transplant pathology. The potential implementations are vast—from improved allocation algorithms, smart donor-recipient matching and dynamic adaptation of immunosuppression to automated analysis of transplant pathology. We are convinced that we are at the beginning of a new digital era in transplantation, and that AI has the potential to improve graft and patient survival. This manuscript provides a glimpse into how AI innovations could shape an exciting future for the transplantation community.

Advancements of Artificial Intelligence in Liver-Associated Diseases and Surgery

Background and Objectives: The advancement of artificial intelligence (AI) based technologies in medicine is progressing rapidly, but the majority of its real-world applications has not been implemented. The establishment of an accurate diagnosis with treatment has now transitioned into an artificial intelligence era, which has continued to provide an amplified understanding of liver cancer as a disease and helped to proceed better with the method of procurement. This article focuses on reviewing the AI in liver-associated diseases and surgical procedures, highlighting its development, use, and related counterparts. Materials and Methods: We searched for articles regarding AI in liver-related ailments and surgery, using the keywords (mentioned below) on PubMed, Google Scholar, Scopus, MEDLINE, and Cochrane Library. Choosing only the common studies suggested by these libraries, we segregated the matter based on disease. Finally, we compiled the essence of these articles under the various sub-headings. Results: After thorough review of articles, it was observed that there was a surge in the occurrence of liver-related surgeries, diagnoses, and treatments. Parallelly, advanced computer technologies governed by AI continue to prove their efficacy in the accurate screening, analysis, prediction, treatment, and recuperation of liver-related cases. Conclusions: The continual developments and high-order precision of AI is expanding its roots in all directions of applications. Despite being novel and lacking research, AI has shown its intrinsic worth for procedures in liver surgery while providing enhanced healing opportunities and personalized treatment for liver surgery patients.

Development and Application of Artificial Intelligence in Auxiliary TCM Diagnosis

As an emerging comprehensive discipline, artificial intelligence (AI) has been widely applied in various fields, including traditional Chinese medicine (TCM), a treasure of the Chinese nation. Realizing the organic combination of AI and TCM can promote the inheritance and development of TCM. The paper summarizes the development and application of AI in auxiliary TCM diagnosis, analyzes the bottleneck of artificial intelligence in the field of auxiliary TCM diagnosis at present, and proposes a possible future direction of its development.

Application of artificial intelligence in the diagnosis and treatment of hepatocellular carcinoma: A review

Although artificial intelligence (AI) was initially developed many years ago, it has experienced spectacular advances over the last 10 years for application in the field of medicine, and is now used for diagnostic, therapeutic and prognostic purposes in almost all fields. Its application in the area of hepatology is especially relevant for the study of hepatocellular carcinoma (HCC), as this is a very common tumor, with particular radiological characteristics that allow its diagnosis without the need for a histological study. However, the interpretation and analysis of the resulting images is not always easy, in addition to which the images vary during the course of the disease, and prognosis and treatment response can be conditioned by multiple factors. The vast amount of data available lend themselves to study and analysis by AI in its various branches, such as deep-learning (DL) and machine learning (ML), which play a fundamental role in decision-making as well as overcoming the constraints involved in human evaluation. ML is a form of AI based on automated learning from a set of previously provided data and training in algorithms to organize and recognize patterns. DL is a more extensive form of learning that attempts to simulate the working of the human brain, using a lot more data and more complex algorithms. This review specifies the type of AI used by the various authors. However, well-designed prospective studies are needed in order to avoid as far as possible any bias that may later affect the interpretability of the images and thereby limit the acceptance and application of these models in clinical practice. In addition, professionals now need to understand the true usefulness of these techniques, as well as their associated strengths and limitations.