Biliary complications continue to be the Achilles heel of orthotopic liver transplantation. These include ischemic-type biliary lesions that mostly affect liver allografts donated after cardiac and lead to increased morbidity and retransplantation in patients undergoing liver transplantation. Although this entity has been recognized for >20 years, the true mechanism of injury remains unknown. Identification of the pathogenesis will likely lead to the increased use of grafts donated after cardiac death and thus increase the organ pool. This update reviews the risk factors that have been implicated in ischemic-type biliary lesion formation, potential therapies, and mechanisms that might lead to their formation.
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