Expert consensus on the use of immune checkpoint inhibitors in the liver transplant setting: Guidance from the Liver Transplant Committee of the Italian Association for the Study of the Liver (AISF)

Immune checkpoint inhibitors (ICIs) have transformed the treatment landscape for advanced hepatocellular carcinoma, increasing opportunities for downstaging and conversion to liver transplantation (LT) eligibility. However, the use of ICIs in the LT setting raises challenges regarding the optimal timing and duration of treatment, safety, and assessment of tumor response. Moreover, the use of ICIs for hepatocellular carcinoma recurrence after LT is associated with an increased risk of acute cellular rejection and potential graft failure. This article presents expert consensus guidance developed by a panel of 9 LT experts from the Permanent Transplant Commission of the Italian Association for the Study of the Liver (AISF) and conducted based on the modified Delphi method. Fifteen clinically relevant questions were developed through an iterative process involving structured literature review, clinical experience, and identification of practice gaps. Each question was assigned to 1 to 2 panel members with topic-specific expertise, who were responsible for performing a targeted literature review, drafting the evidence summary, and proposing a recommendation. Statements receiving >75% agreement in 2 rounds of voting were considered approved and presented in this article. Until prospective data become available, this guidance aims to assist clinical decision making within the evolving field of LT oncology.