Liver transplantations in Finland over 40 years: evolution and recent trends.

Background: Liver transplantation (LT) is a life-saving treatment for patients with end-stage liver disease, with significant improvements in short-term survival over the decades. However, long-term survival and trends in LT indications and outcomes remain areas of active research. This registry-based study evaluates 40 years of LT in Finland, assessing patient and graft survival, retransplantation rates, changing recipient and donor demographics, indications and benchmarking outcomes against international standards. Methods: Data were extracted from the nationwide Finnish LT registry, covering all LTs performed in Finland between 1982 and 2024. Survival analyses were estimated using the Kaplan-Meier methodology and retransplantation rates were assessed using the cumulative incidence function. Benchmark cases were defined by international criteria. Results: A total of 1763 LTs were performed, with a mean recipient age of 46 years. The most common aetiologies were alcohol-related liver disease (19%) and primary sclerosing cholangitis (PSC; 16%). Over time, recipient and donor age, body mass index and prevalence of diabetes increased. One-year patient survival improved from 83% in the 1980s to 96% in 2020-2024, with the overall 5-year, 10-year, 20-year and 30-year patient survival being 83%, 73%, 53% and 28%, respectively. The retransplantation rate was 13% at 30 years overall and 28% in PSC. Benchmark cases had one-year patient and graft survival rates of 97% and 96%, respectively. Acute rejection rates declined from 62% during 1980-1989 to 19% during 2022-2023. Post-transplant kidney-replacement therapy peaked at 26% in 2010-2021, thereafter decreasing to 8% after the year 2022. Conclusion: The Finnish LT programme demonstrates sustained improvements in short- and mid-term survival, with evolving indications and recipient and donor demographics. Benchmark analyses confirm high-quality outcomes. Continued efforts are needed to optimise long-term survival and reduce the need for retransplantation, especially in PSC.