Comparative landscape of small RNAs in tissue and liquid biopsies for liver transplant outcomes

Background: Ischemia-reperfusion injury (IRI) is an inevitable consequence of liver transplantation, arising during donor organ procurement and reoxygenation. Severe IRI is a leading contributor to early allograft dysfunction (EAD), a post-transplant complication associated with reduced graft survival. Current postoperative biomarkers provide limited time for intervention, highlighting a need to identify preoperative biomarkers of IRI. Meanwhile, tRNA fragments (tRFs) have emerged as novel biomarkers in various diseases but remain unexplored in the context of liver transplant. Results: We performed small RNA sequencing on 96 paired donor liver biopsies from 48 patients to investigate IRI-associated transcript changes. In parallel, 161 donor liver perfusates were analyzed as a non-invasive surrogate for tissue. Across samples, microRNAs (miRNAs) and tRFs were the most abundant. Perfusate expression strongly correlated with biopsies, supporting their value as a non-invasive source of small RNAs. Comparison between post-reperfusion and pre-implantation biopsies revealed that IRI reprogrammed tRF expression. Stratification by clinical outcome showed that patients who developed EAD exhibited specific small RNA signatures in both biopsy and perfusate. Receiver operating characteristic (ROC) analysis revealed a miRNA-based model that achieved an AUC of 0.772, outperforming donor risk index alone (AUC = 0.665), representing a 10.7 % increase in discriminative capacity. Conclusions: These results are the first to establish tRFs as IRI-responsive biomolecules abundant in both donor liver tissue and non-invasive perfusate. In particular, various small RNAs emerged as promising candidate biomarkers for early detection of EAD. These results lay the foundation to further investigate the prognostic utility of tRFs/miRNAs in liver transplantation.