Paul J Thuluvath Md Frcp and Cary H PattMD

Over the past 20 years, liver transplantation (LT) has evolved from an experimental procedure into a successful therapeutic option for patients with end-stage cirrhosis and those with hepatocellular cancer. The recent data from the United Network for Organ Sharing (UNOS) suggest that the 1-year and 5-year patient survival rate has reached close to 95% and 85%, respectively, in many transplantation centers. This remarkable survival rate is due to many factors, including improvements in surgical techniques, better immunosuppression, and, more importantly, better patient selection.

The improvement in outcome and better awareness has resulted in an increasing demand for LT in the United States over the past 10 years. However, the increase in organ demand has exceeded the supply resulting in longer waiting periods and higher death rates on the waiting lists. Approximately 10 to 20% of patients on the LT list die each year without receiving an organ in a timely fashion. Transplantation physicians have responded to this increased demand by developing several strategies, including the use of older donors, grafts from hepatitis C (HCV) positive donors or those with previous hepatitis B infection (positive HBV core immunoglobulin G antibody), grafts from nonheart-beating donors, domino transplantation (livers from patients with familial amyloid polyneuropathy transplanted into older recipients), split liver grafts, and, more recently, live donor liver transplantation (LDLT). There is also ongoing research in the field of xenotrans-plantation, artificial liver support systems, and hepatocyte transplantation. Advances in stem cell research may lead to further developments in this exciting field. However, currently there is an enormous disparity in supply and demand for liver grafts in this country. It has therefore become incumbent on the transplantation community to ration the available organs in a way that serves the best interest of the population as a whole.

When examining a potential candidate for LT, it is imperative to determine whether the recipient is going to benefit from the procedure immediately and in the long term. For instance a patient with Child A (Table 110-1) alcoholic cirrhosis without any major complication may have a comparable 5-year survival with or without transplantation. When the long term complications from immunosuppres-

sive drugs, costs, and the immediate surgical mortality are considered, this patient may be better off with conservative treatment. Similarly, a noncirrhotic patient with primary sclerosing cholangitis (PSC) may request preemptive transplantation because of the fear of developing a cholangio-carcinoma. This patient's lifetime risk of developing cancer is around 15%, and the mortality associated with LT in the first 5-years is around 20%. This patient should be educated about the expected outcome and discouraged from early transplantation until the patient develops serious complications or when prediction models (eg, Mayo Model) suggest that the patient's life expectancy is < 2 years without transplantation. Although mortality is an important consideration, the quality of life is equally important. Patients who may not fulfill all criteria for LT may be transplanted for intractable pruritis, fatigue, repeated bouts of cholan-gitis, and hepatic encephalopathy. In this review, we will discuss the process of selection and examination of potential transplantation recipients, and the issues surrounding transplantation waiting lists.

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