Abstract
Orthotopic liver transplantation (OLT) is now accepted as definitive therapy for a wide variety of irreversible acute and chronic liver diseases.104 Human OLT was first attempted in 1963, but results were poor until the early 1980s, when the 1-year survival rate increased from approximately 30% to more than 60%.221 Refinements in organ preservation, more effective and safer immunosuppressive therapy (i.e., cyclosporine), and improvements in surgical technique and perioperative care have contributed to a remarkable increase in survival. Survival rates have continued to improve, with rates greater than 85% at 1 year and greater than 70% at 5 years in many centers. The dramatic growth of liver transplantation over the past decade was facilitated by a National Institutes of Health Consensus Development Conference in 1983, which concluded that liver transplantation should no longer be considered an experimental procedure, adding that it was “a therapeutic modality for end-stage liver disease that deserves broader application.”151 Since that first Consensus Conference in 1983, more than 20,000 patients worldwide have undergone OLT. The number of patients surviving more than 5 or even 10 years is growing rapidly.18
At present, more than 3000 liver transplantations in over 100 centers are performed each year in the United States. Up to 10,000 candidates, however, could benefit from OLT each year, and, as a result, the disparity between the number of available cadaveric donors and candidates requiring a liver transplant continues to grow.26 Thus, the transplant community's challenges include maximizing the use of every donor liver, not only expanding the suitability criteria for donor livers (i.e., use of older donor livers), but also continuing efforts to increase organ donation, perfecting and expanding novel techniques such as split-liver187 and living-related transplantation,103 developing modalities that may delay the need for transplantation (i.e., transjugular intrahepatic portosystemic shunts [TIPS]), and carefully examining the long-term outcome of recipients undergoing liver transplantation.116,216 The United Network for Organ Sharing (UNOS) dictates urgency as the single most important selection factor. It is clear, however, the quality of life after liver transplantation, the incidence and severity of recurrence of the underlying disease, and survival should be equally important factors in patient selection.250 For example, patients transplanted with chronic hepatitis B as their primary liver disease before the introduction of effective immunoprophylaxis to prevent recurrence had a significantly lower 1- and 5-year graft survival compared with patients with chronic cholestatic liver disease, such as primary biliary cirrhosis (PBC) or primary sclerosing cholangitis (PSC).250 As increasing numbers of transplant candidates on the UNOS waiting list die (the number has increased by 50% between 1989 and 1992), it becomes increasingly difficult to justify transplantation for certain diseases with a poor outcome post-OLT owing to disease recurrence.3
Judicious selection and timing of patient referral for transplant evaluation remain critical to achieving good patient outcomes. Patients with severely decompensated liver disease pretransplantation have a higher risk of perioperative mortality. Thus, patients should be referred for OLT evaluation before they become debilitated owing to liver disease and before the development of recurrent life-threatening complications, such as spontaneous bacterial peritonitis or variceal hemorrhage.
