Liver Transplantation (updated)

Liver transplantation is an emerging surgical procedure that has been widely accepted for treatment of End-stage acute and chronic liver diseases. It is now possible for patients to resume a normal life after the operation and the number of patients who have benefited from a liver transplant is increasing rapidly.Recent attention in liver transplantation has focused on equity in organ allocation and management of posttransplant complications. Adaption of the model for end-stage liver disease for liver allocation has been successful in implementing a system based on medical urgency rather than waiting time. Refinements are being studied in improving the prediction of mortality and improving transplant benefit by balancing pretransplant mortality and posttransplant survival. Emerging literature is examining expansion of the current criteria for transplantation of hepatocellular carcinoma and the role of neoadjuvant therapy. Chronic renal dysfunction after liver transplantation is a source of considerable morbidity. Nephron-sparing immunosuppression regimens are emerging with encouraging results. Hepatitis C virus infection is difficult to differentiate histologically from rejection, although newer markers are being developed. Antiviral and immunosuppressive strategies for reducing the severity of hepatitis C virus recurrence are discussed. Alcohol relapse is common after liver transplant in alcoholic liver disease patients and can lead to worse outcomes.A one-year survival of >80% after liver transplantation is now not uncommon. Most mortality occurs within the first 90 days. After one year, few patients or grafts are lost. Furthermore, 60% of patients return to gainful employment, demonstrating that this procedure is not only of benefit to the patient, but to society as a whole. Liver transplantation is less expensive than costs of caring for similar patients treated for complications of cirrhosis.Liver transplantation is challenged by a shortage of organs and a prolonged waiting list time. The large disparity between the number of available cadaver donor organs and recipients awaiting LT has created an ongoing debate regarding the appropriate selection criteria. The rationale of allocation systems utilizing the MELD score is to prioritize patients with severe liver dysfunction (”the sickest first”). Novel surgical techniques, including split cadaveric livers, LDLT, and broadening the donor criteria towards acceptance of marginal donors have been used as strategies in order to expand the donor pool.HCV has become the leading indication for cadaveric transplantation and LDLT in the United States, accounting for approximately 50% of all cases. Moreover, the number of patients with HCV cirrhosis continues to increase. There is ongoing research aiming to define host or viral factors that predict recurrence, the impact of immunosuppressive regimens, and the appropriate timepoint and dose for antiviral treatment.