An update on liver transplantation: A critical review.
Liver transplantation, although now a routine procedure, with defined indications and usually excellent outcomes, still has challenges. Donor shortage remains a key issue. Transplanted organs are not free of risk and may transmit cancer, infection, metabolic or autoimmune disease. Approaches to the donor shortage include use of organs from donors after circulatory death, from living donors and from those previously infected with Hepatitis B and C and even HIV for selected recipients. Normothermic regional and/or machine perfusion, whether static or pulsatile, normo- or hypothermic, are being explored and will be likely to have a major place in improving donation rates and outcomes. The main indications for liver replacement are alcoholic liver disease, HCV, non-alcoholic liver disease and liver cancer. Recent studies have shown that selected patients with severe alcoholic hepatitis may also benefit from liver transplant. The advent of new and highly effective treatments for HCV, whether given before or after transplant will have a major impact on outcomes. The role of transplantation for those with liver cell cancer continues to evolve as other interventions become more effective. Immunosuppression is usually required life-long and adherence remains a challenge, especially in adolescents. Immunosuppression with calcineurin inhibitors (primarily tacrolimus), antimetabolites (azathioprine or mycophenolate) and corticosteroids remains standard. Outcomes after transplantation are good but not normal in quality or quantity. Premature death may be due to increased risk of cardiovascular disease, de novo cancer, recurrent disease or late technical problems.
Liver Unit, Queen Elizabeth Hospital, Birmingham, B15 2TH, UK; Organ Donation and Transplantation, NHS Blood and Transplant, Fox Den Road, Bristol, BS34 8RR, UK. Electronic address: james.neuberger@nhsbt.nhs.uk.
James
J
Neuberger
D000293:Adolescent; D000305:Adrenal Cortex Hormones / Q000627:therapeutic use; D000328:Adult; D000963:Antimetabolites / Q000627:therapeutic use; D065095:Calcineurin Inhibitors / Q000627:therapeutic use; D046148:Donor Selection / Q000941:ethics; D006084:Graft Rejection / Q000517:prevention & control*; D006801:Humans; D007165:Immunosuppression Therapy; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D008107:Liver Diseases / Q000601:surgery*; D016031:Liver Transplantation; D008297:Male; D008875:Middle Aged; D010477:Perfusion / Q000379:methods; D012008:Recurrence; D012307:Risk Factors; D014019:Tissue Donors / Q000706:statistics & numerical data; D023001:Transplantation Tolerance; D016896:Treatment Outcome
D000305:Adrenal Cortex Hormones; D000963:Antimetabolites; D065095:Calcineurin Inhibitors; D007166:Immunosuppressive Agents
De novo cancer; Death; Donation after circulatory; Liver transplantation; Machine perfusion; Recurrent disease