Controversies in liver transplantation

Abstract

The success of liver transplantation continues to grow at a rapid pace in improved survival, immunosuppression, and technical advancements. These improvements however have led to many more choices and decisions regarding selection of donors, recipients, and who should or should not be transplanted. Furthermore, the challenges facing the care providers of these patients transplanted have now evolved to management of recurrent disease, metabolic, and side effects of immunosuppression, rather than initial graft function. Set in this environment, controversies exist regarding what strategies will maximize outcomes. The American Association for the Study of Liver Disease/International Liver Transplantation Society Transplant Course gives us the opportunity to explore these controversial topics. Given the continued donor shortage, how can we optimally match recipients with the proper graft? This topic will be addressed in Session I (Which Recipients Should Receive Which Graft). Use of extended donors has broadened the donor pool, but what is the down side for the recipient? When should a split graft be considered in an adult? Should the allocation system be altered to match donor and recipients? And finally when should you not consider transplantation. Session II (Difficult Scenarios: Can We Transplant?) attends to the difficult scenarios in selection of recipients and those with co-morbid diseases that may impact long-term survival. Should alcoholic hepatitis be considered an indication for transplantation? What are the implications for donation rates? Under what circumstances should retransplantation be considered? Especially with the high rate of recurrent hepatitis C, should these patients be considered given a poorer reported outcome? Regarding the impact of renal failure or diabetes mellitus, should this be part of the recipient selection process? Most everyone agrees that acute liver failure patients should be given an opportunity for transplantation. Unfortunately many still die prior to transplantation; can we improve the management and selection criteria to give many more a chance? Hepatocellular carcinoma has risen as one of the leading indications for transplantation. Management prior to transplantation varies both in techniques and geographically. What is the optimal management and has it lead to improved survival post transplant? Lastly, in Session III (Challenging Problems in Long-Term Follow-Up) issues in management of common difficult clinical scenarios in the liver transplant patient will be addressed. Recurrent hepatitis C is universal with up to 30% losing their graft due to recurrent disease. What progress has been made in predicting who may be at high risk and what advancements in treatment have been made? Long-term use of immunosuppression may lead to renal dysfunction in up to 20% of patients. What strategies can be used to prevent this devastating complication? Furthermore, the lack of proper immunosuppression may lead to chronic rejection. How do we manage this condition? What are the outcomes? Two of the most common causes of death in long-term survivors are recurrent tumor and cardiovascular related deaths. How can we surveillance patients to reduce this risk? This course will provide a starting point to evaluate these controversial areas in liver transplantation. It is our intentions through interactions/discussions of faculty and course participants that advancement through further education will improve the care of liver transplant patients. On behalf of my course co-director, Dr. Andrew Burroughs, I thank the authors for the time required in the preparation/writing of the supplement and look forward to the talks and discussions.