Introduction: Pushing the boundaries in liver transplantation

Abstract

Liver disease is a major cause of mortality worldwide and liver transplantation remains the most effective therapeutic modality for the treatment of decompensated cirrhosis, acute liver failure, and small HCC. The field of liver transplantation has dramatically evolved over the past 50 years from an experimental endeavor to a highly successful life-saving procedure for patients with sustained irreversible liver injury. Advances in surgical technique, perioperative and postoperative management, and immunosuppression provided for increased application of liver transplantation with excellent 1-year survival rates reaching 90%. However, the ubiquity of liver transplantation has created its own unique challenges including determining patient eligibility and the shortage of deceased donor organs. The allocation of organs is predicated upon the fine balance between utility and justice. Applying these principles shapes public policy related to patient selection and organ allocation. Candidate selection is increasingly important when optimizing the selection of the recipients who would derive the most benefit from liver transplantation given the scarcity of organs. The trend toward viable organ donation scarcity continues while there has been exponential growth in the number of transplant candidates over the same period of time. The ever-expanding wait list registry reflects the rising tide of NAFLD, specifically the more advanced form, NASH, and alcohol-associated liver disease. Furthermore, ground-breaking success in liver transplantation for hepatic and biliary malignancies paved a path for reaching even more candidates. As perioperative and postoperative management continues to improve, those being considered for liver transplantation have more comorbidities including obesity, diabetes mellitus, and cardiovascular disease. Despite the growing number of potential recipients, the pool of donor organs is failing to keep pace and poses a highly challenging global problem. The mismatch between supply and demand requires the transplant community to ration already limited liver allografts and continually reassess allocation policies based on need versus survival benefit. Efforts were made to expand the pool of potential donors, including utilization of extended criteria donors and donation after cardiac death. Nevertheless, there remains a scarcity of organs. In recent years, the increasing application of living donor liver transplantation has helped mitigate the organ shortage. But this practice is still fraught with contentious elements that have hindered extensive implementation. We are in a new era of liver transplantation. As a transplant community, we must pioneer not only the rising obesity and alcohol epidemics but also successfully manage our aging population while minimizing waitlist mortality. The need for more innovative practices is upon us. In this Clinical Liver Disease series, “Pushing the Boundaries in Liver Transplantation,” the authors review select challenging indications for liver transplantation, the currently accepted practices, and innovative ways that endeavor to expand the reach of liver transplantation.