Optimization of the use of the cadaveric liver

Abstract

THE AVAILABILITY of organs for transplantation is one of the most critical limiting factors in the expansion of liver transplantation (LT) activities worldwide. In our region of Eurotransplant (ET), well-established organ procurement organization (OPO) legislation would have a major impact on organ donation. In countries with favorable legislation, including presumed consent (Austria, Belgium), the rate of liver donation is 14.7 per million population (pmp), almost double that of Holland and Germany, which have rates of 8.6 and 6.5 pmp, respectively. In Asia the situation even less encouraging, because the structure of the health-care systems and the sociocultural, economic, and legislative conditions represent a major obstacle to cadaveric organ donation and to the development of transplantation. Optimizing the use of cadaveric donors means continuing to strive to increase the supply of cadaveric livers, and to apply strict rules for the efficient use and proper administration of this very precious resource. Political and social attitudes must maintain an open mind in regard to organ donation. In the hands of health-care professionals the most logical way to increase the supply of organs is with educational programs or by rational institutional approaches, as demonstrated by the model implemented in Spain. The demand for LT (ie, the large number of patients on waiting lists) continues to heavily outweigh the “offer,” or amount, of organs available for transplantation. If the first measures fail, an alternative solution could be to regulate and limit the number of LTs; however, this would further complicate the already complex and problematic waiting-list selection process. Exclusion of more patients from selection or even more strict indication criteria, allowing only the “good candidates” to be transplanted, would be an undesirable result. High risk patients, like High Urgencies, retransplantation, or critical patient categories like very old or young, hepatitis, some tumor patients would have no chance of access to life-saving therapy. The attitude of our group has always been the opposite— that is, accepting the high-risk candidates that routinely present in large centers, and instead seeking new solutions to increase the donor organ pool. This has resulted in the development and employment of segmental liver transplantation. In 1984, the pioneering work of Broelsch, Pichlmayr, and Bismuth led to the development of reduced liver transplantation (RLT) in an attempt to reduce pediatric pretransplant mortality. Since then, RLT has became routine in pediatric L T. RLT, nevertheless, is not an efficient LT modality, because part of the liver is wasted because it has to be discarded. As a result, in our program, RLT has a number restriction parameters: very small-sized recipients; unilaterally traumatized donor livers; lower quality livers; livers not amenable to splitting; and emergency situations. More efficient organ use techniques have been in existence since living-related (LRT) and split-liver transplantation (SLT) came into being. LRT is nowadays more accepted from an ethical standpoint. After its introduction into clinical practice by Broelsch et al it found fertile terrain in Asia, due to the scarcity of cadaveric donors. It is still the most frequently used technique in the majority of Asian LT programs. We continue to use LRT, and we propose it as a standard option to parents of pediatric LT recipients. LRT is also very important in the economics of a LT program with a preponderance of cadaveric LTs. The good results and the possibility of transplanting patients in an elective condition expedites the dynamics of the waiting list. This in turn provides a chance for other patients to be transplanted earlier, in better conditions, thus helping to avoid posttransplant morbidity and retransplants. Ultimately, LRT increases the chance of survival of all patients, particularly those awaiting a cadaveric organ. The use of LRT in adults is presently under investigation as a way to decrease waiting-list mortality in larger patients. Most of the experience and innovation in this regard have come from Asian LT programs. LRT was the initial response of our program to the relatively difficult conditions imposed by the allocation rules of our OPO to a developing program. Since 1993, we were further forced to employ SLT, a technique that allows transplantation of two patients with a single cadaveric organ liver, due to the high incidence of patients dying while on