Use of high-risk liver donors for urgent and elective liver transplantation

Abstract

ORGAN SHORTAGE is now the main factor limiting the growth of orthotopic liver transplantation (OLT). There is an increasing gap between need and transplantation in both the United States and in Europe. Moreover, the number of patients who benefit from this procedure has been broadened, resulting in patients who are less ill. To assure the best possible outcome, the pioneering transplant clinicians applied strict criteria when selecting potential donors, based on arbitrary medical grounds. This policy has resulted in the refusal of many potential donors, while deaths on waiting lists continue to constitute an unfortunate scenario. The use of high-risk or marginal donors is the most viable short-term means to boost the organ supply. Expansion of the liver donor pool calls for new organselection criteria. The use of older donor livers has been the most “liberalized” criterion. Other criteria such as longer hypotension and cold ischemia times, high-dose inotropic drug use, ICU stay, and morbid obesity status have recently been expanded. We have also reported the influence of unstable and hypernatremic liver donors on graft and patient survival. However, the relationship between these criteria and recipient status is poorly understood. Networks of organ-sharing worldwide aim to providing equity and efficacy of organ distribution, giving highest priority to patients most urgently in need. One major issue in organ allocation concerns which of the following options would contribute most to saving lives and improving longterm survival: (1) allocating organs according to sequence on the waiting list; (2) avoiding the confluence of risk factors from recipients and those from donors; or (3) reserving higher risk organs for higher risk recipients.