Hot topics in liver transplantation: Organ allocation – extended criteria donor – living donor liver transplantation

Abstract

Liver transplantation has become the mainstay for the treatment of end-stage liver disease, hepatocellular cancer and some metabolic disorders. Its main drawback, though, is the disparity between the number of donors and the patients needing a liver graft. In this review we will discuss the recent changes regarding organ allocation, extended donor criteria, living donor liver transplantation and potential room for improvement. The gap between the number of donors and patients needing a liver graft forced the transplant community to introduce an objective model such as the modified model for end-stage liver disease (MELD) in order to obtain a transparent and fair organ allocation system. The use of extended criteria donor livers such as organs from older donors or steatotic grafts is one possibility to reduce the gap between patients on the waiting list and available donors. Finally, living donor liver transplantation has become a standard procedure in specialized centers as another possibility to reduce the donor shortage. Recent data clearly indicate that center experience is of major importance in achieving good results. Great progress has been made in recent years. However, further research is needed to improve results in the future.

Extended criteria donors in liver transplantation Part I: reviewing the impact of determining factors

“…The age is a relevant factor [23,24], that has steadily increased: in 1994 only 20% of donors were 50 years or older, and it has doubled till today in the US [13]. The annual number of donors aged >65 years has been increased 14-fold between 1991 to 2001 in the UNOS database, and the rate of donors >60 years increased from 2% to 20% in the ELTR [3].…”

“…The Paris consensus meeting reported that there is no absolute limit of donor age for liver transplantation, however it is strongly recommended not to allocate elderly donors to HCV-infected recipients [7], since a donor age between 61-70 gives a relative risk 1,53 (Odds Ratio) for HCV recurrence, while it is 1.65 over 70 years of age [13]. Others did not confirmed donor gender as a risk factor [13], and successful utilization of liver graft from donors older than 80 years of age are published [24]. In contrast Serrano et al reported an increased risk of non-anastomotic biliary stricture in case …”

“…A prerequisite to better understand the impact of graft steatosis on outcome will be to obtain routine donor liver biopsy at the time of harvest [13].…”

Initial Poor Graft Dysfunction and Primary Graft Non-Function After Orthotopic Liver Transplantation

“…An extremely BMI is defined as a BMI < 18.5 kg/m 2 or a BMI > 40 kg/m 2 . In a study of the UNOS database, which reviewed 73,538 adult liver transplants, there was no significant impact of underweight or very severely obese on the occurrence of PGNF though these patients experienced significantly higher rates of morbidity and mortality compared with recipients with intermediate BMI range (Dick et al, 2009 (Müllhaupt et al, 2008). Definition for ECD by the suggestion of Chung et al includes age > 65 years, macrovesicular steatosis > 40%, serum sodium > 155 mmol/L, positive serological data, carcinoma outside the liver, DCD, and split-graft liver transplantation (Chung et al, 2010).…”

Who should get a liver graft?

“…This, however, is not the case, and it has been shown in numerous studies that the risk of graft failure and recipient mortality differs depending on the quality of the donor liver [24][25][26][27]. Donor quality represents a continuum of risk rather than a dichotomous diversion between ''good" or ''bad".…”