© Thieme Medical Publishers
23 February 2009 (online)
The last three decades have seen major advances in human liver transplantation. In the early days, the procedure was heroic: the short-term outcomes were very poor, and the resource utilization great; it is a tribute to all the early pioneers that they maintained their belief in the benefits of the procedure, often in the face of skepticism and disbelief, and persevered so that the procedure has now become a routine and successful procedure. It is, however, important to stress that the major advances made in the field of liver transplantation should not divert attention away from developing better treatments for people with liver disease so that the need for transplantation will be averted. Of course, transplantation has helped increase the understanding of some disease processes, and some treatments, which were developed for the transplant recipient, have been used in those with a native liver.
Although outcomes after transplantation have improved enormously, this has been largely incremental. Improvements not only in surgical techniques but also in recipient selection, donor management and selection, anesthesia, and postoperative care, as well as advances in understanding of the microbiology and better usage and a greater spectrum of immunosuppressive agents have all contributed to the success of the procedure. Also, medicine used in conjunction with transplantation has achieved its place as a specialty in its own right. This success has been reflected by the number of volumes of Seminars in Liver Disease that have been devoted to aspects of transplantation.
Most of the improvements in outcome are associated with a reduction in the early (1 year) mortality, but in those who have survived 1 year after transplantation, the rates of graft and patient loss have not greatly improved; major problems remain in nearly all areas of the transplantation process. Perhaps the most important is the shortfall of donors: selection criteria have focused primarily not on identifying who would benefit from the procedure but who would benefit enough. The shortfall has resulted in rationing of transplantation, with the associated moral, ethical, and, increasingly, legal issues. Although advances in surgical techniques have effectively increased the donor pool, the increase in donor organs has not kept pace with the increasing demand. The shortage of organs has encouraged surgeons to develop other approaches that make better use of organs that are available: splitting livers; reducing livers; and using livers from extended-criteria donors, from non–heart-beating donors, and from living donors have been of great benefit to the recipients. However, these techniques may hide the consequences of the increasing gap between supply and demand; furthermore, splitting livers may reduce the mortality of some patients on the waiting list (especially small adults and children) but may increase the morbidity and even mortality of the larger recipient. Other, more radical approaches such as the use of stem cells and xenografts remain for the future.
Among the many issues that need resolution are the need for better selection criteria; the need for allocation procedures that are transparent, open, objective, evidence-based, and just and equitable; and the need for better immunosuppression and, in time, effective regimes for inducing tolerance. The longer survival of recipients has changed the focus of the clinicians to address long-term issues, such as recurrence, renal and other organ damage, the risks of de novo cancer and infection, and other complications.
In planning this volume of Seminars, I have selected topics that are of importance for the longer term outcome of liver transplantation recipients and focused on those areas that have not been covered in recent previous issues of the journal. I am indebted to Paul Berk for his invitation to edit this volume and his timely and invaluable advice and to the contributors, all active and prominent in their fields, for contributing their expertise in a timely fashion.
James Neuberger, M.D.
The Liver Unit, Queen Elizabeth Hospital
Birmingham B15 2TH, United Kingdom