Liver transplantation

Abstract

Over the last three decades liver transplantation has become an established therapy for patients suffering from end-stage liver disease. In 1955, Welch reported the first attempt at experimental heterotopic grafting of a liver in a dog [1]. The first known experimental orthotopic liver transplantation (OLT) was reported by Cannon in 1956 at the University of California [2]. In 1963, Starzl performed a human-to-human OLT in a 3 year old child with congenital biliary atresia who died intraoperatively [3]. The following 2 transplant recipients lived for 22 days and 1 week, respectively [3]. In 1967, Starzl succesfully transplanted several patients [4]. The evolution of liver transplantation was paralleled by several major advances in the early 1980s such as the improvement of immunosuppressant regimens [5], organ preservation [6], surgical techniques [7] as well as improvement of post-operative management with reduction of infectious complications and prevention of disease recurrence. Before the introduction of cyclosporin A (CSA) in the early 1980s, 5-year survival after OLT was about 20% [8]. The advent of CSA resulted in a dramatic reduction in the incidence of acute rejection, thus leading to widespread use throughout the 1980s, and 1990s. During the 1990s, tacrolimus (TAC) emerged as the mainstay immunosuppressive agent, with or without corticosteroides, in many transplant centers in the United States. New concepts in immunosuppressive therapy and improvement in patient management, operative techniques, and organ preservation have achieved 1 year and 5 year survival rates of 80% to 90% and 60% to 80%, respectively [9]. Today most common transplant indications are endstage liver diseases with cirrhosis caused by viral hepatitis and alcoholic disease. Other common indications are metabolic or genetic disorders of the liver as well as acute liver failure. Also in selected cases of liver malignancies, liver transplantation is the therapy of choice in a continually increasing list of indications [10-11]. Approximately 50-70 out of 100.000 inhabitants are in need of liver transplantation. The limited pool of cadaver donor organs prompted in the development of split-liver (SLT) techniques and living-donor liver transplantation (LDLT) as innovative techniques in adult liver transplantation [12-13]. Long-term patient and graft survival rates for these advanced techniques are comparable to those for whole organ transplantation procedures [14]. While split liver grafts are technically demanding, the use of livingdonor-liver grafts incurs additional ethical problems. The benefits of living donation include decreased rates of graft dysfunction (lack of trauma and ischemia to the graft before retrieval), the ability to schedule an elective operation and the reduction of mortality and morbidity while waiting for a suitable graft. The main consideration is the potential risk for the donor and the difficulty of eliminating coercion in this life-saving situation. Thus, stringent medical and psychological criteria must form the basis of the selection criteria. © 2006 Springer-Verlag/Wien.