Changing Trends in Liver Transplantation: Challenges and Solutions

Abstract

Despite improvements in postliver transplant outcomes through refinements in perioperative management and surgical techniques, several changing trends in liver transplantation have presented challenges. Mortality on the waitlist remains high. In the United States, Europe, and the United Kingdom, there is an increasing need for liver transplantation, primarily as a result of increased incidence of nonalcoholic steatohepatitis-related cirrhosis and cancer indications. Meanwhile, donor suitability has decreased, as donors are often older and have more comorbidities. Despite a mismatch between organ need and availability, many organs are discarded. Notwithstanding this, many solutions have been developed to overcome these challenges. Innovative techniques in allograft preservation, viability assessment, and reconditioning have allowed the use of suboptimal organs with adequate results. Refinements in surgical procedures, including live donor liver transplantations, have increased the organ pool and are decreasing the time and mortality on the waitlist. Despite many challenges, a similar number of solutions and prospects are on the horizon. This review seeks to explore the changing trends and challenges in liver transplantation and highlight possible solutions and future directions.

Intent‐to‐treat survival in liver transplantation has not improved in 3 decades due to donor shortage relative to waitlist growth

“…The wider acceptance of liver transplant as well as improved outcomes have allowed clinicians to list patients they would not have otherwise. 3 Additionally, the public burden of patients requiring transplant from diseases such as alcoholic liver disease, non-alcoholic steatohepatitis, and hepatocellular carcinoma has vastly increased over the past few decades. 4 To further contribute to this issue, successes in LT have increased the scope of this therapy, as patients with colorectal cancer metastasis and intrahepatic cholangiocarcinoma are now being considered for transplant.…”

“…On a similar note, increases in the transplant waitlist have indeed contributed to our observations. The wider acceptance of liver transplant as well as improved outcomes have allowed clinicians to list patients they would not have otherwise 3 . Additionally, the public burden of patients requiring transplant from diseases such as alcoholic liver disease, non‐alcoholic steatohepatitis, and hepatocellular carcinoma has vastly increased over the past few decades 4 .…”

Hyperspectral Imaging and Machine Perfusion in Solid Organ Transplantation: Clinical Potentials of Combining Two Novel Technologies

“…ECD liver grafts include categories such as advanced age, donation after circulatory death (DCD), hepatic steatosis, split liver grafts, cold ischemia time (CIT) >8-12 h, donors with increased risk of communicable disease transmission, those with active or past extrahepatic malignancy, hypernatraemia, and prolonged donor intensive care unit stay. ECD grafts are associated with an increased risk of early allograft dysfunction (EAD), delayed graft function (DGF), post-transplant complications, as well as higher rates for re-transplantations [8][9][10]. The key factor limiting the applicability of SCS in marginal grafts is given by the increased ischemia-reperfusion injury (IRI).…”

Patients with liver cirrhosis due to nonalcoholic steatohepatitis have lesser chances for liver transplantation

“…In contrast, alcohol‐related liver disease and nonalcoholic steatohepatitis (NASH) have increased due to lifestyle changes 9–11 . Regarding liver transplantations, a decrease in the number of cases of cirrhosis due to viral hepatitis and an increase in those due to alcohol‐related liver disease and NASH have been remarkably observed worldwide and also in Japan 12–14 …”