[Liver transplantation: deciding between need and donor allocation]

Liver transplantation represents an established therapeutic option for advanced liver diseases. The spectrum of indications encompasses infectious, vascular, immunological and toxic diseases leading to cirrhosis, in addition to genetic, metabolic, developmental and selected neoplastic diseases. On the one hand the timing of liver transplantation is determined by the disease specific course until decompensation and the disease manifestation involving bile ducts or hepatocytes. On the other hand it represents gene therapy of diseases affecting the liver, or entities where the genetic defect lies in the liver. In view of the shortage of donor organs and an increasing requirement for liver transplantation the challenge is to provide an effective and fair waiting list management. Reform of allocation criteria has put the focus on urgency. This in turn leads to an increase in waiting time for elective transplantations, inclusion of end stage diseases and critical patients, higher perioperative costs, problems with the matching of organs and the problem of an effective use of organ resources. Fair allocation and medical necessity therefore define the challenges surrounding the indications for liver transplantation.