Issues affecting liver transplantation

The process of liver transplantation is a complex intermixture of patient disease, timing of transplantation, and quality of organ eventually received. Because of the shortage of cadaveric organs, efforts to expand the pool of donors have led to the use of organs from donors of marginal quality. Recent data suggest that aggressive management of all brain-dead donors, but especially marginal donors, improves the likelihood that their organs will be acceptable and function adequately. Pulmonary pathology, especially portopulmonary hypertension, is especially problematic during the perioperative period. Recent recommendations are discussed. The timing/waiting time of liver transplantation has been a contentious issue from the beginning. While most would like to transplant patients who are sufficiently sick but not too sick for a successful result, past scoring systems have often allowed time on the waiting list to trump acuity of patient disease. The recently adopted model for endstage liver disease and pediatric endstage liver disease systems have dramatically changed the way recipients are listed and medically followed, and when they receive an organ. Each of these areas directly and indirectly affects perioperative care.