The use of marginal grafts in liver transplantation

Because of the shortage of organ supplies, more transplant programs have begun to use marginal grafts in liver transplantation. A number of single-center experiences with marginal grafts have yielded encouraging results, but recent analyses using nationwide databases show that outcomes are inferior to results with normal whole-liver grafts. Use of marginal grafts is still acceptable, however, and plays an important role in expanding the donor pool and decreasing mortality on the waiting list. In the broadest terms, national data and single-center experiences show that: (1) there is no limit in donor age for liver transplantation, (2) appropriate selection of steatotic livers improves outcomes, (3) prolonged graft ischemia is a preventable factor, (4) livers from donors with hepatitis B or C virus can be safely transplanted, and (5) adequate prophylaxis prevents recurrence of hepatitis B without significant graft loss. In addition, grafts procured after cardiac death are another growing source of marginal grafts. Transmission of malignancy from donors is rare but life-threatening. Reduced-size grafts from living-donor or split-liver transplantation have shown similar outcomes to whole-liver transplantation. In this review, we will discuss the current status of the utility of these marginal grafts in liver transplantation.