Liver transplantation: current status, complications and prevention

The results of liver transplantation have improved dramatically over the past 15 years and this has produced a marked increase in demand for the procedure. Perioperative problems due to haemorrhage have been largely solved by surgical experience, the use of veno-venous bypass and careful control of coagulation parameters. Developments in graft preservation with the introduction of University of Wisconsin Solution led to improved early graft function as well as allowing day-time surgery. The number of technical failures and subsequent need for retransplantation have been markedly reduced: many units have almost eradicated failure due to hepatic artery thrombosis, although biliary complications still occur, which can often be managed non-operatively with the help of skilled radiologists using percutaneous techniques. Despite advances in immunosuppression, rejection remains a significant problem with many patients requiring additional high dose therapy with inherent risks of infective complications. In addition to conventional bacterial infections, opportunistic organisms including Pneumocystis carinii, cytomegalovirus and fungi pose a particular problem. Specific protocols for prophylaxis against opportunistic infection have been developed which have significantly reduced morbidity and mortality. Current survival after liver replacement is 80-90% at 12 months and, apart from patients grafted for malignancy, the survival curves are relatively flat. The next decade is likely to see refinements in selection and timing to reduce morbidity and costs of liver transplantation. Future developments include the use of xenografts which could provide a limitless number of donor livers and allow liver replacement to be performed as an elective service.