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What are the biggest challenges in the field of liver transplantation?

In this article we highlight some of the challenges faced by Hepatologists as they look to the future of liver transplantation.
A selection of medical staff
© University of Birmingham
In Week 1 and Week 2 we discussed the major diseases that cause patients to need a transplant and also heard about the surgery itself. We considered issues like transplant rejection that may impact a recipient’s survival after the operation. For the rest of this week, we will turn our attention to the future of liver transplantation and think about new scientific and medical advances that are in the pipeline. Before we do this, let’s remind ourselves of some of the challenges which should be overcome.
Liver transplantation is now considered a successful procedure, so many patients with end-stage liver disease will be listed for transplantation. This has led to our first major challenge.
There is a big gap between the number of organs available and the demand for transplant
This may be addressed by increasing use of DCD organs and also by trying to treat patients with specific liver diseases using methods other than transplantation. We will hear more about this later this week.
There are barriers to organ donation
Lack of specialist facilities and resources in some hospitals may mean that not all possible donor organs are being collected. Also, maintaining patients on life support purely to preserve an organ for donation is ethically complex. Similarly, in many parts of the world cultural beliefs may restrict the collection and use of cadaveric organs. Some countries such as Wales are changing their laws to try to encourage wider acceptance of organ donation.
Patients may die on the waiting list
There is some evidence that the models used to assess patients for transplant may not yet be perfect. For example, the use of systems such as UKELD scores may mean that whilst the sickest patients are transplanted soonest, paradoxically this may increase mortality risk for them and the other patients on the list who are still waiting. Thus, future assessment criteria may change to reflect competing needs of all patients on the waiting list.
Immunosupressive drugs can cause serious side effects in some patients
As well as causing side effects such as renal toxicity and hypertension, patients who take immunosuppressive drugs are at a higher risk of developing infection and cancer. Thus, future strategies may need to try to take advantage of the tolerogeneic nature of the liver and aim for use of minimal immunosuppression to maintain full immune responses to foreign antigens.
Disease recurrence can occur in some patients
Many diseases for which a transplant is necessary may recur in the new liver after the operation. Thus viral infection and autoimmune conditions can recur, and in some cases the new liver may develop fibrosis much faster than the patient’s original liver. Future management approaches will need to address this issue as some patients may end up having more than one life-saving transplant.
Have you experienced any of the issues highlighted above? Can you suggest any other ‘future challenges’ based on your experiences? Share your thoughts in the comments below.
© University of Birmingham
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Liver Transplant: the Ins and Outs

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