Due to medical and surgical progress,
liver transplantation (LT) is is nowadays a routine treatment for terminal
liver failure and hepatic
malignancies. However, in recent years there has been a change in the indications for LT. Especially in western industrialized countries, the use of LT for chronic hepatis B and
hepatitis C cirrhosis is continuously decreasing since the introduction of effective
antiviral drugs.
Liver cirrhosis due to non-
alcoholic steatohepatitis (NASH),
alcoholic liver disease and
hepatocellular carcinoma (HCC) in
cirrhosis are now among the leading indications for LT. Due to tremendous progress in oncology, immunology, and technical aspects, multidisciplinary
cancer treatment increasingly includes LT for non-HCC hepatobiliary
malignancies. Excellent 5-year survival rates of 75 to 80% can now be achieved after LT. However, in patients with
liver cirrhosis, the implementation of a 'sickest first' principle for liver allocation has led to an increasing number of
critically ill patients undergoing
liver transplantation. This results in an increased morbidity and mortality after
liver transplantation. Moreover, donor characteristics have markedly shifted to less ideal grafts due to an increasing shortage of donor organs in many countries. In this context, normothermic machine perfusion with oxygenated blood components using pulsatile flow has been shown to reduce liver damage despite a prolonged preservation time and might be able to provide viability testing for otherwise discarded organs. With favorable donor and recipient conditions, excellent long-term results can be obtained with a 10-year survival rate of close to 70%. However, in patients with a high MELD score (>30), survival rates markedly decrease by 12-18%. Future research should focus on optimization of organ allocation, optimization of immunosuppression including tolerance induction, and on increasing the donor organ pool to further improve and the numbers of successful LT.