Status of Liver Transplantation
Authors: T E Starzl
Journal: New England Journal of Medicine (1968)

The number of medical centers that perform liver transplantations in the United States is small but growing. About a dozen centers have had experience in performing half a dozen or more liver transplants. Other centers with lesser experience are now beginning to spring up—in Phoenix, Jackson, Birmingham, Madison, Milwaukee, Boston, and Philadelphia. Some of these have attained outstanding results.

In Europe there are now almost a dozen medical centers as well that have experience with a half a dozen or more cases, and some other centers are beginning to develop—a second center in London, one in Oslo, in Helsinki, Innsbruck, Milan, Nice, and Rome. This extraordinary growth in the number of centers affords the possibility of establishing a European network similar to what we hope to develop in the United States.

As of September 1984, a total of 568 orthotopic liver transplantations had been carried out in the United States over the past 20 years. Almost half of the recipients are still alive. In 1983 alone, 145 liver transplants were performed, more than the number done the previous year. It is difficult to collect accurate survival figures from the various centers because of the differences in data collection and, perhaps more importantly, the differences in when these programs were begun.

Until the advent of cyclosporine in 1980, survival prospects for liver transplant patients were poor. In my own experience at the University of Colorado with an initial series of some 120 patients, two-thirds of the patients had died by the end of the first year. In a later series, the one-year survival rose to 50 percent, but a third series of patients had a one-year survival rate of about 40 percent. The limiting factor in these operations was that there was no margin of safety between toxicity and therapeutic levels of drugs in either the double-drug (azathioprine-prednisone) or triple-drug programs, the latter including antilymphocyte globulin.

The only really encouraging thing about that early dreary experience was that patients who lived for one or, especially, two years had an extraordinary chance of living for a long time afterward. About one in five of the patients who received liver transplants at the University of Colorado between 1963 and 1980 are still alive.

Cyclosporine has had a tremendous influence on survival. Better than two-thirds of patients treated with cyclosporine-steriod therapy since early 1980 survived for one year. Among patients I treated at the University of Colorado in 1980, survival was about 80 percent. In 1981, my first year at Pittsburgh, patient survival was almost as good. Then in 1982, one-year survival went down to 50 percent. This was the first year of truly mass production of liver transplantation operations. In one year, we treated 62 new patients plus some 20 who underwent re-transplantation.

It also was a year of intensive training of multiple teams to perform donor hepatectomies, and a time when several younger faculty members were gaining experience with the recipient operation. The payoff came in subsequent years in which the survival went up to its present rate of over 80 percent.