Liver transplantation.
Authors: R Y Calne
Journal: Gut (1968)

Liver transplantationRecent advances in renal transplantation permit excellent therapy in many patients and surgeons are now turning to the possibility of transplantation of other organs.The clinical need for liver transplantation in man is difficult to assess and it varies in different parts of the world.In the United Kingdom fatal liver disease accounts for perhaps 200 to 300 cases under the age of 50 each year in a population of 50 million, and represents 10% of deaths from irreversible renal disease.The incidence increases rapidly after the fifth decade.'Fatal liver disease, however, is far commoner in certain other countries, particularly the Far East, where carcinoma of the liver is one of the main malignant causes of death.There are two categories of fatal liver disease in which transplantation can be considered, namely, progressive liver disease with cirrhosis and often portal hypertension and primary malignant tumours of the liver.This excludes a very large number of cases with secondary carcinomatous deposits of the liver.Both types of liver disease occur in adults and children and represent different problems from the point of view of liver transplantation.The prognosis of chronic progressive liver disease is exceedingly difficult to assess.Well compensated cirrhotics may be able to live a reasonable existence for many years, but they are liable to sudden catastrophic haemorrhage and porto-systemic encephalopathy.If the cirrhosis is due to alcohol then variation in alcohol intake can alter the prognosis even when the disease is well advanced.In contrast malignant disease of the liver usually progresses inexorably and rapidly to a fatal outcome.The liver may be transplanted orthotopically, that is to the normal anatomical site of the liver.This operation obviously requires preliminary hepatectomy of the recipient before transplantation.Alternatively, an additional liver can be inserted-'auxiliary' or 'heterotopic' transplantation.With a vital unpaired organ like the liver the only possible source of donors at the present time is human cadavers.Partial transplantation of the liver from a live volunteer donor is not considered to be surgically feasible since the risks involved to the donor would be excessive and the chances of obtaining a satisfactory surgical result in the recipient are poor.Live animal donors would be an ideal solution, removing all the difficulties of liver preservation and the problems involved in procuring organs from cadavers.It seems likely, however, that much research is still required before liver heterografts will be a clinical possibility.One of the greatest difficulties with liver transplantation, in contrast to renal transplantation, is the lack of comparable supportive measures for a patient with little or no hepatic function.Although exchange transfusion, ex-vivo perfusion through an animal or cadaver liver, or cross-circulation may provide temporary improvement, these three methods are all limited.The benefits they can offer are far inferior to those produced by recurrent haemodialysis in kidney disease.It is therefore attractive to consider auxiliary liver transplantation, since the patient's own residual liver function, 262on August 21, 2023 by guest.