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Abstract Liv•r transplantation is now th•tr•atm•nt of choic•for childr•n and adults Immunosuppr•ssiv• th•rapv bas•d on c closporin•-pr•dnison• has tipp•d th•seal•• mer•than anv other factor , but improv•m•nts in organ proc:urem•nt techniques and in th•recipi•nt op•ration hav•also contribut•d • The •xt•nt to which patient ••l•ction can influence results of transplantation is hard to assess • As results hav• improved • th•r•is increased justif ication for avoidance of invasive and l•••eff•ctive alt•rnative treatments and for •arl i•r referral of pati•nts to th•transplant center It is also cl•ar that l iv•r transplantation is of l imited , if anv , benefit for most pati•nts with primarv h•patic mal ignanc v and for moribund patients in the terminal phase of advanced liver Liver transplantation is costlw t and th•suppl w of donor organs is l•••than the demand for them Should prioritization of candidat•s for l iv•r transplantation be based on the probabi litv of success or on th•urgencv of need? Except at extreme ends of th•spectrum it is diff icult now to quantif y risk • It was d ifficult for most patients to pred i ct the l ikel ihood of success based on perioperative assessment of risk • Manv patients who might seem to be at high risl<sotan excellent chance for survival in the hand of a sk il led transplant team Giv•n th•unc•rtainti•• of pr•d ictin9 outcom•b•••d on risk 1 w•continu•to ••l•ct pati.nts for liv•r transplant•tion bas•d on th•urg•ncy of n••d but with congnizanc• of tho•• •xtr•m• circumstanc•• in which transplantation would b• wast•ful and inappropriat• • This plac•• us und•r constant pr•s•ur•not to n•g l•ct th•provr•••ion of illn••• in pati•nt• who hav• accru•d months of waiting on th•candidat•l ist and •nabl•s us to off•r transpl•ntation on •basis th• phwsicians , pati•nts t famili•• and th•v•n•ral publ ic can acc•pt as •quitabl• • Sine•th•introduction of cwclosporin•-pr•dnison•th•rapw in March 1990 , manw prim•rw orthotopic liv•r transplants hav• b••n p•rform•d • Actuarial survival•at 1 and 5 w•ars h•v• improv•d to 69.7 p•r c.nt and 62.B p•r c•nt , r••p•ctiv•lw Bi liarw atr••ia i• now th•most common indication for l iv•r r•plac•m•nt In adults , primarw b i liary cirrhosis and scl•rosing cholangiti• hav•b•com•mor•common indications for transplantation and alcohol ic cirrhosis and primary liv•r mal ignancw as indications hav•d•cl in•d • Early •nthusiasm for liv•r transplantation in pati•nt•with h•patic canc•r hav•b•en t•mp•r•d by the finding that recurr•nce is both common and rapid • An increasing numb•r of pati ents with inborn •rrors of metabol ism originating in the l iver ar•r•ceiving transplants including patients with Wi lson’s d isease , trosinemia ’ alpha-1-antitr psin deficiency g l cogen storage disease fami l ial hyperchol esterolemia 1 and hemochromatosis Survival in th is groL1p of patients has been excel lent < 74,4 per cent at 1 and 5 years > • About 20 per cent of patients require retransp lantat ion for reject ion , technical failure , or primary graft fai lure An aggressive approach to retransplantation in the pat ient with a fai led graft is justified • |