Controversies In Liver Transplantation

Throughout the history of liver transplantation(LT),controversies and LT seems to be synonymous with each others.The outcomes of LT recipients have significantly enhanced throughout the years through therapeutic advances,including ameliorated surgical techniques,powerful antimicrobial treatment,effective immunosuppressive drug regimen,and cutting edge interventional radiology.At present,LT turned out to be the gold standard and only the cure for end-stage liver diseases.Despite the improvements in results,LT is still facing lots of challenges,where demand is high and the resources,primarily concerned to donor,are very limited.Although,the marginal supply of organ donors has been increased through innovations such as a living donor liver transplant,donation after circulatory death(DCD),split liver transplantation,auxiliary liver transplant,extended criteria for donors,extended criteria of LT for HCC,and ABO incompatible(ABOi)LT.Nonetheless,there are lots of controversies that are needed to be discussed among the transplant community,primarily focusing on the question about the selection of patients that are in need of LT,best use of new drugs,and procedures in this area which has quickly advanced in the course of recent decades.It is believed that DCD LT poses higher risks of graft failure and biliary complication in comparison with donation after brain death(DBD)LT,that are related to warm ischemia,early allograft dysfunction and prolonged cold ischemia time.Similarly,in the time of organ shortage the strategy of salvage liver transplant(SLT)is used for the patients with HCC in the case of recurrence after resection.However,SLT still remain controversial in compared to primary liver transplant(PLT)mainly due to surgical difficulties due to adhesions,increased rate of post-transplant complications,and poor long-term outcomes.Likewise,the approach of ABOi LT was to increase the donor pool and to provide LT in emergency condition.However,ABOi LT remains to be a controversial approach in comparison to ABO-compatible(ABOc)LT,mainly due to different risks associated to it,especially earlier graft loss,acute cellular rejection(ACR),antibody mediated rejection(AMR),vascular,biliary complications and HCC recurrence.Moreover,other concerns are related to timing and criteria of LT for acute decompensated liver and LT for severe alcoholic hepatitis.The aim of this dissertation is to address an important disparity and controversies in the literature that is specific to outcomes of LT.