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ORGAN ORGAN
DONATION DONATION

Innovations in

Liver Transplantation

By Fred Poordad, MD, FAASLD, and Corrie Berk, DNP, MBA, APRN

F he first known mention of transplantation, specifically

skin grafting for burns, dates to 1550 BC, but the first
human-to-human solid organ transplant was not until
1933. By the 1950s, kidney transplantation (KT) had become
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rather well-established, but still plagued with a high rate of re-
jection.
Inspired by the success of KT, Dr. Thomas Starzl performed
the first liver transplant (LT) in 1963 at the University of Col-
Figure 1: Anastomosis of left and right liver grafts. University Health Transplant Institute generally performs duct-duct anastomosis of bile ducts.
orado before ultimately establishing a program at the University
Borhani AA. https://doi.org/10.1148/rg.2021210012
of Pittsburgh in the early 1980s. By the mid-1970s, 35 trans-
plant programs opened around the world.
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As impressive as the surgical component was, the real success Emerging Areas in Liver Transplantation Liver Transplantation and Gastric Sleeve Resection
story in transplantation was the development of immunosup- The Best Treatment for Liver Cancer Since obesity and metabolic-associated steatotic liver disease
pressive agents that allowed for long-term graft and patient sur- Surprising to many healthcare providers, liver transplantation is (MASLD) are the driving forces for most liver transplants in South
vival. With the approval of cyclosporine in 1983 and tacrolimus the best therapy for hepatocellular carcinoma (HCC), provided the Texas, a new concept of performing a sleeve gastrectomy along with
in 1994, excellent survival and manageable rejection rates were cancer is confined to the liver and not too large. By removing the liver transplantation has emerged. This decreases recurrent steatotic
realized, compared with predecessor regimens such as 6-mer- diseased liver, which is the “fertile soil” for cancers to grow, it not liver disease as well as diabetes and obesity-related complications since
captopurine. Since then, dosing optimization aimed at mini- only cures the cancer, but the underlying disease. Resecting a liver lifestyle modifications typically fail, offering a “jump-start” to a health-
mizing toxicity, preventing opportunistic infections, and cancer does nothing to change the milieu that allowed it to blossom, ier post-transplant lifestyle.
surveilling for malignancy, has led to patient survival >30 years which is why most liver cancers recur after surgical resection. Resec-
Dr. Fred Poordad with a patient. Photo courtesy of University Health Transplant Institute.
and counting after organ transplantation. tion and chemotherapy are used for patients when liver transplanta- Liver Transplantation at the University Health Transplant
Until recently, the most common indication for liver trans- tion is not an option. Institute in San Antonio
plantation in the U.S. was chronic hepatitis C infection. Ironically, ex- in addition to bilirubin, creatinine, sodium and INR, incorporates al- Liver transplantation can also be performed for other cancers such The liver transplant program at the University Health Transplant In-
tended donor criteria (EDC) now include the use of hepatitis C bumin and sex to better account for disparities between men and as neuroendocrine tumors, intrahepatic cholangiocarcinoma and stitute was established in 1992, under the leadership of Dr. Glenn Halff,
infected organs transplanted into non-infected recipients, with post- women. Nonetheless, nearly 20 percent of patients die or become too nonresectable colorectal metastases. As aggressive as this may who was later joined by Dr. Francisco Cigarroa. The addition of several
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transplant eradication of hepatitis C using direct-acting antivirals. The sick waiting for a cadaveric liver transplant. sound, selected candidates do very well and life can be extended outstanding surgeons from around the country, a core of eight hepa-
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rising obesity epidemic in the U.S. over the past several decades has led Living donor liver transplantation (LDLT), however, is not depend- many years. tologists, two transplant fellows, ten advanced practice providers, an
to steatotic liver disease (formerly known as fatty liver disease) becom- ent on the MELD score. Recipients and donors can electively schedule army of nurse coordinators, and a multi-disciplinary team of healthcare
ing the leading indication for transplantation along with alcohol liver their respective procedures, allowing for ample timing and preparation. Acute alcohol-associated liver injury professionals has led the program to:
injury. Roughly two-thirds of all transplants are now for these indica- The recipient’s insurance provider covers medical costs for the donor, Until recently, a 6-month sobriety rule was enforced prior to trans- • Transplanting ~150 livers per year.
tions. and most donors are discharged five days post operatively. Paired organ plantation for alcohol-associated liver disease. This was challenged in • Growing to the second largest living donor liver program
exchanges can be done if a donor and recipient do not match due to 2011 since data did not support this arbitrary mandate. Furthermore, in the U.S.
Cadaveric Versus Living Donor Transplantation blood type or organ size. requirements for dietary change largely did not apply to obesity and • Establishing a pediatric living donor transplant program.
The conventional liver transplant uses donation after brain death The life-years gained with LDLT are similar or greater than any other steatotic liver disease, which histologically is very similar to alcohol-as- • Increasing opportunities for transplant as the first program to
(DBD) organs. A higher risk comes with donation after circulatory life-saving procedure. Accounting for ~6 percent of all liver trans- sociated liver disease. Hence, many U.S. programs are now transplant- do paired living donor organ exchanges.
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death (DCD), which is often used in patients who are in more urgent plants, LDLT requires a surgical team with specialized training as well ing select patients with alcohol use disorder if they were unaware of a • Being named as the #1 liver transplant program in the U.S. out
need of an organ. Both use the Model for End Stage Liver Disease as a network of ancillary medical specialists including hepatologists, liver issue, have good insight about alcohol use, are otherwise healthy of 86 programs reviewed.
(MELD) score to rank candidates by priority. The original MELD advanced endoscopists and interventional radiologists familiar with and have a good support system. The outcomes are excellent and, with
score was replaced by MELD Na, and recently by MELD 3.0, which, the nuances of the procedure and outcomes (Figures 1 and 2). appropriate follow-up and care, harmful relapse is rare. continued on page 16
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