Liver transplantation: an appraisal of the present situation.

Liver transplantation (LT) is an established approach to treatment of end-stage liver diseases, metabolic diseases and early hepatocellular carcinoma, and the results of this procedure have improved considerably. MELD allocation and the great number of transplant centers had a negative influence on outcome in Germany. Typical surgical issues following transplantation are vascular thrombosis and the development of biliary lesions. Nonanastomotic strictures impact graft survival and cause considerable posttransplant morbidity. Nonsurgical issues in LT are hepatitis C reinfection, selection of appropriate patients with hepatocellular carcinoma and individualized immunosuppression. In hepatitis C the new antiviral drugs (protease and polymerase inhibitors) are promising tools to prevent reinfection. Nephrotoxicity caused by calcineurin inhibitors - which remain the mainstay of immunosuppression - can only partially be avoided. So far, alternative forms of treatment using mycophenolic acid and mTOR inhibitors cannot totally replace calcineurin inhibitors. In view of graft scarcity, we need to think about a benefit-based model of liver allocation which focuses on the optimal use of this resource. Deciding on this form of organ allocation requires an ethical consensus: not the most urgent patient is the first candidate to receive a graft, but rather the patient who is supposed to have the greatest benefit.