GUT 1998;43:728-728
( November )
Letters to the editor
Tomorrow's challenge in liver transplantation:
diminishing the imbalance between donor organ availability and
need
EDITOR, It was with great interest that we read
Periera and William's article (Gut 1998;42:883-5) reviewing
the problem of the great imbalance between the limited number of
donor livers versus the increasing need for transplantation in the
UK and possible remedies to this tragic situation: strategies to
increase the number of actual donations from the annual pool of
potential donors. This great imbalance between allograft supply and
demand is a challenging problem which confronts transplant centres
everywhere. Furthermore, as medical science advances and clinical
epidemiological analysis of post-transplant outcomes become
clearer, we find that diseases that were previously either
absolutely or relatively contraindicated for transplantation, such
as chronic hepatitis B1 and alcoholic cirrhosis,2 3 are now
conditions potentially treatable by transplantation, further
widening the differential between those in need of a transplant and
number of available organs.
Clearly, as Periera and Williams point out, there is a need to
increase the numerator side of the organ supply:demand ratio and
use every available organ. It must be emphasised, however, that the
need to reduce the denominator side of this ratiothat is, reduce the need
for transplantation, is equally as great. Currently, alcoholic
cirrhosis and chronic hepatitis C
(HCV) infection are the two most common indications for
transplantation for liver disease in British Columbia, comprising
15 and 22% of all transplants as of 1997. These
proportions are comparable to other centres across Canada and the
United States. When one also considers that many of those infected
with HCV acquired the infection from intravenous drug misuse and
that alcohol consumption is reported to be an exacerbating factor
in the progression of HCV towards cirrhosis,4 it is clear that primary prevention of
behaviourally acquired liver disease could substantially reduce the
donor supply/demand imbalance. The benefits of effective public
health measures to reduce alcohol dependence, intravenous drug
misuse, as well as immunisation of those at risk of hepatitis B, may not help those currently in need
of a transplant but would be expected, over the next few decades,
to impact favourably on pretransplant waiting lists. The solution
to today's donor shortage lies not only with those actively
involved in transplantation or organ procurement but, ultimately,
with all who are involved in health care.
E M YOSHIDA
Department of Medicine
S W CHUNG
Department of Surgery, University of British Columbia, British
Columbia Transplant Society, Vancouver, BC, Canada
Correspondence to: Dr Yoshida, The British Columbia Transplant
Society, East Tower, 4th Floor, 555 West 12th Avenue,
Vancouver, BC V5Z 3X7, Canada.
References
- Yoshida EM.
Hepatitis B infection and liver transplantation. Can J
Gastroenterol 1997;11:462-468.
- Gish RG, Lee AH,
Keefe EB, et al. Liver transplantation for patients with
alcoholism and end-stage liver disease. Am J Gastroenterol
1993;88:1337-1342.
- Orsorio RA, Ascher
NL, Avery M, et al. Predicting recidivism after orthotopic
liver transplantation for alcoholic liver disease.
Hepatology 1994;20:105-110.
- Poynard T, Bedossa
P, Opolon P. Natural history of liver fibrosis progression in
patients with chronic hepatitisC.
Lancet 1997;349:825-832.
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© 1998 by
Gut
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