THE NEW-AGE OF LIVER-TRANSPLANTATION

The advent of cyclosporin A for immunosuppression (IS) in liver transp lantation (LTx) in the early 1980s heralded a new age for LTx, resulti ng in widespread application, rapidly expanding indications, relaxatio n of restrictions in donor selection and advances in the preservation of liver grafts and management of LTx operations. Liver transplantatio n, together with the transplantation of other organs (kidney, pancreas , heart, heart-lung, intestine), became possible. In Australia, around 125 LTx (22% in children) are performed each year. Indications are: p rimary sclerosing cholangitis; primary biliary cirrhosis; auto-immune hepatitis; chronic viral hepatitis; biliary atresia; metabolic disorde rs; fulminant hepatic failure (FHF); alcoholic cirrhosis; and malignan cy (cancer, CA). Since 1965, 810 patients underwent LTx and 70 (9%) re -Tx. Patient survivals at 1, 5 and 9 years post-Tx are 80, 74 and 66%, respectively. Patients with primary diseases that recur in the LTx (h epatitis B and CA) do less well following LTx, with 5-year survival ra tes of 55 and 40%, respectively). Recent developments include: increas ing the availability of donor organs by the use of living donors, 'spl it' cadaveric donor (CD) grafts, 'marginal' and non-heart-beating CD g rafts and xenografts; expanding the indications for LTx; development o f effective liver support systems for patients with FHF: the treatment of diabetics with liver failure with islet Tx (at the time of LTx); m ore effective immunosuppression; and methods to diminish recurrent dis ease in LTx. Some understanding of the unique 'tolerogenic' capabiliti es of the liver has come with the recognition of 'two-way microchimeri sm'. The satisfactory 5-9 year outcomes for patients underline the cos t-effectiveness of LTx.