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Clinical Review

Adult liver transplantation: what non-specialists need to know

BMJ 2009; 338 doi: (Published 22 May 2009) Cite this as: BMJ 2009;338:b1670
  1. G M Hirschfield, assistant professor of medicine and general hepatologist1,
  2. P Gibbs, consultant in liver transplant surgery2,
  3. W J H Griffiths, consultant transplant hepatologist2
  1. 1Liver Centre, Toronto Western Hospital/University of Toronto, Toronto, ON, Canada M5T 2S8
  2. 2Hepatology and Liver Transplant Service, Addenbrooke’s Hospital, Cambridge, UK
  1. Correspondence to: G M Hirschfield gideon.hirschfield{at}

    Summary points

    Potential transplant recipients often outnumber donors

    Improved donor schemes, broader donor criteria, split liver grafts, and live donors (who donate a portion of their liver) can increase the number of transplants

    Long term survival after transplant is excellent

    Family doctors are important in the management and monitoring of hypertension, diabetes, hyperlipidaemia, and renal function, and in cancer surveillance after the transplant

    The prevention of end stage liver disease and the early detection of liver complications could reduce the number of transplants needed

    Sources and selection criteria

    There have been few large-scale randomised controlled trials and Cochrane reviews on liver transplantation; data mostly come from extensive registry descriptions, multiple case-series, or small trials. We have combined our knowledge with that published in recent guidelines and in articles identified by Pubmed searches with the term liver transplantation.

    The UK has approximately 6 000 surviving liver transplant recipients,1 and annually about 600 people with liver disease receive new livers. The post-transplant population is growing, since nearly 550 of those 600 patients are alive one year after the operation, and at least 300 are alive 20 years after.2 3 We review liver transplantation for a non-specialist audience, with an emphasis on transplants in adults.

    Who needs a liver transplant?

    Common triggers for referral in people with chronic, usually cirrhotic, liver disease are progressive jaundice, diuretic-resistant ascites, or hepatocellular carcinoma (box 1). Early referral is recommended since patients vary in their disease progression, and the assessment must be thorough. Liver transplantation is principally aimed at restoring health and improving survival, but, unlike other operations with similar potential benefit, limited resources restrict the number of people who receive transplants.

    Box 1 Underlying indications that can lead to transplantation

    Liver failure
    Acute/subacute (approximately 10% of transplants)
    • Drug induced:

    • Direct toxicity (for example from paracetamol or herbal remedies)

    • Idiosyncratic (for example from isoniazid or nitrofurantoin)

    • Viral hepatitis

    • Acute fulminant autoimmune hepatitis

    • Acute Budd-Chiari syndrome not amenable to radiological treatment

    • Metabolic disease (such …

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