Liver transplantation: an update 2009

Purpose of review In this review we focus on three challenging aspects of liver transplantation: living donor liver transplant, transplantation in HIV-positive recipients and down-staging of hepatocellular carcinoma for liver transplantation. Recent findings The adult-to-adult living donor liver transplantation cohort study is providing valuable information on recipient and donor outcomes associated with living donor liver transplantation. The recipient outcomes with living donor liver transplantation are comparable to those with deceased donor liver transplantation for most diseases, but increased hepatocellular carcinoma recurrence has been reported with living donor liver transplantation. Donor morbidity is not infrequent and donor mortality remains a concern. Liver transplantation for HIV-positive recipients is associated with equivalent outcomes as HIV-negative recipients for selected recipients. Transplantation in coinfected recipients (HIV and HCV+) is associated with less favorable outcomes. Drug interaction between immunosuppression and highly active antiretroviral therapy is increasingly recognized and requires major modifications in dosing. Down-staging hepatocellular carcinoma to within transplant criteria is being used in some centers using loco-regional therapy. Waiting time after loco-regional therapy is currently the best predictor of recurrence. The role of newer chemotherapeutics is being tested as part of neoadjuvant therapy after resection or loco-regional therapy. Summary Living donor liver transplantation is a viable strategy to increase transplantation and reduce death on the waiting list. Donor morbidity should be the subject of further efforts to minimize these risks. The increased recurrence risk with living donor liver transplantation for hepatocellular carcinoma warrants further study. Careful coordination between transplant professionals and HIV experts is necessary to monitor issues of posttransplant care of the HIV-infected recipient. The role of loco-regional therapies in down-staging patients with hepatocellular carcinoma is expanding.