What are some common myths about liver transplantation?

Common Myths About Liver Transplantation

Myth 1: Liver Transplantation is Experimental or Unproven

Liver transplantation is now a well-established, standard therapy for end-stage liver disease with excellent outcomes, not an experimental procedure. 1

• Current survival rates reach 96% at 1 year and 71% at 10 years post-transplant, demonstrating this is a mature, proven intervention 1
• The procedure has evolved from its first performance in 1968 to become the most effective treatment for acute and chronic liver failure from various causes 1
• Costs have steadily declined in recent years, further supporting its role as standard care 1

Myth 2: HIV Infection is an Absolute Contraindication

HIV infection is no longer an absolute contraindication to liver transplantation when well-controlled with highly active antiretroviral therapy (HAART). 1

• Early experiences were discouraging, but with HAART, short-term survival in HIV-positive recipients is now comparable to HIV-negative recipients 1
• Most patients maintain undetectable HIV RNA after transplantation 1
• A critical caveat: Management requires a well-coordinated, multidisciplinary team with expertise in both transplantation and HIV management due to serious drug interactions between antiretrovirals and immunosuppressants 1
• The list of absolute contraindications has diminished; only extrahepatic malignancy, advanced AIDS (not HIV positivity alone), and severe cardiorespiratory disease remain absolute contraindications 1

Myth 3: Alcoholic Liver Disease Patients Must Wait 6 Months Before Transplant

While a 6-month sobriety period is widely adopted for alcoholic cirrhosis, patients with severe alcoholic hepatitis not responding to medical therapy may be considered without this arbitrary waiting period due to their disastrous short-term prognosis. 1, 2

• Recent evidence shows that early liver transplantation for severe alcoholic hepatitis can be life-saving with stringent patient selection and low post-transplant relapse rates 2
• The 6-month rule cannot be reasonably imposed when patients face imminent death without transplantation 2
• Alcoholic liver disease accounts for a significant proportion of transplants (part of the 42% from alcohol, hepatitis C, and tumors in the UK) 3

Myth 4: Portal Vein Thrombosis Prevents Transplantation

Isolated portal vein thrombosis is no longer an absolute contraindication and can be circumvented surgically. 1

• Portal vein thrombosis can be successfully bypassed using jump grafts or after thromboendovenectomy 1
• Only complete portal venous system thrombosis with occlusion or hypoplasia of the entire splanchnic blood supply remains a contraindication due to increased perioperative mortality risk 1
• Computed tomographic and magnetic resonance angiography provide accurate preoperative assessment of portal inflow integrity 1

Myth 5: Older Age is a Contraindication

The upper median age limit for liver transplant recipients has been relaxed, and age alone is not an absolute contraindication. 1

• Recent guidelines acknowledge that age limits have generally been relaxed 1
• The focus has shifted to assessing frailty, cardiovascular risk, and functional status rather than chronological age alone 1
• Comprehensive cardiac risk assessment and evaluation for rehabilitation and nutritional support are now prioritized over arbitrary age cutoffs 1

Myth 6: Hepatocellular Carcinoma is a Contraindication

Hepatocellular carcinoma (HCC) confined to the liver is an established indication for transplantation, not a contraindication. 1

• Liver transplantation should be viewed as the treatment of choice for selected HCC patients who are not candidates for surgical resection 1
• Optimal results are achieved with a single lesion ≥2 cm and <5 cm, or no more than three lesions with the largest <3 cm, without extrahepatic disease 1
• Historically, HCC was considered a contraindication, but this changed as selection criteria improved 1
• Important caveat: Cholangiocarcinoma remains a contraindication as it usually recurs rapidly after transplantation 1

Myth 7: Living Donor Transplantation Has Poor Outcomes

Living donor transplantation, while having higher perioperative complications, achieves long-term patient survival comparable to deceased whole liver transplantation. 1

• Living donor transplantation for children using a portion of the left lobe is a well-established procedure 1
• Adult living donor transplantation using the donor right lobe is performed at many centers 1
• Critical concern: Donor safety remains an ongoing issue that must be carefully considered 1

Myth 8: Transplant Recipients Cannot Have Good Quality of Life

Patients now have the opportunity for extended survival with excellent quality of life after liver transplantation. 1

• Before transplantation, patients with advanced liver disease usually died within months to years; transplantation has fundamentally changed this trajectory 1
• Long-term outcomes and quality of life have become main concerns as patients survive longer 1
• Quality of life, metabolic complications control, sexual function, and safe pregnancy are now recognized as relevant outcome measures 1