How far can we go with marginal donors?

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Very few areas in medicine have enjoyed the success of liver transplantation, and as with any success this has resulted in a wide gap between demand and supply. In addition, many countries have observed a decrease in the number of available cadaveric donors, which has exacerbated this discrepancy resulting in increasing death rates on most waiting lists. Therefore, a focus of the transplantation community has been the search for strategies to increase the pool of available liver grafts, one of them being the use of organs that were previously considered “unusable” by many, often labelled as “marginal” organs. In this seventh forum of the series Forum on Liver Transplantation, we will attempt to define “marginal” grafts and explore how to use them. In previous Forums other strategies to increase the pool of available organs have been discussed such as the use of partial liver grafts including living donation [1], [2], [3], [4], and therefore this topic will not be covered here.

In the 1st article in this forum, R. Merion, N.P. Goodrich and S. Feng present their extensive statistical analysis to define marginal donors, which they rather call “extended criteria for liver donors”. Combining in the same equation many factors regarding donor characteristics, cause of death, type of donor (brain death vs. death after cardiac arrest), use of partial graft, and underlying graft condition, they propose a continuous donor risk index. Such an index should eventually lead to an optimal donor/recipient match for a given population of patients with liver diseases. Building on this information P. Burra and R. Porte discuss the complexity of matching donor with the most appropriate recipient. A strong emphasis is given to developing models balancing individual need or benefit vs. population utility. In the third article in this forum, A. Nocito, A. El-Badry, and P.A. Clavien critically review the topic of liver steatosis, and highlight the lack of convincing data in this field, while many centers empirically use clear guidelines. Livers with moderate steatosis (<60%) should no longer be discarded, but used cautiously, particularly in the presence of other risk factors. Another, almost unlimited source of liver grafts may arise from donors after cardiac death, also known as non heart beating donors (NHBD). R. Deshpande and N. Heaton present an excellent overview of this type of donors suggesting that the greatest potential lies with uncontrolled NHBD; i.e., death occurring outside the hospital or in the emergency room after unsuccessful resuscitation. While the development of such a program requires special infrastructure, additional resources and a clear legal framework, it could increase the number of available organs by 40% or more over the next 10 years. The last two articles in this forum address the controversial issue of the risk of transmission of infection and tumour from a donor organ to a recipient. J. Buell, R.R. Alloway and S. Woodle review the different types of cancer in potential donors and propose recommendations on the use of the liver for transplantation. N.J. Mueller and J.A. Fishman provide a detailed overview of the complex field of potential infection in donors, and propose guidelines for absolute and relative contraindications as well as guidelines for routine and selective laboratory evaluations.

While the question “how far can we go with marginal donors?” remains open and represents a moving target based on new knowledge and novel protective strategies, I hope that this forum will provide a timely overview and help the clinician in accepting or selecting “marginal” liver graft for a specific recipient.

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References 

1. Trotter JF. Living donor liver transplantation: is the hype over? in: First Forum on Liver Transplantation. J Hepatol 2005;42:20–25.
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2. Tanaka K, Yamada T. Living donor liver transplantation in Japan and Kyoto University: what can we learn? in: First Forum on Liver Transplantation. J Hepatol 2005;42:25–28.
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3. Clavien P-A. Living donor liver transplantation. Who needs it? How to do it? Who should do it? in: Third Forum on Liver Transplantation. J Hepatol 2005;43:11–12.
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4. Tan HP, Patel-Tom K, Marcos A. Adult living donor liver transplantation: who is the ideal donor and recipient? in: Third Forum on Liver Transplantation. J Hepatol 2005;43:13–17.
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