In summary, we answer the three questions we have previously posed: (a) Can liver transplantation prolong survival? Evolving data from several centers indicate that liver transplantation indeed prolongs survival in patients with PBC and PSC as compared with estimated survival using disease- specific risk scores based on the natural history of PBC and PSC. (b) Can we optimize timing of liver transplantation? Although many factors enter into the timing of liver transplantation, including when the patient is actually referred for liver transplantation and the individual desires of the patient to pursue liver transplantation, evidence is growing that having patients with chronic liver diseases like PBC and PSC undergo transplantation a little earlier in the course of the disease rather than waiting until the patients have experienced life-threatening complications or are on life-support measures can indeed improve early postliver transplant survival. In patients with PBC and PSC, the survival risk score, which reflects disease severity, can serve as an objective measurement to assess and evaluate the effect of liver disease severity on transplant outcome. Indeed, a number of studies have strongly suggested that optimal timing of liver transplantation may indeed be important to improve outcome, decrease morbidity and decrease cost. (c) Does the present allocation system in the United States allow for optimal use of our scarce donor organ resource? Evidence is growing that the results of liver transplantation in high-risk groups of patients (for example, patients with acute fulminant hepatic failure, patients requiring retransplantation and patients requiring care in the intensive care unit or on life support) are all associated with a significantly decreased survival when compared with patients who do not have these high-risk factors. The results of recent studies suggest that the assessment of outcome should indeed be a component of future allocation planning so that recipients with the best opportunity for success are not at an inherent disadvantage compared with recipients with a high likelihood of failure (42). It is likely that the shortage of donor liver allografts will continue and may even get worse in the near future. Therefore many are of the opinion that future revised policies should expand the criteria for distribution of donor organs to include outcome in the allocation equation. Of equal importance, however, is the education of our referring hepatologists, gastroenterologists and internists regarding the importance of determining the optimal timing of liver transplantation and defining objectively when in the course of a chronic liver disease a patient should be referred to a liver transplant center. We believe timing of liver transplantation is best assessed with the use of prognostic models, which in turn can be used to estimate survival for the individual PBC and PSC patient with and without liver transplantation at any point in the disease course.
ASJC Scopus subject areas