Progress in liver transplantation, but better access is needed

The face of liver transplantation has changed over the 20 years after the implementation of MELD for waitlist prioritization, with multiple factors making an impact. Despite the liver transplant recipients being older and more medically complex than they were in 2002, posttransplant survival can be as high as 80% at 5 years after transplant.1 The contemporary liver transplant recipient presents unique challenges because of the need for multidisciplinary care of problems not cured by the transplant, specifically alcohol use disorder2 and metabolic syndrome.3 As we reflect on National Donate Life Month, increasing organ availability, including wider and better use of living, as well as donation after cardiac death and ECD donors, and improving access to transplants for all patients regardless of race or socioeconomic status remain our largest challenges in reaching the maximal benefits of transplantation on end stage liver disease (ESLD). We encourage everyone to read the National Donate Life Month collection compiled by Liver Transplantation at ltxjournal.com, which highlights many of these points. With the growing demand for liver transplant, because of the increasing incidence of alcohol-associated liver disease and NAFLD, as well as the expansion of indications for transplant, it has become even more pressing to increase timely access to transplant. Xenotransplantation in its current state makes for exciting headlines in the press but is likely many years away, owing to the need for additional genetic engineering to reduce complications related to immune activation and thrombosis, which contribute to posttransplant survival of only days in animal studies.4 The use of HCV+ livers has become more acceptable to patients since the advent of direct-acting antiviral therapy, with 60% of liver transplant candidates now willing to accept livers from HCV+ donors, and has resulted in a 20% reduction in the rate of discarded livers due to HCV status.1 This has been an important advance, but not one that is able to keep up with the growing demand for donor livers. Normothermic machine perfusion has been demonstrated to increase the utilization of livers from donation after cardiac death donors.5 More recently, the use of normothermic regional perfusion, a mode of perfusion that occurs before liver procurement, demonstrated similarly high rates of organ recovery from donation after cardiac death donors as machine perfusion.6 The optimal mode of machine perfusion that results in the highest yield of organs procured and the best graft quality and survival is not yet defined. This technology is exciting yet a potentially costly investment. Ultimately, machine perfusion may be cost-saving and improve incremental quality of life-years gained, as demonstrated by a recent single-center Canadian study.7 It is yet to be determined whether the increased cost of travel to recover more organs will still retain its cost-effectiveness, though more lives saved will be a desirable outcome for many patients and their families. Living donor liver transplantation (LDLT) is widely accepted as an option for liver transplant candidates, and although the absolute number of LDLTs performed has increased, the proportion of LDLTs has not changed substantially over time.1 Jackson et al8 recently reported on an updated analysis of the Scientific Registry of Transplant Recipients database demonstrating the survival benefit of LDLT in patients with MELD scores as low as 11, suggesting that we should be considering more patients for LDLT. However, given that the largest proportion of LDLT recipients had cholestatic liver disease, caution should be used in applying these results to the general liver transplant population. Action to increase LDLT is critical to improve access to liver transplant. Living donor protection is needed to remove potential financial barriers for donors. The legislation was initially introduced in 2014 without further action, and currently, 28 states have laws that protect living donors. The most recently introduced federal legislature, the Living Donor Protection Act of 2021, was introduced to protect the ability of donors to acquire, maintain, and afford health, life, disability, and long-term care insurance, as well as designating living donation surgery as a condition that entitles medical leave from work. Despite the bipartisan sponsorship from 160 US House representatives and 43 US senators from 47 states, this important bill has still not progressed. Congress must act by passing this bill to protect donors now. Living donor-paired exchange as a method to increase utilization of livers from donors who are not compatible with donors at their home center is potentially appealing, but the yield of this approach is not yet clear and is currently being studied. Living donor champion programs are utilized at many programs to help increase awareness of LDLT and to help support patients in identifying donors, and this approach has had a measurable impact on the volumes of LDLT at single centers.9 More resources are needed to support LDLT programs and develop their champion programs to further expand the donor pool. Access to liver transplant has long been burdened by inequities. Implementation of acuity circles for liver allocation sought to improve geographic disparities in MELD at the time of transplant. An initial analysis of this policy demonstrated improved access to transplant for the sickest patients, but this did not necessarily represent a national trend, as a small proportion of centers drove these results.10 Transplant access has not increased uniformly across racial and ethnic groups over time, with the proportion of Black liver transplant candidates and recipients decreasing, Hispanic patients increasing, and all other groups remaining relatively stable. Numerous studies have now been published describing known inequities that result in Black patients being referred for transplant at lower rates than other racial and ethnic groups, which is likely a result of the long-standing effects of systemic racism on these patient populations. The American Association for the Study of Liver Disease and the American Society of Transplantation have called attention to this important issue with regard to the need to support research in this field, improve the diversity of liver transplant providers to better match the patient racial and ethnic mix, and to provide protections for adequate insurance coverage for transplant as an Essential Health Benefit.11 It is imperative that more resources are dedicated to the early identification of patients with cirrhosis, paired with linkage to specialty care, particularly within communities historically underserved by specialty care. This early linkage to hepatology may allow for the education of patients and their families about what the transplant process entails and to try to mobilize a network of support to get the patient through transplant. Government agencies, insurance companies, and health systems should develop mechanisms to help bridge financial gaps that may exist for patients from lower socioeconomic backgrounds. The past 20 years of liver transplantation have shown exciting progress in liver transplantation, and the expectation is that the next 20 and beyond must bring expanded, more equitable access to transplant for all patients with advanced liver disease.

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