In North America, Britain and continental Europe waiting lists for a liver transplant are lengthening, as the gap between the number of patients listed for transplantation and the number of new donor organs widens.
In the UK, for example, the number of patients on the active liver transplant list increased by 12% in the first 9 months of 1999, while the number of liver transplants increased by only 2% in the same period.
The last few years have seen an increase in mortality for patients on the active transplant list. Dr R Ransford and colleagues at the Queen Elizabeth Hospital in Birmingham, England undertook a retrospective analysis of patients on the transplant list from 1990 to 1996 in order to understand the causes of waiting list mortality.
726 patients were accepted for transplantation in this period. By March 1997 9% of the patients had died while on the waiting list (but 87% had been transplanted and 3% were still waiting). Annual mortality rates varied between 5% and 12%.
5% of 254 patients with primary biliary cirrhosis died while waiting for a transplant. 14% of the 88 patients referred because of alcoholic liver disease died while still on the transplant list.
"It's essential that transplant centres and clinicians work closely to ensure that patient referral is optimal."
Dr R Ransford
The team from Birmingham stresses the importance of the timing of the referral for transplants. Paradoxically, if patients are referred too early, their lives may be shortened due to peri-operative risk and early post-transplant mortality. If patients are referred too late, they may die before receiving a new liver.
It is suggested that, for patients with primary biliary cirrhosis, priority should be given to patients who are most likely to die without a transplant. A mathematical model based on their data shows that these patients are just as likely to have a successful transplant as those who are at less immediate risk of death without a donor organ.