Advancing Liver Transplantation.

Donor organ scarcity remains a major limitation in liver transplantation and accounts for a great proportion of wait list mortality. As a result, over the past decade, significant efforts have been made to increase the existing donor pool. These efforts have, in part, resulted in greater use of liver allografts following donation after cardiac death (DCD) along with suboptimal (so-called marginal) and extended criteria donors. Improved understanding of the pathophysiology underlying the inferior outcomes of the liver allografts procured after circulatory arrest has not only resulted in better selection and management of DCD donors, but has also helped in the development of mechanical perfusion strategies. Currently, there is much excitement surrounding the clinical applicability of both hypothermic and normothermic perfusion and the potential to impact patient survival and allograft function. Attempts to decrease late mortality following liver transplantation have focused on minimization of and use of new immunosuppressive medications with specific aims of reducing losses as a result of infection, malignancy, and renal failure. Lastly, there has been increased emphasis on gaining a better understanding of liver immunology and redefining the impact of antibody-mediated rejection on allograft function and patient survival.