Dr. Lo Chung Mao
December 2006

The first liver transplant in Hong Kong was performed at Queen Mary Hospital in October 1991. The initial development of the program was seriously restricted by a scarcity of organ donors and resources. Only a few selected patients benefited from this life-saving procedure and with little or in fact no manpower or funding, the new service was started by the extra work undertaken by the staff members and the diversion of resources from other services.

Over the last 15 years, the supply of deceased donor liver grafts has improved as a result of public education and expanding the criteria for organ acceptability. Marginal donors such as those with advanced age (the oldest donor was 76-year old!), or adverse in-hospital events (such as episodes of cardiac arrest or high-dose inotropic support) were frequently used and the only absolute contraindications for donation were the presence of systemic infection, transmissible disease such as HIV infection, or malignancy. Together with other measures such as international organ sharing, technical advances such as reduced size or split-liver transplant and domino transplant that allow maximal utilization of a liver graft, the number of deceased donor liver transplant has increased from one or two to more than 20 per year in recent years.

The development of living donor liver transplantation has an even larger impact in increasing the applicability of liver transplantation in Hong Kong. A graft from a living donor provides the unique opportunity for the patients and his or her family members to control the timing of the transplant with the transplant team and this is particularly relevant in patients with hepatic cancer and acute liver failure. In recent years, living donor liver transplant has out-numbered deceased donor liver transplant and accounts for about two-third of all the liver transplants performed. Those were the days when patients in Hong Kong had to appeal to the public for financial support in order to travel oversea for a transplant operation. Instead, a number of oversea patients have come to Hong Kong in recent years for the operation.

Nonetheless, although the annual number of liver transplant has increased to over 70 in recent years, the demand has yet to be satisfied. There are currently about 150 patients on the waiting list and all candidates are ranked by disease severity according to the Model for End Stage Liver Disease (MELD) score so that a liver graft can be allocated in a transparent, equitable and objective way. Ironically, while patients low on the list may wish to move up the priority rank, by the time they do so because of increased disease severity, they may not be able to survive long enough until a graft becomes available. Hence, the mortality rate on the waiting list remains high at round 40% and this has prompted patients who do not have suitable living donor to seek the alternative of going north to undergo liver transplant in mainland China. With a significantly higher complication rate in the 40 to 50 post-transplant patients returning to Hong Kong from the mainland each year, the additional workload for the liver transplant service at Queen Mary Hospital is substantial.

The liver transplant service at Queen Mary Hospital has been transformed rapidly from a Mickey-mouse program to one of international repute, particularly in living donor liver transplantation and the 1-year and 5-year patient survival rate of over 90% and 80% respectively exceeds international standard. Nonetheless, the issues of shortage of organs and resources have not been resolved yet. While prevention and treatment of hepatitis B infection may eventually reduce the demand for this life-saving operation, in the near future, the promotion of organ donation and the expansion of living donation are the only solutions to increase the supply. In addition, more patients will seek the option of having a liver transplant in China. With the increasing demand on the liver transplant service, there is a need to ensure that appropriate resources follow to sustain the program. Otherwise, the service would eventually become a victim of its own success.

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