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The first human orthotopic liver transplantation (OLT) was performed in the early 1960s by Thomas Starzl in the USA.1 Up until then there was little to offer patients with advanced liver disease with features of decompensation such ascites, hepatorenal syndrome (HRS), hepatic encephalopathy (HE), spontaneous bacterial peritonitis (SBP), gastro-oesophageal variceal bleeding, and/or hepatocellular carcinoma. These patients had a sinister prognosis because only palliative and symptomatic therapy was offered. The advent of OLT as an accepted therapy for advanced liver disease completely changed this scenario offering patients a cure to their diseased liver. In the initial years, significant advances were made in refining the indications and surgical technique. Nonetheless it took several years to realise that maximally optimising the pre-transplant status of patients would translate into better post-transplant outcomes.2 The most common conditions in decompensated cirrhosis that require aggressive management and alter pre- and post-transplant outcome include hyponatraemia, SBP as well as other bacterial infections, HE, HRS, and hepatocellular carcinoma.
In the USA and Europe, survival rates of patients who undergo OLT are near 85% and 86% at 1 year and 80% and 79% at 3 years, respectively.3 4 However, the high demand for organs and the steady availability of donors has led to increased morbidity and mortality in the waiting list in many transplant centres. Thus, proper care of patients on a liver transplantation list plays a fundamental role in reaching OLT in an adequate condition that ensures a good outcome after OLT. In this respect the appropriate selection of candidates plays a key role in determining waiting list morbidity and mortality. Patients who are selected for OLT undergo a thorough evaluation in order to exclude conditions that may preclude the operation (mainly serious comorbid conditions, metastatic cancer or those who will not survive or benefit are not candidates). …