Editor,—It was with great interest that we read Periera and William’s article (Gut1998;42:883–5) reviewing the problem of the great imbalance between the limited number of donor livers versus the increasing need for transplantation in the UK and possible remedies to this tragic situation: strategies to increase the number of actual donations from the annual pool of potential donors. This great imbalance between allograft supply and demand is a challenging problem which confronts transplant centres everywhere. Furthermore, as medical science advances and clinical epidemiological analysis of post-transplant outcomes become clearer, we find that diseases that were previously either absolutely or relatively contraindicated for transplantation, such as chronic hepatitis B1 and alcoholic cirrhosis,2 ,3 are now conditions potentially treatable by transplantation, further widening the differential between those in need of a transplant and number of available organs.

Clearly, as Periera and Williams point out, there is a need to increase the numerator side of the organ supply:demand ratio and use every available organ. It must be emphasised, however, that the need to reduce the denominator side of this ratio—that is, reduce the need for transplantation, is equally as great. Currently, alcoholic cirrhosis and chronic hepatitis C (HCV) infection are the two most common indications for transplantation for liver disease in British Columbia, comprising 15 and 22% of all transplants as of 1997. These proportions are comparable to other centres across Canada and the United States. When one also considers that many of those infected with HCV acquired the infection from intravenous drug misuse and that alcohol consumption is reported to be an exacerbating factor in the progression of HCV towards cirrhosis,4 it is clear that primary prevention of behaviourally acquired liver disease could substantially reduce the donor supply/demand imbalance. The benefits of effective public health measures to reduce alcohol dependence, intravenous drug misuse, as well as immunisation of those at risk of hepatitis B, may not help those currently in need of a transplant but would be expected, over the next few decades, to impact favourably on pretransplant waiting lists. The solution to today’s donor shortage lies not only with those actively involved in transplantation or organ procurement but, ultimately, with all who are involved in health care.