Until recently, a transplant unit’s success was measured by its one year recipient survivalfigure. Early results were poor, but transplantation has evolved during the 1980s and 1990s into a routine treatment for which one year recipient survival approaches 90%. Developments responsible for improved recipient outcome include the refinement of patient selection criteria, advances in surgery, anaesthesia and intensive care, and refinement of immunosuppressive protocols. As the results of transplantation improved, indications for transplantation expanded and contraindications were relaxed. The inevitable consequence of success has been a consistent expansion of the recipient population. Unfortunate for the potential recipient, however, has been the failure of the organ donor pool to expand at the same rate. Of course, the relative shortage of suitable organ donors need not affect the results of transplantation, but is reflected by a growing number of waiting list deaths. Though the outcome oftransplanted patients still provides one important measure of a unit’s performance, it is now appropriate that the focus shifts to an examination of the fate of allpotential transplant recipients. Reflecting this change of focus, the allocation of donor organs should inevitably shift towards recipients (and liver diseases) for whom superior patient and graft outcome are predicted. Thus, graft longevity assumes increasing importance as graft loss and the need for regrafting aggravate waiting list pressure. Appropriate rationing of all resources, including the donor organ, must ensure maximum benefit for the greatest number of patients. In forthcoming years, and reflecting all constraints, it may become unacceptable to nominate high risk or high cost recipients. For many transplant programmes, these constraints are a reality, and already are reflected in waiting list management.

Thus, for each liver disease, the long term outcome of transplantation must be examined. Can transplantation be undertaken with good prospects for patient and graft …