Liver allocation: urgency of need or prospect of success? Ethical considerations.

In German legislation and in Eurotransplant's practice of liver allocation, urgency of need is considered as the primary distribution criterion. However, at a certain stage, the "sickest-first" principle is regarded as counterproductive as the performance status of these patients receiving an organ is on average critical and mortality and morbidity after liver transplantation increase. Within the medical transplant community, the criterion of prospect for success is highly accepted. As clinicians having a certain scope in decision-making as "gatekeepers" in regard to which patient gets on the waiting list and at which stage a patient is defined as "not transplantable" and as transplantation centers aspire good success rates, the goal of high prospect for success might become more weighty than intended by legislation and professional guidelines. From an ethical point of view, it is submitted a so-called mediatory approach in between the two extremes "sickest-first" and "fittest-first." Beyond that, it is argued for further development of a prognostic score for post-operative outcome after liver transplantation - as long as questions of social justice are borne in mind - to support "objective" decision-making.

Quantitative therapy response assessment by volumetric iodine-uptake measurement: initial experience in patients with advanced hepatocellular carcinoma treated with sorafenib.

OBJECTIVES: To investigate the volumetric iodine-uptake (VIU) changes by dual-energy CT (DECT) in assessing the response to sorafenib treated hepatocellular carcinoma (HCC) patients, compared with AASLD (American Association for the Study of Liver Diseases) and Choi criteria. MATERIALS AND METHODS: Fifteen patients with HCC receiving sorafenib, monitored with contrast-enhanced DECT scans at baseline and a minimum of one follow-up (8-12 weeks) were retrospectively evaluated. 30 target lesions in total were analyzed for tumor response according to VIU and adapted Choi criteria and compared with the standard AASLD. RESULTS: According to AASLD criteria, 67% target lesions showed disease control: partial response (PR) in 3% and stable disease (SD) in 63%. 33% lesions progressed (PD). Disease control rate presented by VIU (60%) was similar to AASLD (67%) and Choi (63%) (P>0.05). For disease control group, change in mean VIU was from 149.5 ± 338.3mg to 108.5 ± 284.1mg (decreased 19.1 ± 42.9%); and for progressive disease group, change in mean VIU was from 163.7 ± 346.7 mg to 263.9 ± 537.2 mg (increased 230.5 ± 253.1%). Compared to AASLD (PR, 3%), VIU and Choi presented more PR (33% and 30%, respectively) in disease control group (P<0.05). VIU has moderate consistency with both AASLD (kappa=0.714; P<0.005) and Choi (kappa=0.648; P<0.005), while VIU showed a better consistency and correlation with AASLD (kappa=0.714; P<0.005; r=0.666, P<0.005) than Choi with AASLD (kappa=0.634, P<0.005; r=0.102, P=0.296). CONCLUSION: VIU measurements by DECT can evaluate the disease control consistent with the current standard AASLD. Measurements are semi-automatic and therefore easy and robust to apply. As VIU reflects vital tumor burden in HCC, it is likely to be an optimal tumor response biomarker in HCC.