Acquired cow's milk sensitization after liver transplant in an adult: "clinical implications" and future strategies.

BACKGROUND: Identifying the mechanisms responsible for the development of food allergy in liver transplant recipients is more complex as there are several different clinical scenarios related to the immunological function of the liver. CASE PRESENTATION: We describe the first case of Transplant Acquired Food Allergy (TAFA) to cow milk in an adult following LT from a donor dead because of anaphylactic shock. A 67-year-old woman with primary biliary cirrhosis was referred to the Transplant Center of our hospital because of an acute-on-chronic liver failure. The donor was a 15-year-old girl deceased for anoxic encephalopathy due to food induced anaphylaxis after eating a biscuit. In the donor's history food allergies to cow milk and eggs were present. CONCLUSION: This case emphasizes the need for a standardized assessment of both solid-organ donors and recipients including donor allergy history in order to detect recipients at risk for anaphylaxis due to passive IgE transfer. Despite several reports of TAFA after solid organ, especially liver, an appropriate protocol to avoid risk for the recipient doesn't exist at the moment. The SPT (skin prick test) or specific IgE level are not enough to ensure a correct management in these cases and a correct education of the patients and the medical staff involved is absolutely necessary. It is the first case of milk allergy sensitization after solid organ transplant by passive transfer of IgE.

Diaphragmatic hernia as a spontaneous sequela of a surgically-treated left infiltrating renal tumor: a case report.

A diaphragmatic hernia is a protrusion of abdominal structures within the thoracic cavity through a defect in the diaphragm, which can be either congenital or acquired. Diaphragmatic rupture, as a sequela following abdominal surgery, is rarely documented. Approximately 80% of the reported cases, the injury occurred on the left side. We discuss a case of a 37 year-old male who underwent a left nephrectomy with ipsilateral adrenalectomy and diaphragmatic resection, by direct reconstruction that developed the sequela of a diaphragmatic hernia. We chose a surgical transthoracic approach for herniation repair.

Early right hepatectomy for severe liver trauma: a case report.

Liver is frequently involved and injured in blunt abdominal trauma. Although over the last three decades the management of blunt hepatic trauma has gradually shifted toward nonoperative approach whit a significant reduction in overall mortality, surgery remains the main option for hemodinamically unstable patients whit severe liver injuries. A 16-yr-old male in good health suffered a blunt abdominal trauma from a sport accident falling while playing football resulting in a grade V liver injury according to the American Association for the Surgery of Trauma Organ Injury Score. He underwent first to liver packing and next to an early right hepatectomy to arrest the clinical condition impairment In high grade liver injuries, liver resection makes possible to effectively control bleeding, remove necrotic tissue and prevent complications as bile leak. Nevertheless when patient's clinical condition continue to deteriorate despite optimal management a quickly and experienced hands performed hepatectomy may solve the situation.

Spontaneous Bilateral Adrenal Haemorrhage after Duodenopancreatectomy: a case report.

it is difficult to diagnose because of its nonspecific presentation. This condition frequently occurs in association with an extreme physical stress and may lead to acute adrenal insufficiency or death if not promptly and properly treated. We report a rare case of acute bilateral adrenal hemorrhage with adrenal insufficiency following duodenopancreatectomy for ampulloma in absence of surgical complications. Early diagnosis and corticosteroid replacement with aggressive management of the precipitating pathology are essential to enable a successful outcome.

Conversion from twice-daily to once-daily Tacrolimus administration in liver transplant patient: results of long term follow-up.

OBJECTIVES: The aim of this study was to assess the long term effects of once-daily tacrolimus (OD-TAC) in a cohort of stable liver recipients converted from the twice daily tacrolimus (TD TAC), with a particular attention on the possible effects on renal function. PATIENTS AND METHODS: Between September 2008 and September 2010 conversion from TD-TAC to OD-TAC was proposed in adult stable liver transplant recipients who were followed as outpatients in our Transplant centre. Conversion from TC-TAC to OD-TAC was based on a 1 mg: 1 mg proportion. Tacrolimus through levels, laboratory parameters, metabolic disorders and any adverse events were evaluated at 1, 3, 6, 12 and 24 months after conversion. Renal function was evaluated using creatinine plasma levels and estimated glomerular filtration rate (GFR) derived from the Modification of Diet in Renal Disease (MDRD). Analysis of variance and t test for paired data were utilised for the comparison of the results obtained at the scheduled controls. RESULTS: Sixty-five patients were enrolled in the study (50 males, 15 females, mean age 59±8 years). Median time since liver transplant (LT) was 39 months (range: 6 to 83 months). All patients were followed for a minimum of 12 months. Ninety per cent of patients stabilized their blood levels within 45 days. Liver function, glucose and plasma lipids concentration and arterial blood pressure remained stable during the study. Renal function improved during the 24 months of follow-up. No adverse events or acute rejection episodes were recorded during the study. CONCLUSIONS: Considering the advantage on patient compliance, the equivalent efficacy and the adequate safety of OD-TAC formulation may represent a useful option in liver transplant patients, with a possible advantage on renal function.

Expanded criteria for hepatocellular carcinoma after liver transplantation: a 20-year evolution.

BACKGROUND/AIM: Milan Criteria (MC) consent excellent survivals for hepatocellular carcinoma (HCC) after liver transplantation (LT). However, several new expanded criteria were proposed, with the intent to increase the HCC patients eligible for LT, maintaining acceptable recurrence rates. The aim of the present study was to analyze a cohort of HCC patients, evaluating the evolutions in its management during the last 20 years and comparing the disease-free survivals among three different periods. METHODOLOGY: HCC patients (n = 122) were transplanted and stratified in three periods: 1st (1988-1998, liberal selection), 2nd (1999-2003, use of MC) and 3rd (2004-2008, use of UCSF criteria). The three periods were analyzed and their survivals were compared. RESULTS: Statistical differences were reported at univariate analysis regarding to both dimensional (total tumor diameter) and biological (alpha feto-protein, microvascular invasion) HCC features. Comparing the 5-year survival rates, a progressive increase was observed in the three periods (62.6%, 87.9% and 88.4%, respectively), with a significant difference between 1st and the second periods (p = 0.008). CONCLUSIONS: In our experience, use of UCSF criteria is safe, with a contemporaneous increased number of transplants and better survivals. Introduction of new selection criteria, also based on biological features, is on the way.

Safety of polymyxin-B-based hemoperfusion in kidney and liver transplant recipients.

Infection represents one of the primary barriers to successful organ transplantation. Our principal end point was to use a new assay, Entotoxin Activity Assay (EAA), which was developed to rapidly detect endotoxin activity (EA) for an early diagnosis of this complication. We also sought to prove the validity and safety of endotoxin removal using polymyxin-B-based hemoperfusion (PMX-DHP). The criterion for inclusion in the study was suspected infection when a patient experienced at least 2 of the 4 criteria of the systemic inflammatory response syndrome. EAA was performed on 71 patients: 29 liver transplantations and 42 kidney transplantations. Twenty-eight patients (39.5%) with EA >0.60 underwent PMX-DHP treatment to remove endotoxins. Each treatment was performed for 2 hours with a blood flow of 100 mL/min. All of the patients were treated with PMX-DHP until achieving an EA <0.4. Stabilization of hemodynamic and inflammatory frameworks was observed after the PMX-DHP. At 30 days follow-up, all of the patients were alive with good graft function and low levels of EA. We think it might be useful to determine EA routinely in transplant patients and look forward to large multicenter clinical trials to accurately assess the benefits of the EAA plus DHP-PMX to treat transplant patients with sepsis.

Does caval reconstruction technique affect early graft function after liver transplantation? A preliminary analysis.

BACKGROUND: In the past decades, the inferior vena cava (IVC) reconstruction technique has undergone several evolutions, such as biopump, piggyback technique (PB), and laterolateral approach (LLPB). Several advantages are reported comparing the PB technique to biopump use. However, comparison between PB and LLPB has not been as well investigated. The aim of this study was to compare the results in terms of immediate graft function and intermediate graft survival among 3 subgroups characterized by distinct caval reconstruction techniques. METHODS: We retrospectively analyzed a cohort of 200 consecutive adult patients who underwent liver transplantation from January 2001 to December 2009. The patients were stratified according to 3 caval reconstructive techniques: biopump (n=135), PB (n=32) and LLPB (n=33). RESULTS: The LLPB group showed the shortest cold and warm ischemia times and the best immediate postoperative graft function. Survival analysis revealed LLPB patients to present the best 1-year graft survival rates: namely, 90.9% versus 75.0% and 74.1% among the PB and biopump groups, respectively (log-rank tests: LLPB vs biopump: P=.03; LLPB vs PB: P=.05). In our experience, LLPB showed the best graft survivals with an evident reduction in both cold and warm ischemia times. However, it is hard to obtain an irrefutable conclusion owing to the retrospective nature of this study, the small sample, and the different periods in which the groups were transplanted. CONCLUSIONS: LLPB technique was a safe procedure that minimized the sequelal of ischemia-reperfusion damage. This technique yielded results superior to venovenous bypass. No definitive conclusions can to be obtained in this study comparing classic PB or LLPB.

Impact of anti-hepatitis B core-positive donors in liver transplantation: a survival analysis.

INTRODUCTION: The current shortage of organs for liver transplantation (OLT) requires expansion of the donor pools. A possible approach to this problem may be the use of donors positive for antibody against hepatitis B core antigen (anti-HBc). However, it is not clear whether recipients who receive anti-HBc-positive livers show worse survival. The aim of this study was to retrospectively analyze the patient and graft survivals of two groups of OLT recipients according to the anti-HBc status of their respective donors. METHODS: We stratified 133 patients into group 1 (n = 120; anti-core-negative donors) versus group 2 (n = 13; anti-core-positive donors). RESULTS: Comparing the two groups by univariate analysis, there was no significant differences with regard to recipient, donor, or transplant characteristics. Group 2 showed worse 5-year patient (46.2% vs 72.0%; P = .006) and graft survivals (38.5% vs 68.4%; P = .003). After adjustment for several risk factors for post-OLT death and graft failure, there was no significant difference between patients who received anti-core-positive versus anti-core-negative donors, in terms of patient and graft survivals, particularly only after adjustment for Model for End-stage Liver Disease (MELD) degree of severity. CONCLUSION: The use of anti-HBc-positive donors resulted in worse post-OLT patient and graft survival rates. Unlike the results obtained in the United States, we did not find possible confounders in our results, excluding MELD ≥ 20. However, due to the small size of our cohort, future prospective multicenter studies are required to clarify the safety of anti-core-positive grafts.

Bone disorders in patients with chronic liver disease awaiting liver transplantation.

BACKGROUND: An important complication of chronic liver disease is osteodystrophy, which includes osteoporosis and the much rarer osteomalacia. Both conditions are associated with significant morbidity through fractures resulting in pain, deformity, and immobility. Liver transplantation may further deteriorate bone metabolism. The aim of the present study was to investigate the frequency and severity of hepatic osteodystrophy among patients with liver cirrhosis who were referred for liver transplantation. We also evaluated modifications in bone metabolism after liver transplantation. MATERIALS AND METHODS: We recruited 35 consecutive patients with chronic liver disease who were undergoing assessment for transplantation over a 1-year period. Bone mass in the total skeleton and proximal hip was evaluated using a dual-energy X-ray absorptiometry device (Lunar Prodigy Advance, GE Healthcare, USA). According to World Health Organization recommendations, osteoporosis was defined as a T score < -2.5 and osteopenia as T score between -1 and -2.5. RESULTS: We enrolled in the study 35 patients, including 8 females and 27 males of overall mean age of 57 +/- 7, who showed a viral etiology (57%) or alcohol etiology (28%), Child-Pugh 8.7 +/- 2.3. The overall prevalence of osteodystrophy was 40% (26% osteopenia and 14% osteoporosis). No difference was evident according to gender, severity of liver disease (Child-Pugh, Model for End-stage Liver Disease), or origin of liver disease. A subgroup of 10 transplanted patients reached 3-month follow-up, showing total body T score with a significant decrease after 3 months while femoral T scores tended to decrease insignificantly. CONCLUSIONS: This study revealed a high prevalence of low bone mineral density among cirrhotic patients before liver transplantation. We suggest that both bone mineral density and biochemical examinations should be considered to be routine tests to identify the status of bone mass and bone metabolism among recipients prior to liver transplantation.

Preoperative donor scores and postoperative early measures of graft function: relevance to the outcome of liver transplantation.

BACKGROUND: Several donor and recipient parameters play a role in the determination of post-liver transplant allograft function. The identification of prognostic indices presents great implications for correct allocation of donors and more targeted recipient management. The aim of our review was to detect the role of preoperative scoring systems and early postoperative measures of graft function as predictive factors for the development of graft failure and recipient death. METHODS: We stratified a cohort of 97 patients in two groups according to a 1-year functional (Group A; n = 72) versus non-functional (Group B; n = 25) status of the allograft. RESULTS: Patients in group B showed higher preoperative Model for End-stage Liver Disease (MELD) values, longer warm ischemia times, reduced bile outputs and increased peak values of transaminases and INR content within the first 3 days after transplantation. Group B showed 48% of patients with initial poor graft function. The parameters which resulted in a significant prediction of graft loss by multivariate analysis were MELD (P = .012); postoperative day 1 serum alanine aminotransferase (ALT) (P < .0001) and day 3 ALT (P = .003). The predictive factors for patient death were postoperative day 1 serum ALT (P < .0001) and day 3 ALT (P = .001). CONCLUSIONS: MELD score was a useful preoperative parameter for the prediction of post-transplant graft survival. Early ALT values predicted both graft and recipient survivals. Minimization of parameters related to their peaks (warm ischemia time) may improve graft and patients survival rates.

Conversion from twice-daily to once-daily tacrolimus administration in liver transplant patient.

BACKGROUND: Compliance to immunosuppressive therapy is critical to prevent organ rejection and possible graft loss. A once-daily Tacrolimus formulation that may improve adherence-to-therapy while allowing the same patient care strategies, total daily dose and monitoring techniques that have been recently approved. The present study was sought to evaluate the feasibility of this formulation among liver transplantation patients (OLT). MATERIALS AND METHODS: Patients transplanted for at least 6 months were enrolled if they had stable doses of Tacrolimus over the last 3 months. Conversion from a twice to a once-daily regimen was based on a 1 mg:1 mg proportion. Tacrolimus blood levels were assessed at 0, 15, 30, 60, 90 days as well and 6 months after conversion. We recorded liver and renal function as well as adverse events. RESULTS: Among twenty-eight patients enrolled in the study including 23 males and 5 females the overall mean age was 59 +/- 8 years and the mean distance from OLT was 39 +/- 22. 32% of patients did not require any dose adjustment. In contrast, 43% required an increase (+0.6 +/- 0.3 mg/d), while 25%, a decrease (-0.5 +/- 0.0 mg/d) in the drug dose to maintain the same tacrolimus blood concentrations as at baseline. Ninety percent of patients stabilized blood levels within 45 days. None of the patients experienced adverse events or alterations in liver function. CONCLUSIONS: Our study confirmed that once-daily Tacrolimus is a useful therapeutic option for OLT patients; however dose adjustments are frequently needed in the short term. The drug is safe and may improve patient compliance.

Adacolumn treatment in kidney transplant patients with hepatitis C virus.

INTRODUCTION: Patients who have undergone kidney transplantation and suffer from hepatitis C (HCV) cannot be treated with standard therapy (pegylated interferon combined with ribavirin) due to the risk of acute rejection. Furthermore, immunosuppressive therapy facilitates the progression of infection and chronic hepatopathies. Monocytes and macrophages are known to produce extrahepatic breeding sites that spread disease. Our aim was to reduce macrophages, granulocytes, monocytes, proinflammatory cells, and viremia levels using an extracorporeal device: Adacolumn Leukocyte Apheresis (Otzuka Electronics, Japan). METHODS: The Adalcolumn filter is filled with 2-mm cellulose acetate beads immersed in sterile saline solution. These carriers absorb granulocytes and monocytes/macrophanges through their FCR receptors. Six patients affected by viral genotype 1b underwent five 1-hour treatments for 5 consecutive days. RESULTS: Viremia was reduced in Patients 1, 2, 4, and 6 in association with decreased pro-inflammatory cytokine levels and a normal CD4/CD8 T-cell ratio, after 3 months. Subjects 1 and 3 showed inverted CD4(+)/CD8(+) T-cell ratios, which changed at 4-month follow-up in only patient 1. Subject 5 did not show any changes. CONCLUSIONS: The treatment was safe without hemodynamic or infectious complications, suggesting that this method could be used in a greater number of patients to evaluate amelioration of increased viremia.

Predictive factors of recurrence of hepatocellular carcinoma after liver transplantation: a multivariate analysis.

We analyzed predictive risk factors for recurrence of hepatocellular carcinoma (HCC) after orthotopic liver transplantation (OLT). We retrospectively analyzed the clinical data from 109 consecutive HCC patients who underwent OLT at our center from 1988 to 2007. We excluded all patients who died due to factors other than tumor recurrence within the first year (n = 24). The remaining 85 patients were enrolled in either a recurrence group (A; n = 19) or a nonrecurrence group (B; n = 66). Upon univariate analysis, the 2 groups were significantly different for 11 parameters. Group A included more females (P = .05), noncirrhotic liver recipients (P = .003), "up-to 7 status" patients (HCC with 7 as the sum of the size of the largest tumor [cm] and the number of tumors, P < .0001), patients exceeding Milan criteria (MC; P < .0001) or University of California San Francisco (UCSF) criteria (P < .0001), and OLT performed before 1999 (P = .003). Group A also showed a higher number of lesions (P = .035), a greater sum of diameters of the lesions (P < .0001), a major number of macrovascular (P < .0001) and microvascular invasions (P < .0001), and an increased number of G3-G4 grading (P = .006). Only microvascular invasion (P = .007) and exceeding UCSF criteria (P = .003) were independent risk factors for recurrence upon multivariate analysis. Patients with both these parameters are not candidates for OLT. Microvascular invasion is a good predictive parameter, but is impossible to detect preoperatively. New pre-OLT predictive risk factors are needed to achieve optimal results.

Immune-mediated liver dysfunction after antiviral treatment in liver transplanted patients with hepatitis C: allo or autoimmune de novo hepatitis?

BACKGROUND: The recurrence of hepatitis C after liver transplantation is extremely frequent. Antiviral therapy combining pegylated-interferon with ribavirin is therefore increasingly used in these patients. It has been recently reported, however, that during antiviral treatment a hepatic immune-mediated liver dysfunction, similar to "de novo" autoimmune hepatitis, may develop in a few transplanted patients. PATIENTS AND METHODS: Three patients, treated with pegylated-interferon alpha-2a and ribavirin for recurrent hepatitis C after liver transplantation, developed an aggressive hepatitis with clinical, biochemical, and histological features similar to those of autoimmune hepatitis. RESULTS: In all three patients, a liver enzymes increase was evident after hepatitis C virus-RNA had become undetectable. Diagnosis of "de novo" autoimmune hepatitis was proposed, based on the presence of high-titre circulating autoantibodies and liver histology features. Following the introduction of a steroid therapy, clinical and biochemical parameters progressively improved. Hepatitis C virus infection, however, relapsed after a few months in all the patients. CONCLUSIONS: Following liver transplantation, antiviral therapy with pegylated-interferon alpha-2a and ribavirin for recurrent hepatitis C may be associated, in a few patients, with severe immune-mediated graft dysfunction similar to autoimmune hepatitis.

Primary nonfunction: timing retransplantation versus hemodynamic parameters and kidney function.

BACKGROUND: Patients with acute liver failure (ALF) show an aggravated hyperdynamic circulation. We evaluated potential changes in systemic hemodynamics and improved kidney function induced by the molecular adsorbent recirculating system (MARS) in a group of patients with primary nonfunction (PNF). PATIENTS AND METHODS: In the intensive care unit we treated 18 patients with PNF (6 females and 12 males) after orthotopic liver transplantation (OLT) of overall mean age 47.8 years (range, 28-60 years). Continuous MARS treatment was performed on all patients with a kit change every 8 hours during a mean of 10 days (range, 1-20 days). Double-lumen catheter type veno-venous access was used for the blood supply. The blood flow rate was 150 to 250 mL/min, depending on the hemodynamic situation of the patient. Blood passed through an albumin nonpermeable, high flux dialysis membrane. During MARS treatment we monitored the hemodynamic condition, using a series of parameters: heart rate (HR), mean arterial pressure (MAP), cardiac index (CI), systemic vascular resistance index (SVRI), and pulmonary vascular resistance index (PVRI) before (baseline value) as well as after 1 hour (T1), 3 hours (T2), and the end of treatment (T3). RESULTS: There was a progressive decrease in positive inotropic support (dobutamine, norepinephrine) and significant improvement in hemodynamic parameters, such as MAP (P< .01), PVRI/SVRI/V(mean) (P< .002), and KARI (P< .01). The improved kidney functions were shown by significant improvements in serum creatinine (P< .03), urea (P< .02), and urine volume (P< .005). Eleven patients were alive: 6 with OLT and 5 without OLT. Seven patients died: 4 after OLT and 3 before OLT due to multiorgan failure. CONCLUSIONS: The MARS device significantly improved the hemodynamic parameters and kidney function that also determine patient survival in ALF (61.1%) with PNF while awaiting retransplantation presumably by removal of certain vasoactive substances.

Pediatric acute liver failure with molecular adsorbent recirculating system treatment.

BACKGROUND: The prognosis of pediatric acute liver failure (PALF) has been significantly improved by emergency orthotopic liver transplantation (OLT). Since 2004, the molecular adsorbent recirculating system (MARS) has been proposed as a bridging procedure. The aim of our study was to assess its efficacy in children with PALF. PATIENTS AND METHODS: Since 1999 we performed treatment of 39 fulminant hepatic failure (FHF) cases with MARS. Since September 2004 we treated 6 pediatric patients with FHF who were of mean age 10.6 years (range, 3-15 years) including 4 females and 2 males. In 3 cases the cause of FHF was unknown; in 2 cases, it was induced by paracetamol overdose; and in 1, by acute hepatitis B virus. Inclusion criteria were: bilirubin >15 mg/dL; creatinine >or=2 mg/dL; encephalopathy grade >II; and International normalized ratio (INR) >2.5. Other estimated parameters were: AST and ALT serum levels, lactate, and urine volume. Neurological status was monitored using the Glasgow Coma Scale (GCS). Continuous MARS treatment was performed in all patients with a kit change every 8 hours. Intensive care unit (ICU) treatment was applied to optimize regeneration and to prevent cardiovascular complications. RESULTS: We observed a significant improvement among levels of bilirubin (P< .009), ammonia (P< .005), creatinine (P< .02), GCS (P< .002), and predictive criteria and as Sequential Organ Failure Assessment (SOFA) and Pediatric End-Stage Liver Disease (PELD). Three children underwent OLT: 1 died after 5 days due to primary nonfunction and 2 children are alive after a median follow-up of 14 months. In 2 children the MARS treatment led to resolution of clinical status without liver transplantation. One child died before OLT due to sepsis and multiorgan failure. CONCLUSIONS: We concluded that application of the MARS liver support device in combination with experienced ICU management contributed to improve the clinical status in children with PALF awaiting liver transplantation.

Combined liver-kidney transplantation in polycystic disease: case reports.

Polycystic disease causes a progressive decrease in renal function and liver degeneration. The progression of the disease evolves separately between organs and transplantation options vary: simultaneous or sequential liver-kidney transplantation or single-organ transplantation. From September 2006 to June 2007 3 combined liver kidney transplantations (CLKT) were performed for polycystic disease with end-stage renal disease: 2 with polycystic liver disease, and 1 with hepatic failure due to congenital hepatic fibrosis. The widest dimensions of the polycystic liver of 50 and 60 cm diameter were due to extensive cystic degeneration. We performed 1 simultaneous CLKT and 2 sequential transplantations: 1 liver after kidney, and 1 kidney after liver. At present all patients are alive with 100% graft function. Median creatinine level at discharge was 0.9 mg/dL (ranges, +/-0.2). Good liver graft function was reported in all 3 cases. Transplant benefit in polycystic liver-kidney disease has been already demonstrated; conservative surgical options may result in a high incidence of complications in highly involved polycystic livers. Delaying transplantation results in a more difficult surgical technique, a higher rate of postoperative complications, and a disturbance of optimal graft retrieval because of the worse preoperative condition of the patients.

Is legalizing the organ market possible?

INTRODUCTION: Two opposing views of the human body have existed since time began. Can it be traded or does its value go beyond a monetary one? Today it is illegal to sell organs but the success of organ transplantation has give rise to an enormous controversy. The continued increase in the need for organs has lead to a major use of live donors. Consequently, clandestine selling of organs is becoming more widespread for two main reasons: scientific progress and market demand. Our aim was to consider the protection of ethical principles through legislation. MATERIALS AND METHODS: Based on the principle that it is morally unacceptable for people to die on a waiting list, we analysed various ways in which the National Health Service could give incentives to live donors, including reimbursement of health expenses, tax relief, pension or early retirement benefits, or education grants for the children. Possible incentives for cadaveric organ donation included reimbursal of health and funeral costs, or increase in widow/er's pension. CONCLUSION: The tendency may be toward reimbursement of costs rather than actual payments. A legal, ethical organ market could save thousands of human lives, but it must be correctly regulated.