**6.2 Investigate the indication of liver transplantation for uncontrollable liver trauma**

In conclusion, we largely agree with the aforementioned reports. The therapeutic option of liver transplantation also needs to be accessible for patients with liver injuries caused by trauma. However, not least due to the mentioned poor transplantation results in severely injured patients, indication for transplantation needs to be critically proposed by the attending surgeons.

#### **6.3 Try to answer the question – Is transplantation a valuable option or just a "waste of organs" in polytraumatized patients with liver injury –**

It is essential to sensibly and appropriately allocate the organs so that the shortage of donor organs is not further enlarged. In patients where no hemodynamic stabilization can be achieved despite exhaustion of all extensive care measures, transplantation should not be considered any further. Although, there is a fundamental difference regarding the timeframe after trauma during which patients are to be transplanted. It has shown, that especially patients with acute, non-controllable liver injuries as described by us have clinically changed for the worse rapidly after transplantation and have died in MOF. Therefore, we postulate that indication for transplantation in these patients may only be provided after critically reviewing every single case as not to "waste of organs".

#### **6.4 Identifying new approaches to improving organ donation**

It should be noted that the success of transplantation medicine with a simultaneously increasing shortage of donor organs will only be assured if all available resources are exploited. Increasing acceptance of "expanded criteria donor" organs appears more justified than ever under these circumstances, but also with sustained good results despite constantly deteriorating organ quality. Approaches to increase the transplant quality, not only of extended criteria donor (ECD) organs, offer further developed possibilities that support perfusion such as machine perfusion and optimized perfusion solutions. Moreover, shortened ischemic periods are achieved through further improved logistics and allocation processes, which together with individualized, medicinal immune suppression ultimately benefit the transplant and the organ recipient. In addition to this continuously improving and thus optimized use of postmortal organs, it must also be the common objective of the medical profession and politics to increase the overall number of donor organs and to improve their quality.

In order to achieve this, priority should be given to an improved exploitation of the existing organ donation potential through hospital-based advising, for example by a contact person for organ donation at each intensive care unit. Information and advising by Eurotransplant and the transplant centers for physicians, nursing staff and the population are of key importance here. Furthermore, to an ever great extent it will be the task of all parties involved in the field of transplantation to present organ donation, the allocation and transplantation of organs, and all the decisive aspects relating to the readiness of organ donation such as trust, safety and equity in a transparent manner. Conducting advisory discussions on the topic of organ donation with the relatives of the deceased is a special task for physicians. One measure should include involving a physician with special communicative expertise. It remains to be hoped that in this way a higher acceptance rate for organ donation will be more successfully achieved throughout all population groups in the future. In tapping into all resources and approaches for the optimized exploitation of donated postmortal organs, it should be possible to assure the medical care mandate of transplantation medicine in Germany in the future as well.

Based on previous studies, the recording of organ donors with "expanded criteria" in a targeted analysis is useful and necessary for new ways of improving organ donation. Further local, national and international analyses are additionally necessary to identify the limits to expanding donor acceptance criteria.
