Ann Surg 1998 Sep;228(3):411-20

Long-term results of pediatric liver transplantation: an analysis of 569
transplants.

Goss JA, Shackleton CR, McDiarmid SV, Maggard M, Swenson K, Seu P, Vargas J,
Martin M, Ament M, Brill J, Harrison R, Busuttil RW

Dumont-UCLA Transplant Center, Department of Surgery, UCLA School of Medicine,
Los Angeles, California 90095, USA.

Abstract

OBJECTIVE: To analyze a single center's 13-year experience with 569 pediatric
orthotopic liver transplants for end-stage liver disease. SUMMARY BACKGROUND
DATA: Despite advances in medical therapy, liver replacement continues to be the
only definitive mode of therapy for children with end-stage liver disease.
Innovative surgical techniques and improved immunosuppression have broadened the
application of liver replacement for affected children. However, liver
transplantation in the child remains challenging because of the scarcity of
donor organs, complex surgical technical demands, and the necessity to prevent
long-term complications. METHODS: The medical records of 440 consecutive
patients younger than 18 years of age undergoing orthotopic liver
transplantation for end-stage liver disease from March 20, 1984, to November 15,
1997, were reviewed. Results were analyzed using Cox multivariate regression
analysis to determine the statistical strength of independent associations
between pretransplant covariates and patient and graft survival. Actuarial
patient and graft survival rates were determined at 1, 3, 5, and 10 years. The
type and incidence of posttransplant complications were determined, as was the
quality of long-term allograft function. The median follow-up period was 4.1
years. RESULTS: Biliary atresia was the most common cause (50.4%) of endstage
liver disease in this patient population. The median recipient age was 2.4
years; 239 patients (54%) were younger than 3 years of age and 1 11 patients
(25%) were younger than 1 year of age. There were 471 whole organs, 29 were ex
vivo reduced size, 33 were living-related donor, and 36 were in situ split-liver
allografts. Three hundred forty-three (78%) patients underwent a single
allograft, whereas 97 patients required retransplantation; hepatic artery
thrombosis was the most common indication for retransplantation (55 patients).
The 1-, 3-, 5-, and 10-year actuarial patient survival rates were 82%, 80%, 78%,
and 76%, respectively; allograft survival rates were 68%, 63%, 60%, and 54%.
Long-term liver function remains excellent: current median follow-up values for
total bilirubin and aspartate aminotransferase were 0.5 mg/dl and 54 IU/L,
respectively. Cox multivariate regression analysis demonstrated that
pretransplant patient age, the era of transplantation, and the number of
allografts performed significantly and independently predicted patient survival
rates, whereas allograft type and pretransplant diagnosis did not. CONCLUSIONS:
Liver transplantation in the pediatric patient is a durable procedure that
provides excellent long-term survival. Although there have been overall
improvements in patient outcome with increased experience, the effect is most
pronounced for patients younger than 1 year of age. Retransplantation, although
effective in a meaningful number of patients, continues to carry a progressive
decrement in survival with the number of allografts performed. Use of
living-related and in situ split-liver allografts has dramatically reduced
waiting times for small children and has improved patient survival.