One hundred thirty-two consecutive pediatric liver transplants without hospital mortality: lessons learned and outlook for the future

Abstract

Objective: Orthotopic liver transplantation (OLT) has become an established procedure for the treatment of pediatric patients with end-stage liver disease. Since starting our program in 1989, 422 pediatric OLTs have been performed using all techniques presently available. Analyzing our series, we have concluded that the year of transplantation is the most important prognostic factor in patient and graft survival in a multivariate analysis.

Methods: From April 2001 to December 1, 2003, 18 whole organs (14%), 17 reduced-size organs (13%), 53 split organs (42%; 46 ex situ, 7 in situ), and 44 organs from living donors (33%) were transplanted into 115 patients (62 male and 53 female). One hundred twelve were primary liver transplants, 18 were retransplants, one third and one fourth liver transplants. Of the 132 OLTs, 26 were highly urgent (19.7%). The outcome of these 132 OLTs was retrospectively analyzed.

Results: Of 132 consecutive pediatric liver transplants, no patients died within the 6 months posttransplantation. Overall, 3 recipients (2%) died during further follow-up, 1 child because of severe pneumonia 13 months after transplantation and the second recipient with unknown cause 7 months postoperatively, both with good functioning grafts after uneventful transplantation. The third had a recurrence of an unknown liver disease 9 months after transplantation. The 3-month and actual graft survival rates are 92% and 86%, respectively. Sixteen children (12%) had to undergo retransplantation, the causes of which were chronic rejection (3.8%), primary nonfunction (3.8%), primary poor function (PPF; 1.5%), and arterial thrombosis (3%). The biliary complication rate was 6%; arterial complications occurred in 8.3%; intestinal perforation was observed in 3%; and in 5%, postoperative bleeding required reoperation. The portal vein complication rate was 2%.

Conclusions: Progress during the past 15 years has enabled us to perform pediatric liver transplantation with near perfect patient survival. Advances in posttransplant care of the recipients, technical refinements, standardization of surgery and monitoring, and adequate choice of the donor organ and transplantation technique enable these results, which mark a turning point at which immediate survival after transplantation will be considered the norm. The long-term treatment of the transplanted patient, with the aim of avoiding late graft loss and achieving optimal quality of life, will become the center of debate.

FIGURE 1. Patient versus graft survival after 132 consecutive pediatric liver transplants between April 2001 and December 2003.

FIGURE 2. Patient survival in different periods (period 1, 1991–1994, n = 70; period 2, 1995–1997, n = 83; period 3: 1998–2000, n = 87; period 4, 2001–2003, n = 121) after pediatric liver transplantation at the University of Hamburg.

FIGURE 3. Graft survival according to the different types of grafts used during April 2001 and December 2003. LR, n = 44; split, n = 53; OLT, n = 18; RED, n = 17. Log-rank test: LR versus split, P = 0.2244; LR versus OLT, P = 0.135; LR versus RED, P = 0.0053

FIGURE 4. Evolution of perioperative morbidity and PNF from 1997 until 2003.