Choosing a pediatric recipient for orthotopic liver transplantation

Abstract

Between March 3, 1981, and June 1, 1984, 216 children were evaluated for orthotopic liver transplantation. Of the 216 patients, 117 (55%) had received at least one liver transplant by June 1, 1985. Fifty-five (25%) died before transplantation. The 117 patients who received transplants were grouped according to severity of disease and degree of general decompensation at the time of transplantation. The severity of a patient's medical condition with the possible exception of deep hepatic coma, did not predict outcome following orthotopic liver transplantation. Severity variables were assessed at the time of the evaluation. Twenty-three of the 70 variables were found to have prognostic significance with regard to death from progressive liver disease before transplantation. These 23 variables were incorporated into a multivariate model to provide a means of determining the relative risk of death among pediatric patients with end-stage liver disease. This information may allow more informed selection of candidates awaiting liver transplantation.The advent of cyclosporine and advances in surgical technique changed the status of orthotopic liver transplantation from an experimental procedure to accepted care for lethal liver disease. 1 As 1-year survival probabilities approached 66% of OLTx recipients in late 1981 and early 1982, 2 the question of who should receive the next available organ took on critical importance. The improvement in success of OLTx increased the number of children referred for the procedure. More referrals not only sparked an increase in transplantation but drew attention to the shortage of available organs. 3 Twenty-five percent of referred children died of progressive liver disease before transplantation because an appropriate organ could not be located. Donated organs became a precious resource, and their utilization demanded a logical approach to recipient selection.The process of selecting a recipient when a donor liver becomes available is determined primarily by matching the donor and recipient according to size and according to ABO blood group, conforming to blood banking rules of blood transfusions. 4 In situations of great urgency, even ABO incompatibility may be disregarded as a condition for donor recipient matching. 5 No attempt to match minor red cell antigens or Rh factor is made. Extensive tissue typing is not performed because of time constraints, 4 and it appears from retrospective analysis that it may be unnecessary. 4, 5 A number of appropriately matched potential recipients may exist for each donated organ. We attempted to determine whether providing a transplant for the sickest available potential recipient has an adverse effect on transplantation outcome, and second, to develop criteria to distinguish the sickest patient among those with heterogeneous but lethal liver diseases.

Pediatric liver transplantation: 10 years of experience at a single center in Brazil

“…Este estudo tem como objetivo descrever a experiência dos 10 A atresia biliar foi a doença subjacente mais freqüente (Tabela 2). As indicações do transplante nos quatro pacientes com classificação de Child-Pugh A foram prurido intratável (em um paciente com síndrome de Alagille) e hemorragia digestiva alta secundária a hipertensão porta em três pacientes.…”

Transplante hepático pediátrico: experiência de 10 anos em um único centro no Brasil

“…13 The great majority of biliary complications are secondary to thrombosis of the hepatic artery, 28 and were observed in 7.1% of our cases, which is comparable to what is reported in the literature (5 to 30%). 3 One of our patients had lymphoproliferative disease (2.3%), which is described as affecting 5 to 15% of children after transplantation, 10,22,29,30 The principal causes of immediate repeat transplants are primary non-function of the graft and thrombosis of the hepatic artery, 3,8,13,18,22 while, over the long term, chronic rejection is the number one indication. 8 In our sample there were two repeat transplants due to thrombosis of the hepatic artery.…”

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“…Fasting blood sugar ≥ 110 mg/dL are considered abnormal. According to the National Cholesterol Education Program/Adult Treatment Panel III criteria, for children, existence of 3 or more of these factors will establish a diagnosis of metabolic syndrome 6 (Table 1).…”

“…3 In long-term follow-up of pediatric liver transplant recipients, preoperation obesity has correlated with high mortality rate after transplant. 6 Fifteen to 21% of children are overweight or have severe obesity before transplant. Posttransplant, these statistics are 18% to 67%, with variability according to age and preoperation weight.…”