Fifteen-Year Trends in Pediatric Liver Transplants: Split, Whole Deceased, and Living Donor Grafts

Mogul, Douglas; Luo, Xiaobin; Bowring, Mary G.; Chow, Eugene M.; Massie, Allan B.; Schwarz, Kathleen B.; Cameron, Andrew M.; Bridges, John F.P.; Segev, Dorry L.

doi:10.1016/j.jpeds.2017.11.015

Cited by 86 publications

(113 citation statements)

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“…Increasing evidence suggests that outcomes following SLT and WLT are similar . However, this assessment should not be taken to indicate that risk of graft failure is equivalent for all subgroups of patients.…”

Section: Discussionmentioning

confidence: 99%

“…The Studies in Pediatric Liver Transplantation Consortium published outcomes from 1995 to 2006 and identified both higher rates of graft failure as well as biliary strictures and vascular complications in children receiving technical variant grafts . However, it is not clear if these complications currently exist at higher rates in SLT, especially given more recent reports that graft failure in SLT, both immediate and long term, is currently equivalent to WLT . Reports from adult literature have been conflicting with some studies showing similar rates of biliary stricture and vascular thromboses, whereas other studies still showing higher rates of these surgical complications .…”

Section: Discussionmentioning

confidence: 99%

“…The use of split‐liver transplantation (SLT) represents an opportunity to increase the supply of organs and has the potential to shorten wait‐list times and decrease pretransplant morbidity and mortality, particularly for children. Recent evidence suggests that outcomes following SLT are now likely comparable to whole liver transplantation (WLT) for both pediatric and adult recipients . At the same time, the benefits of SLT may vary among patients with different donor, recipient, or surgical characteristics.…”

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confidence: 99%

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Expansion of the Liver Donor Supply Through Greater Use of Split‐Liver Transplantation: Identifying Optimal Recipients

et al. 2019

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The increased use of split liver transplantation (SLT) represents one strategy to increase the supply of organs. Although outcomes after SLT and whole liver transplantation (WLT) are similar on average among pediatric recipients, we hypothesized that the relationship between graft type and outcomes may vary depending on patient, donor, and surgical characteristics. We evaluated graft survival among pediatric (<18 years), deceased-donor, liver-only transplant recipients from March, 2002, until December, 2015, using data from the the Scientific Registry of Transplant Recipients. Graft survival was assessed in a Cox proportional hazards model, with and without effect modification between graft type and donor, recipient, and surgical characteristics, to identify conditions where the risk of graft loss for SLT and WLT were similar. In a traditional multivariable model, characteristics associated with graft loss included donor age >50 years, recipient weight <10 kg, acute hepatic necrosis, autoimmune diseases, tumor, public insurance, and cold ischemia time (CIT) >8 hours. In an analysis that explored whether these characteristics modified the relationship between graft type and graft loss, many characteristics associated with loss actually had similar outcomes irrespective of graft type including weight <10 kg, acute hepatic necrosis, autoimmune diseases, and tumor. In contrast, several subgroups had worse outcomes when SLT was used, including recipient weight 10-35 kg, non-BA cholestasis, and metabolic disease. Allocation score, share type, or CIT did not modify risk of graft type and graft failure. Although one might anticipate that individuals with higher rates of graft loss would be worse candidates for SLT, data suggest that these patients actually have similar rates of graft loss. These findings can guide surgical decision-making and may support policy changes that promote the increased use of SLT for specific pediatric recipients. This article is protected by copyright. All rights reserved.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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confidence: 99%

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Expansion of the Liver Donor Supply Through Greater Use of Split‐Liver Transplantation: Identifying Optimal Recipients

et al. 2019

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“…Deceased donor split‐liver transplantation (SLT) holds the potential to increase the donor organ pool in the era of organ shortage . SLT was originally introduced and is now widely accepted in the pediatric population, but it remains underused in adults . SLT is a technically more challenging operation than whole‐liver transplantation (WLT), leading to worse outcomes in the immediate and early postoperative periods .…”

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confidence: 99%

“…As we have learned more about SLT, numerous efforts have attempted to mitigate these technical and strategical difficulties. Examples include in situ splitting to decrease CIT, optimal vessel‐sharing strategies, introduction of vascular reconstruction techniques from living donor liver transplantation (LT), and optimizing donor‐recipient matching …”

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confidence: 99%

Elevated Risk of Split‐Liver grafts in adult liver Transplantation: Statistical Artifact or Nature of the Beast?

et al. 2019

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A recent study using US national registry data reported, using Cox proportional hazards (PH) models, that split‐liver transplantation (SLT) has improved over time and is no more hazardous than whole‐liver transplantation (WLT). However, the study methods violated the PH assumption, which is the fundamental assumption of Cox modeling. As a result, the reported hazard ratios (HRs) are biased and unreliable. This study aimed to investigate whether the risk of graft survival (GS) in SLT has really improved over time, ensuring attention to the PH assumption. This study included 80,998 adult deceased donor liver transplantation (LT) (1998‐2015) from the Scientific Registry Transplant Recipient. The study period was divided into 3 time periods: era 1 (January 1998 to February 2002), era 2 (March 2002 to December 2008), and era 3 (January 2009 to December 2015). The PH assumption was tested using Schoenfeld’s test, and where the HR of SLT violated the assumption, changes in risk for SLT over time from transplant were assessed. SLT was performed in 1098 (1.4%) patients, whereas WLT was used in 79,900 patients. In the Cox PH analysis, the P values of Schoenfeld’s global tests were <0.05 in all eras, which is consistent with deviation from proportionality. Assessing HRs of SLT with a time‐varying effect, multiple Cox models were conducted for post‐LT intervals. The HR curves plotted according to time from transplant were higher in the early period and then decreased at approximately 1 year and continued to decrease in all eras. For 1‐year GS, the HRs of SLT were 1.92 in era 1, 1.52 in era 2, and 1.47 in era 3 (all P < 0.05). In conclusion, the risk of SLT has a time‐varying effect and is highest in the early post‐LT period. The risk of SLT is underestimated if it is evaluated by overall GS. SLT was still hazardous if the PH assumption was considered, although it became safer over time.

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Living Donor Liver Transplant in Children

Adeyemi

Rand

Olthoff

2021

Liver Transplantation

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Fifteen-Year Trends in Pediatric Liver Transplants: Split, Whole Deceased, and Living Donor Grafts

Abstract: In recent years, outcomes after the use of technical variant grafts are comparable with whole grafts, and may be superior for LDLT. Greater use of technical variant grafts might provide an opportunity to increase organ supply without compromising post-transplant outcomes.

Cited by 86 publications

References 28 publications

Expansion of the Liver Donor Supply Through Greater Use of Split‐Liver Transplantation: Identifying Optimal Recipients

Expansion of the Liver Donor Supply Through Greater Use of Split‐Liver Transplantation: Identifying Optimal Recipients

Elevated Risk of Split‐Liver grafts in adult liver Transplantation: Statistical Artifact or Nature of the Beast?

Living Donor Liver Transplant in Children

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