Liver Retransplantation in Children: A SPLIT Database Analysis of Outcome and Predictive Factors for Survival

Abstract

To examine outcomes and identify prognostic factors affecting survival after pediatric liver transplantation, data from 246 children who underwent a second liver transplantation (rLT) between 1996 and 2004 were analyzed from the SPLIT registry, a multi-center database currently comprised of 45 North American pediatric liver transplant programs. The main causes for loss of primary graft necessitating rLT were primary nonfunction, vascular complications, chronic rejection and biliary complications. Three-month, 1-and 2-year patient survival rates were inferior after rLT (74%, 67% and 65%) compared with primary LT (92%, 88% and 85%, respectively). Multivariate analysis of pretransplant variables revealed donor age less than 1 year, use of a technical variant allograft and INR at time of rLT as independent predictive factors for survival after rLT. Survival of patients who underwent early rLT (ErLT, <30 days after LT) was poorer than those who received rLT >30 days after LT (late rLT, LrLT): 3-month, 1-and 2-year patient survival rates 66%, 59%, and 56% versus 80%, 74% and 61%, respectively, log-rank p = 0.0141. Liver retransplantation in children is associated with decreased survival compared with primary LT, particularly, in the clinical settings of those patients requiring ErLT.

Prognostic Factors in Pediatric Early Liver Retransplantation

“…In our study, since 1992, in 4.4% of LTs an eRe‐LT was necessary. In 67% of the patients, vascular complications led to the need for eRe‐LT, whereas in the remaining 33% the cause was PNF, similar to reports in other pediatric series …”

“…In a large single‐center series of children undergoing LT, Venick et al found that eRe‐LT was an independent prognostic factor for poor outcome . Ng et al reported the results of re‐LT in children registered in the Studies of Pediatric Liver Transplantation database from the United States . The authors showed that children who underwent re‐LT ≤30 days after the first LT (eRe‐LT) had a significantly lower survival rate (1‐ and 4‐year patient survival rates of 59% and 56%, respectively) compared with children who underwent late re‐LT.…”

“…Patients who face an urgent re‐LT are typically in a critical clinical condition that may affect their chances for survival. Although the results of re‐LT have improved over time, much lower patient survival rates are still consistently reported for re‐LT when compared with a first graft LT …”

A Multivariate Analysis of Pre-, Peri-, and Post-Transplant Factors Affecting Outcome After Pediatric Liver Transplantation

“…4 An extensive series of publications from the SPLIT research group have already examined important factors influencing outcome related to diagnosis, including biliary atresia 5 and fulminant liver failure, 6 for complications such as rejection, 7 infection, 8 diabetes, 9 renal dysfunction, 10 and other known factors important to outcome such as retransplantation, 11 age at transplant, 12 graft type, 13 and surgical complications. 14 In this study, our hypothesis is that multivariate analyses of the comprehensive range of factors from the pre-, peri-, and posttransplant periods recorded in the SPLIT database will elucidate the most important variables affecting patient and graft survival 6 months after transplantation.…”

Selection and work-up for liver transplantation

“…16 Age at diagnosis, severity of illness, and possibly the technical variants of grafts utilised (reduced-size and split grafts), may be associated with increased morbidity and decreased overall survival. 17 Ng et al reported second and third transplantation rates of 12% and 2%, respectively, 5% chronic rejection, and 6% post-transplant lymphoproliferative disease in their paediatric LT cohort. 18 Although tests of graft function were preserved in 90% of 5-year survivors in the cohort, one-third of children did not have complete normalisation of liver enzymes, suggesting ongoing graft inflammation.…”