Long‐term Outcomes of Pediatric Living Versus Deceased Donor Liver Transplantation Recipients: A Systematic Review and Meta‐analysis

Abstract

Living donor liver transplantation (LDLT) emerged in the 1980s as a viable alternative to scarce cadaveric organs for pediatric patients. However, pediatric waitlist mortality remains high. Long‐term outcomes of living and deceased donor liver transplantation (DDLT) are inconsistently described in the literature. Our aim was to systematically review the safety and efficacy of LDLT after 1 year of transplantation among pediatric patients with all causes of liver failure. We searched the MEDLINE, Medline‐in‐Process, MEDLINE Epub Ahead of Print, Embase + Embase Classic (OvidSP), and Cochrane (Wiley) from February 1, 1947 to February 26, 2020, without language restrictions. The primary outcomes were patient and graft survival beyond 1 year following transplantation. A meta‐analysis of unadjusted and adjusted odds and hazard ratios was performed using a random‐effects model. A total of 24 studies with 3677 patients who underwent LDLT and 9098 patients who underwent DDLT were included for analysis. In patients with chronic or combined chronic liver failure and acute liver failure (ALF), 1‐year (odds ratio [OR], 0.68; 95% confidence interval [CI], 0.53‐0.88), 3‐year (OR, 0.73; 95% CI, 0.61‐0.89), 5‐year (OR, 0.71; 95% CI, 0.57‐0.89), and 10‐year (OR, 0.42; 95% CI, 0.18‐1.00) patient and 1‐year (OR, 0.50; 95% CI, 0.35‐0.70), 3‐year (OR, 0.55; 95% CI, 0.37‐0.83), 5‐year (OR, 0.5; 95% CI, 0.32‐0.76), and 10‐year (OR, 0.26; 95% CI, 0.14‐0.49) graft survival were consistently better in LDLT recipients compared with those in DDLT recipients. In patients with ALF, no difference was seen between the 2 groups except for 5‐year patient survival (OR, 0.60; 95% CI, 0.38‐0.95), which favored LDLT. Sensitivity analysis by era showed improved survival in the most recent cohort of patients, consistent with the well‐described learning curve for the LDLT technique. LDLT provides superior patient and graft survival outcomes relative to DDLT in pediatric patients with chronic liver failure and ALF. More resources may be needed to develop infrastructures and health care systems to support living liver donation.

Living Donor Liver Transplant Center Volume Influences Waiting List Survival Among Children Listed for Liver Transplantation

“…19 Multiple studies have already demonstrated the survival benefit of LDLTs toward achieving superior posttransplant survival in comparison with deceased donor transplants in children. [4][5][6][7]11,12 This study is novel in demonstrating the pretransplant waiting list survival benefit of LDLTs. Given that we found that LDLT center volume is associated with lower overall waiting list dropout at the center, the availability of LDLT at a center may actually benefit all candidates listed at that center by also decreasing the competition for size-matched deceased donor grafts, although additional studies focused on this potential indirect impact of pediatric LDLTs are needed to definitively make this conclusion.…”

A review of racial, socioeconomic, and geographic disparities in pediatric liver transplantation

“…Superior graft and patient survival have been described in pediatric LDLT compared with deceased donor liver transplantation. [14][15][16] In 2019, 14% of pediatric liver transplantation registrants underwent LDLT, but this was not further stratified by race or ethnicity. [5] For Black children, Mogul et al found a reduced incidence of LDLT (subhazard ratio, 0.56) compared with White children using Scientific Registry of Transplant Recipients (SRTR) data.…”

Factors associated with improved patient and graft survival beyond 1 year in pediatric liver transplantation

“…Reasons for this are likely multifactorial, reflecting improvements in organ allocation for pediatric recipients and Status 1b designation for many of the metabolic and malignancy patients; however, additional factors such as lack of surgical expertise and societal barriers are also likely contributors. [ 21 ] As LDLT was shown to be protective in our multivariable model and has been shown by others to provide superior outcomes, [ 22,23 ] it will be important to prioritize how additional resources could be applied to enable infrastructure development and resource allocation that support broad LDLT use. Furthermore, perioperative IS regimens do not reflect long‐term management, and adherence to IS therapy has been well recognized to impact long‐term outcomes.…”