Retransplantation of the Liver in Children

Abstract

Retransplantation is a significant event after pediatric liver transplantation. Outcome after hepatic retransplantation in children is inferior compared with single transplantation. This difference is explained by low survival after early retransplantation and can be explained by the poor clinical condition of the children at time of retransplantation, especially in children with biliary atresia, and by the predominant use of technical variant liver grafts in retransplantations.

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

“…During this 9-year study period, the rate of rLT of our multicenter study cohort was 11.2%, similar to rLT rates of 5-22% reported in adult series (9,11,(13)(14)(15)(17)(18)(19) and pediatric single center experiences in the United States and Europe (3,6,8).…”

“…Except in the settings of extrahepatic sources of sepsis, disseminated malignancies and severe, irreversible neurologic injuries which are absolute contraindications to liver retransplantation (rLT), the approach of most pediatric LT programs is to offer the option of rLT to children with documented allograft failure. In an era when demand for livers far exceeds available supply, the judicious use of limited organs requires continual reevaluation of both indications for and outcomes after LT. To date, multiple single center experiences report 1-year patient survival rates of up to 77% after pediatric rLT (2)(3)(4)(5)(6)(7)(8), similar to results of rLT reported in adults (7,(9)(10)(11)(12)(13)(14)(15)(16), but inferior to the survival of children after primary LT. As single center experiences on the outcomes of pediatric rLT are subject to a number of limitations, we herein present the outcomes and identify prognostic factors affecting survival of children from the SPLIT database who have undergone rLT.…”

“…Survival after rLT is likely to be dependent upon the interactions of a number of factors, such as the timing of the rLT. Children who required rLT within the first 30 days after first LT (ErLT) had even poorer survival (1-and 4-year patient survival rates of 59% and 56%, respectively) compared with those children who underwent LrLT (1-and 4-year rates of 74% and 61%), as previously reported in both pediatric and adult single center reports (2,3,6,8,17). Conversely, improved outcomes in children after LrLT versus ErLT are likely explained by their being less debilitated to withstand the trials of a second LrLT, even within the context of the increased technical difficulty involved with fibrosis surrounding the graft and blood vessels complicating the LrLT surgery (17).…”

Challenges to achieving clinical transplantation tolerance

“…Important factors to consider in patient selection include the chances of success and the consequences of failure in particular groups. For example, young children (<3 years old) have the best long-term renal graft survival with a significantly different rate of chronic allograft loss (49), but children also have higher rates of liver retransplantation with worse outcome than adults, making graft failure less acceptable (50). Alternatively, older recipients, who may have developed a degree of immunological senescence, may be an easier group in which to successfully induce tolerance.…”

Alternativen zur Spenderorgantransplantation bei Patienten mit hepatischen Erkrankungen

“…Der andere Anteil von etwas weniger als der Hälfte (40-46%) entfällt auf Retransplantationen in einem größeren Zeitintervall nach der Ersttransplantation. Die häufigsten Gründe, die zu einer späteren Retransplantation führen, sind das Wiederauftreten der Grunderkrankung, die Entwicklung einer chronischen Abstoßung oder die langfristigen Folgen von Gallenwegs-oder Gefäß-komplikationen[24,25,26,27,28,29,30].Im klinischen Einsatz befindliche alternative Verfahren zur postmortalen LebertransplantationLeitthema: Transplantationsmedizin der Retransplantationen verringern kön-nen. Eine Fortsetzung dieser Tendenz ist für die Zukunft zu erhoffen, obwohl ein weiterer Aspekt, nämlich die zunehmende Überlebenszeit nach Lebertransplantation, immer mehr Patienten das langfristige Risiko einer erneut notwendigen Transplantation erleben lässt.…”