Update of pediatric liver transplantation

Abstract

Liver transplantation is an effective and widely accepted therapy for children with end-stage liver disease. Major indications include primary liver disease, resulting in hepatic insufficiency, or severe morbidity secondary to chronic non-progressive liver disease and metabolic diseases of the liver. Liver replacement should not be considered if there is an acceptable alternative therapy. Relative contraindications to transplantation include irreversible impairment of other organ systems, major systemic infection and diseases expected to recur after transplantation. Early referral for pre-transplant evaluation is important to confirm the proper diagnosis and determine priority for transplantation, to identify potential contraindications, and to assist in supportive care of the patient with chronic liver disease. Innovations such as reduced-sized liver grafts and most recently, living related liver transplantation have increased the donor supply of organs for small infants and significantly reduced pre-transplant mortality. In addition, living donor transplantation allows infants to benefit from transplantation before developing severe complications of end-stage liver disease and reduces the incidence of primary graft non-function and rejection. Immunosuppression following transplantation is maintained with methylprednisolone, azathioprine and cyclosporine. Acute rejection is treated with short bursts of high-dose corticosteroids and when necessary OKT3. With this approach, 90% of the episodes of rejection can be successfully controlled. Survival after transplantation has steadily improved and survival rates of 70%-90% are routine. Following transplantation, children experience rapid nutritional restoration, increased muscle strength, marked progress in gross motor development and improved general health.

Analysis of recent pediatric orthotopic liver transplantation outcomes indicates that allograft type is no longer a predictor of survivals

“…LDLT was introduced in 1989 and was initially used in very limited circumstances. In these highly selected patients, LDLT patient survival rates were reported to be equivalent to or better than those obtained with WLT and DDSLT 11–14. These reports of superior outcomes may be attributed to conservative selection of recipients and comparison of early LDLT outcomes to the relatively poor early DDSLT outcomes.…”

“…Four previous studies have used the UNOS database to compare outcomes for children treated with WLT, DDSLT, and LDLT 15–18. In addition, many other single‐center comparisons of these allograft types have been reported 9, 10, 12. The large number of studies comparing WLT, DDSLT, and LDLT outcomes emphasizes the magnitude of effort that the pediatric liver transplant community has invested in novel strategies aimed at increasing the number of allografts available without compromising posttransplant patient outcomes.…”

Postoperative infectious complications in paediatric liver transplantation: a study of 48 transplants

“…Liver transplantation is a well‐established therapy for children with endstage liver disease. In spite of progress made in surgical technique and antibiotic or immunosuppressive treatment, infectious complications remain one of the major causes of post‐transplantation morbidity and mortality ( 1–2).…”

Surgical site infections following pediatric liver transplantation: risks and costs

“…Orthotopic liver transplantation (OLT) has proven to be a successful treatment for end‐stage liver disease in children (1–5). Five‐year survival rates for pediatric liver transplants have improved from approximately 30% in 1980 to approximately 80% in 1998, in large part due to improvements in immunosuppression, organ preservation, and management of complications (5–8).…”