One Thousand Pediatric Liver Transplants During Thirty Years: Lessons Learned

Robert S Venick; Douglas G Farmer; Jose R Soto; Jorge Vargas; Hasan Yersiz; Fady M Kaldas; Vatche G Agopian; Jonathan R Hiatt; Sue V McDiarmid; Ronald W Busuttil

doi:10.1016/j.jamcollsurg.2017.12.042

One Thousand Pediatric Liver Transplants During Thirty Years: Lessons Learned

J Am Coll Surg. 2018 Apr;226(4):355-366. doi: 10.1016/j.jamcollsurg.2017.12.042. Epub 2018 Feb 2.

Affiliations

¹ Department of Pediatrics, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, CA; Department of Surgery, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, CA. Electronic address: Rvenick@mednet.ucla.edu.
² Department of Surgery, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, CA.
³ Department of Pediatrics, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, CA.
⁴ Department of Pediatrics, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, CA; Department of Surgery, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, CA.

PMID: 29410290
DOI: 10.1016/j.jamcollsurg.2017.12.042

Abstract

Background: Pediatric liver transplantation (pLTx) has been the standard of care for children with liver failure since the 1980s. This study examined the world's largest single-center experience and aimed to identify unique preoperative predictors of early graft and patient survival for primary transplantation (1°-pLTx) and retransplantation (Re-pLTx).

Study design: We conducted an IRB-approved, retrospective study of all consecutive, isolated pLTx patients 18 years of age or younger. Twenty-eight demographic, laboratory, and perioperative variables were analyzed as potential outcome predictors. Univariate and multivariate analyses were performed using log-rank test and Cox's proportional hazards model.

Results: There were 806 children who received 1,016 isolated pLTx between February1984 and June 2017. Median follow-up was 12 years. Leading indications for pLTx were cholestatic liver disease (40%), re-pLTx (21%), and fulminant hepatic failure (14%). Seventy-three percent received cadaveric whole grafts. Overall graft and patient survival rates at 0.5, 1, 5, 10, and 20 years were: 76%, 73%, 67%, 63%, 53%, and 87%, 86%, 81%, 78%, 69%, respectively. Relative to 1°-pLTx, re-pLTx recipients were significantly older, larger, with worse renal function, and more likely to be awaiting pLTx in an ICU. Independent significant predictors of graft survival for 1°-pLTx included weight, transplantation era, and renal replacement therapy; for re-pLTx, warm ischemia time and time between 1°-pLTx and re-pLTx. Independent significant predictors of patient survival were renal function, mechanical ventilation, and etiology of liver disease.

Conclusions: This is the largest reported single-center experience of pLTx with substantial follow-up time and a large re-pLTx experience. Important transplant predictors of graft survival include weight, renal function, modern era, warm ischemia time, and time between primary transplantation and re-pLTx. Renal function, mechanical ventilation, and underlying cause of liver disease affect patient survival. Awareness of these factors can help in the decision making for children requiring pLTx.

MeSH terms

Adolescent
Child
Child, Preschool
Female
Graft Survival
Humans
Infant
Liver Failure / diagnosis
Liver Failure / mortality
Liver Failure / surgery*
Liver Transplantation*
Male
Proportional Hazards Models
Reoperation
Retrospective Studies
Risk Factors
Survival Rate
Treatment Outcome