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Outcome of liver retransplantation in children
O A Achilleos1, D F Mirza, D Talbot
1Liver and Hepatobiliary Unit, Queen Elizabeth Hospital, Children's Hospital, Birmingham, UK.
Insights
Pediatric liver retransplantation (ReTx) offers a chance for survival after primary graft failure, though outcomes are worse than for initial transplants. Improvements in care have reduced graft failure rates over time.
Area of Science:
- Pediatric surgery
- Transplant immunology
- Hepatology
Background:
- Liver graft failure is a critical complication in pediatric liver transplantation.
- Primary graft failure necessitates retransplantation, impacting patient survival.
Purpose of the Study:
- To review outcomes of pediatric liver transplantation and retransplantation.
- To identify causes of graft failure and trends over time.
- To evaluate the effectiveness of retransplantation in pediatric liver recipients.
Main Methods:
- Retrospective review of the first 200 pediatric liver transplantations.
- Analysis of graft failure indications: primary nonfunction (PRNF), vascular complications (VASC), and chronic rejection (CHRE).
- Comparison of survival rates between primary graft recipients and retransplant recipients, considering graft types and timing of retransplantation.
Main Results:
- Graft failure occurred in 41 children, with PRNF, VASC, and CHRE as main causes.
- Retransplantation (ReTx) had lower patient survival (63%) compared to single grafts (76.5%).
- Graft survival improved significantly over time, with reduced incidence of primary graft failure and PRNF.
- Emergency ReTx within one month showed worse outcomes (37% survival) than later ReTx (72% survival).
Conclusions:
- Retransplantation is a viable option for children with primary liver graft failure.
- Improvements in surgical techniques, intensive care, graft preservation, and immunosuppression have led to better outcomes.
- Graft survival rates have improved, particularly for whole grafts and in later transplant cohorts.
Abstract:
Irreversible liver graft failure is a life-threatening complication. We reviewed the first 200 pediatric liver transplantations in Birmingham. Forty-one children developed primary graft failure, 9 of whom developed secondary graft failure. The main indications for graft failure were primary nonfunction (PRNF; 8 patients), vascular complications (VASC; 23 patients), and chronic rejection (CHRE; 19 patients). Thirty-two children underwent retransplantation (ReTx) (21 children received reduced grafts; 11 children, whole hepatic grafts). Patient survival was significantly worse for retransplant recipients compared with children receiving a single graft (63% v 76. 5% actuarial patient survival at 1 year; P <.05). Primary graft 1-year actuarial survival was 74% in first grafts compared with 47% for regrafts (P <.05), but improved with time. The graft 1-year survival rate was 55% for whole grafts and 45% for reduced and/or split grafts in the first 100 grafts compared with 83% and 66% in the second 100 grafts, respectively (P <.01). Emergency ReTx within a month of transplantation was associated with more complications and a worse outcome (1-year survival rate, 37%) compared with patients who underwent ReTx later (1-year survival rate, 72%; P <. 01). The incidence of primary graft failure decreased from 33% in the first 100 grafts to 16% in the second 100 grafts (P <.01), as did the incidence of PRNF, which decreased from 8% to 0% (P <.05). Although the rates of graft failure from VASC decreased from 15% to 8% (P =.2) and CHRE decreased from 11% to 8% (P =.6), neither reached statistical significance. The improved results overall are because of advances in surgical techniques, intensive care management, and graft preservation and refinements in immunosuppression. We conclude that ReTx for a child with primary graft failure is justified.