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Liver transplantation for children--the Red Cross Children's Hospital experience
A J W Millar1, W Spearman, M McCulloch
1Department of Paediatric Surgery, Paediatrics, Medicine and Surgery, Red Cross Children's Hospital, Institute of Child Health and Medical Research Council Liver Research Centre, University of Cape Town, Cape Town, South Africa. amillar@ich.uct.ac.za
Insights
Pediatric liver transplantation in South Africa demonstrates successful long-term outcomes, emphasizing improved quality of life. Challenges include donor scarcity and immunosuppression complications, requiring dedicated caregiver education and follow-up.
Area of Science:
- Pediatric Hepatology
- Transplant Surgery
- Immunology
Background:
- Liver transplantation for infants and children has been established in South Africa for over a decade.
- The focus has shifted from early survival to long-term quality of life.
- South Africa hosts the only pediatric liver transplant service in Sub-Saharan Africa.
Purpose of the Study:
- To evaluate the outcomes of pediatric liver transplantation in a developing country context.
- To identify challenges and long-term complications associated with pediatric liver transplants.
- To assess the quality of life in long-term survivors.
Main Methods:
- Retrospective analysis of 225 assessed patients, with 146 undergoing transplantation since 1985.
- 71 orthotopic liver transplants (OLTx) performed, with biliary atresia as the most common indication.
- Analysis of survival rates, causes of mortality, and long-term morbidities including infections and renal toxicity.
Main Results:
- Actuarial survival post-1996 improved to >82% with donor screening and prophylactic ganciclovir.
- Late morbidity and mortality (20%) were primarily linked to viral infections (Hepatitis B, EBV, CMV) and immunosuppression.
- Long-term survivors (74%) demonstrated good quality of life, attending school normally with minimal liver function abnormalities.
Conclusions:
- Successful pediatric liver transplantation is feasible in resource-limited settings.
- Key challenges include donor scarcity, waiting list mortality, and long-term immunosuppression sequelae.
- Caregiver education and close follow-up are crucial for managing compliance and improving outcomes.
Unlabelled:
Liver transplantation for infants and children has been available in South Africa at a single centre, the only established service in Sub-Saharan Africa, for more than a decade. Current concerns have shifted from an initial target of early post-transplant survival to quality of life in the long-term.
Materials And Methods:
Since 1985, 225 infants and children have been assessed, with 146 accepted for transplantation. Sixty-nine have had 71 orthotopic liver transplants (OLTx). Biliary atresia was the most frequent diagnosis (54%) followed by acute liver failure (ALF) (15%). Waiting list mortality has remained high (23%), particularly for the ALF group (50%). Forty-three were reduced size transplants with donor: recipient weight ratios ranging from 2:1 to 11:1. Twenty-seven were <10 kg.
Results:
Fifty (74%) survive 1 month-12 years post-transplant. Actuarial survival after 1996 since HBV core antibody positive donor livers were refused and prophylactic IV ganciclovir used has been >82%. Early post-OLTx mortality was low (5%), one primary non-function, one IVC thrombosis, one PV thrombosis, but late morbidity and mortality (20%) was mainly due to viral infection: de novo hepatitis B (five patients, three deaths), EBV-related post-transplantation lymphoproliferative disease (PTLPD) (eight patients, six deaths) and CMV disease (11 patients, five deaths). Tuberculosis prophylaxis, required in six cases, resulted in major morbidity in two and mortality in one. Poor compliance played a significant role in seven deaths. Hypertension requiring medication along with some compromise of renal function has been present in all but two patients. However, all those of school-going age (25) attend school normally and remain in good health and only three of the survivors have abnormal liver function tests.
Conclusions:
Successful liver transplantation is possible in a developing country with limited resources. Scarcity of virus-free donors (HBV and HIV) leading to waiting list mortality and infrequent re-transplantation along with long-term consequences of immunosuppression (infection, lymphoma and renal toxicity) remain problems. Intense education of the caregiver and close follow-up, particularly of those living at long distances has partly addressed the compliance problem.
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