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Liver transplantation for children: Red Cross Children's Hospital experience
C W N Spearman1, M McCulloch, A J W Millar
1Red Cross Children's Hospital and School of Child and Adolescent Health and University of Cape Town, Cape Town, Republic of South Africa. wendy@uctgsh1.uct.ac.za
Insights
This study highlights successful pediatric liver transplants in sub-Saharan Africa, achieving over 80% 5-year survival with improved protocols. Donor shortages due to Hepatitis B virus and Human Immunodeficiency Virus remain a challenge.
Area of Science:
- Pediatric Surgery
- Transplant Immunology
- Hepatology
Background:
- The Red Cross Children's Memorial Hospital runs the sole pediatric liver transplant program in sub-Saharan Africa.
- Since 1985, 250 children have been evaluated, with 155 proceeding to transplantation.
- The program has performed 79 liver transplants on 76 children since 1987.
Purpose of the Study:
- To evaluate the outcomes of a pediatric liver transplant program in sub-Saharan Africa.
- To identify challenges and successes in establishing and maintaining this vital service.
Main Methods:
- Analysis of 79 liver transplants performed between 1987 and the study period.
- Review of patient demographics, diagnoses, transplant types (including reduced-size and combined), and donor:recipient weight ratios.
- Assessment of survival rates, causes of early and late mortality, and morbidity.
Main Results:
- Overall patient survival at 1 and 5 years was 79% and 70%, respectively.
- Introduction of gancyclovir prophylaxis and exclusion of Hepatitis B virus (HBV) positive donors improved projected 5-year survival to over 80%.
- Major causes of mortality included infections (Epstein-Barr virus, cytomegalovirus, de novo Hepatitis B) and early complications like thrombosis and sepsis.
Conclusions:
- A successful pediatric liver transplant program has been established despite resource limitations, demonstrating good patient and graft survival.
- Infections and donor shortages due to HBV and Human Immunodeficiency Virus (HIV) pose significant challenges, impacting waiting list mortality and transplant frequency.
Background:
The liver transplant program for infants and children at the Red Cross Children's Memorial Hospital is the only established pediatric service in sub-Saharan Africa. Since 1985, 250 infants and children have been assessed and 155 accepted for transplantation.
Methods:
Since 1987, 76 children (range 6 months to 14 years) have had 79 liver transplants, with biliary atresia being the most frequent diagnosis. The indications for transplantation include biliary atresia (n = 44), metabolic (n = 7), fulminant hepatic failure (n = 10), redo transplants (n = 3), and other (n = 15). Three combined liver/kidney transplants have been performed. Forty-nine were reduced-size transplants with donor: recipient weight ratios ranging from 2:1 to 11:1, and 29 children weighed < 10 kg.
Results:
Fifty-six (74%) patients survived 3 months to 12 years posttransplant. Cumulative 1- and 5-year patient survival data are 79% and 70%, respectively. However, with the introduction of prophylactic intravenous gancyclovir and the exclusion of hepatitis B virus (HBV) IgG core Ab-positive donors, the projected 5-year pediatric survival has been >80%. Early (<1 month) post-liver-transplant mortality was low, but included: primary malfunction (n = 1); inferior vena cava thrombosis (n = 1); bleeding esophageal ulcer (n = 1); and sepsis (n = 1). Late morbidity and mortality was mainly due to infections: de novo hepatitis B (5 patients, 2 deaths); Epstein-Barr virus (EBV)-related posttransplantation lymphoproliferative disease (12 patients, 7 deaths); and cytomegalovirus disease (10 patients, 5 deaths). Tuberculosis (TB) treatment in three patients was complicated by chronic rejection (n = 1) and TB drug-induced subfulminant liver failure (n = 1).
Conclusions:
Despite limited resources, a successful pediatric program has been established with good patient and graft survival figures and excellent quality of life. Shortage of donors due to HBV and human immunodeficiency virus (HIV) leads to significant waiting list mortality and infrequent transplantation.
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