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Published on: November 7, 2020
Liver transplantation at Red Cross War Memorial Children's Hospital
C W N Spearman1, M McCulloch, A J W Millar
1School of Child and Adolescent Health, University of Cape Town and Red Cross War Memorial Children's Hospital, Rondebosch, Cape Town, South Africa. wendy@uctgsh1.uct.ac.za
Insights
This study highlights the success of sub-Saharan Africa's only pediatric liver transplant program, achieving over 80% 5-year survival with improved protocols. Donor shortages due to Hepatitis B virus (HBV) and Human Immunodeficiency Virus (HIV) remain a challenge.
Area of Science:
- Hepatology
- Transplant Surgery
- Pediatric Gastroenterology
Background:
- The Red Cross War Memorial Children's Hospital runs the sole established pediatric liver transplant program in sub-Saharan Africa.
- The program serves South Africa and neighboring countries, receiving referrals for liver transplant assessments.
Purpose of the Study:
- To evaluate the outcomes of the pediatric liver transplant program.
- To identify challenges and successes in pediatric liver transplantation within a resource-limited setting.
Main Methods:
- Retrospective analysis of 84 liver transplants performed on 81 children between 1987 and the study period.
- Analysis of patient demographics, diagnoses (predominantly biliary atresia), transplant types (including reduced-size and combined liver/kidney), and outcomes.
Main Results:
- Overall patient survival rates of 79% at 1 year and 70% at 5 years.
- Introduction of prophylactic ganciclovir and exclusion of Hepatitis B virus (HBV) positive donors improved 1-year survival to 90% and projected 5-year survival to over 80%.
- Major causes of mortality included infections such as de novo Hepatitis B, Epstein-Barr virus (EBV)-related post-transplant lymphoproliferative disease, and cytomegalovirus (CMV) disease.
Conclusions:
- A successful pediatric liver transplant program has been established despite resource limitations, demonstrating good patient and graft survival.
- Donor shortages, exacerbated by HBV and Human Immunodeficiency Virus (HIV) prevalence, contribute to significant waiting-list mortality.
- Ongoing challenges include managing infections and optimizing donor pool utilization in a high-prevalence region.
Unlabelled:
The liver transplant programme for infants and children at Red Cross War Memorial Children's Hospital is the only established paediatric service in sub-Saharan Africa. Referrals for liver transplant assessment come from most provinces within South Africa as well as neighbouring countries.
Patients And Methods:
Since 1987, 81 children (range 6 months-14 years) have had 84 liver transplants with biliary atresia being the most frequent diagnosis. The indications for transplantation include biliary atresia (48), metabolic (7), fulminant hepatic failure (10), redo transplants (3) and other (16). Four combined liver/kidney transplants have been performed. Fifty-three were reduced-size transplants with donor/recipient weight ratios ranging from 2:1 to 11:1 and 32 children weighed less than 10 kg.
Results:
Sixty patients (74%) survived 3 months-14 years post-transplant. Overall cumulative 1- and 5-year patient survival figures are 79% and 70% respectively. However, with the introduction of prophylactic intravenous ganciclovir and the exclusion of hepatitis B virus (HBV) IgG core Ab-positive donors, the 1-year patient survival is 90% and the projected 5-year paediatric survival is > 80%. Early (< 1 month) post-liver-transplant mortality was low. Causes include primary malfunction (1), inferior vena cava thrombosis (1), bleeding oesophageal ulcer (1), sepsis (1) and cerebral oedema (1). Late morbidity and mortality was mainly due to infections: de novo hepatitis B (5 patients, 2 deaths), Epstein-Barr virus (EBV)- related post-transplantation lymphoproliferative disease (12 patients, 7 deaths) and cytomegalovirus (CMV) disease (10 patients, 5 deaths). Tuberculosis (TB) treatment in 3 patients was complicated by chronic rejection (1) and TB-drug-induced subfulminant liver failure (1).
Conclusion:
Despite limited resources, a successful paediatric programme has been established with good patient and graft survival figures and excellent quality of life. Shortage of donors because of infection with HBV and human immunodeficiency virus (HIV) leads to significant waiting-list mortality and infrequent transplantation.
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