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Liver transplantation: an Australian experience
A G Sheil1, G W McCaughan, J F Thompson
1Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney.
Insights
Liver transplantation in Australia shows a 70% survival rate, with reduced-size adult livers benefiting children. Urgent cases, including fulminant hepatic failure, show promising outcomes with ABO-incompatible grafts.
Area of Science:
- Hepatology
- Transplant Surgery
- Pediatric Gastroenterology
Background:
- 283 patients referred to Australian National Liver Transplant Unit over 4.5 years.
- 60% were children, with biliary atresia and inborn errors of metabolism as primary causes of liver failure.
- 197 patients (69%) were accepted for liver transplantation.
Purpose of the Study:
- To evaluate the outcomes of liver transplantation in Australia.
- To assess the efficacy of reduced-size adult grafts for pediatric recipients.
- To determine the survival rates and identify factors influencing graft success.
Main Methods:
- Analysis of 283 referred patients and 100 liver grafts transplanted over 4.5 years.
- Comparison of survival rates based on patient age, weight, underlying condition, and graft type.
- Evaluation of graft survival and patient rehabilitation post-transplantation.
Main Results:
- Overall 1-year survival was 73%, with 67% at 2-4 years. Adults with benign conditions had 76% survival, contrasting with 20% for malignancy.
- Children >8 kg had good outcomes (75-80% survival), while infants <8 kg receiving reduced adult grafts had 20% survival.
- 100% survival for fulminant hepatic failure patients, including those receiving ABO-incompatible grafts; 91-94% of survivors achieved excellent rehabilitation.
Conclusions:
- Liver transplantation is highly effective for benign liver disorders but less so for malignancy.
- Reduced-size adult livers are successful for pediatric patients, alleviating donor shortages.
- ABO-incompatible grafts can be lifesaving in urgent situations, though retransplantation may be needed.
Abstract:
During a 4 and a half-year experience, 283 patients were referred to the Australian National Liver Transplant Unit. Sixty (21%) were children. The major causes of liver failure in the adults were chronic active hepatitis (27%), primary biliary cirrhosis (13%), primary sclerosing cholangitis (12%), fulminant hepatic failure (9%), alcoholic cirrhosis (9%), and malignancy (9%). In the children they were biliary atresia (43%) and inborn errors of metabolism (18%). One hundred and ninety-seven (69%) were accepted for liver transplantation. Of 111 (39%) accepted for early transplantation, 18 (16%) died before a donor became available. There were 319 possible organ donors. Ninety patients (24 of them children) received 100 grafts. Sixty-three (70%) patients survived. For all recipients, 1-year survival was 73%. Two-, 3- and 4-year survivals were 67%. One- to 4-year survivals for adults with benign conditions were 76%, contrasting with results for those with hepatic malignancy (20% 1-year survival). Children weighing greater than 8 kg did well whether they received whole grafts (80% 1- to 4-year survival) or reduced grafts (75% 1- to 4-year survival). Infants weighing less than 8 kg who received reduced adult grafts did significantly worse (20% 1- to 4-year survival). All 8 (100%) patients with fulminant hepatic failure who received grafts survived, including 3 who received ABO-incompatible grafts, though 2 of these subsequently required retransplantation. Rehabilitation of survivors was excellent with 91% of adults and 94% of children pursuing normal activities. Only 2 (2%) grafts failed with primary nonfunction, both in infants because of infarction. Graft survival was significantly worse (p less than 0.01) in patients with a positive direct crossmatch test against the donor. We calculate that the need for liver transplantation in Australia is approximately 7 per million of population per year. Increased donor offers are required to avoid deaths of patients on the waiting list. Reduced-size adult livers are successful for children and have alleviated considerably the critical shortage of pediatric donor livers. Liver transplantation is a highly satisfactory treatment for patients with benign liver disorders but not for those with malignant conditions. Patients with fulminant hepatic failure not responding to conservative therapy should be treated by liver transplantation. In this and other urgent circumstances, an ABO-incompatible liver may be lifesaving though retransplantation with an ABO-compatible liver may subsequently be required. The results of liver transplantation for nonmalignant conditions have improved steadily with clinical experience, with 1- and 2-year patient survivals during the past 28 months of 85%.