Identifying the futile pediatric liver re-transplant in the PELD era

Survival following pediatric re-transplant is inferior to that following primary transplant. We analyzed UNOS data (1987-2007) to identify factors associated with poor outcomes following re-transplant in both the pre-PELD and PELD eras. There may be a combination of factors associated with a futile pediatric liver re-transplant. Identification of these factors may improve allograft allocation and survival following re-transplantation. Abstract:  Survival following pediatric liver re-transplant is distinctly inferior to that following primary transplant. The purpose of this study was to determine factors associated with futile pediatric liver re-transplants before and after introduction of the PELD criteria in February 2002. We analyzed the UNOS database (1987-2008) and identified pediatric patients requiring liver re-transplants before and after PELD criteria. Descriptive characteristics were evaluated and survival analyzed with Cox proportional hazards method. Analysis of 1248 children identified re-transplant survival in the PELD era was significantly better than the pre-PELD era. Multivariable analysis in the pre-PELD era identified number of re-transplants, African American race, ICU pretransplant, recipient weight, creatinine and bilirubin levels, donor age, and cold ischemia time to be significantly associated with poor survival. In the PELD era, ICU hospitalization, weight, and very high bilirubin levels were associated with poor survival. Kaplan-Meier analysis by risk groups demonstrated a significant difference in survival, with the highest risk group experiencing 40-50% one-yr survival. Survival following pediatric liver re-transplantation varies significantly by era and associated risk factors. There may be a combination of factors that predict a futile re-transplant. Pre-operative identification of these factors may improve allograft allocation and recipient survival following re-transplantation.