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No Child Left Behind: Liver Transplantation in Critically Ill Children
Abbas Rana1, Michael Kueht1, Moreshwar Desai2
1Michael E DeBakey Department of Surgery, Division of Abdominal Transplantation and Hepatobiliary Surgery, Baylor College of Medicine, Houston, TX.
Insights
Orthotopic liver transplantation (OLT) in critically ill children with liver failure yields acceptable survival rates, justifying its use. Advanced critical care enables successful OLT for even the sickest pediatric patients.
Area of Science:
- Pediatric critical care medicine
- Hepatology
- Transplantation surgery
Background:
- Critical care advances improve survival for children with liver failure, increasing eligibility for orthotopic liver transplantation (OLT).
- Determining survival outcomes for pediatric OLT recipients requiring pre-transplant critical care is essential for resource allocation.
Purpose of the Study:
- To evaluate survival rates of pediatric patients undergoing OLT while receiving intensive care.
- To justify the use of donor organs for critically ill children requiring OLT.
Main Methods:
- Analysis of 13,723 pediatric OLTs from the UNOS database (1987-2015), including the MELD/PELD era.
- Evaluation of 1,816 recipients (26.9%) admitted to the ICU at transplantation and institutional data from 354 pediatric OLTs.
- Application of Kaplan-Meier, volume threshold, and multivariable analyses to identify survival predictors.
Main Results:
- Overall 1-year survival improved from 66% (1987) to 92% (2015).
- Institutional ICU recipients achieved 87% 1-year survival, including those on mechanical ventilation and dialysis.
- Low-volume centers (<5 cases/year) showed inferior outcomes (HR 1.68).
- Risk factors for mortality included previous transplant, elevated sodium, dialysis, ventilation, low body weight, and low center volume.
Conclusions:
- Advanced critical care is justified for pediatric OLT, enabling successful transplantation in critically ill children.
- OLT is an appropriate use of scarce donor organs for children with end-stage liver disease.
- Outcomes are acceptable even for the sickest pediatric liver failure patients undergoing OLT.
Background:
Advances in critical care prolong survival in children with liver failure, allowing more critically ill children to undergo orthotopic liver transplantation (OLT). In order to justify the use of a scarce donor resource and avoid futile transplants, we sought to determine survival in children who undergo OLT while receiving pre-OLT critical care.
Study Design:
We analyzed 13,723 pediatric OLTs using the United Network for Organ Sharing (UNOS) database from 1987 to 2015, including 6,746 recipients in the Model for End-Stage Liver Disease/Pediatric End-Stage Liver Disease (MELD/PELD) era (2002 to 2015). There were 1,816 recipients (26.9%) admitted to the ICU at the time of transplantation. We also analyzed 354 pediatric OLT recipients at our center from 2002 to 2015, one of the largest institutional experiences. Sixty-five recipients (18.3%) were admitted to the ICU at the time of transplantation. Kaplan-Meier, volume threshold, and multivariable analyses were performed.
Results:
Patient survival improved steadily over the study period, (66% 1-year survival in 1987 vs 92% in 2015; p < 0.001). Our institutional experience of ICU recipients in the MELD/PELD era had acceptable outcomes (87% 1-year survival), even among our sickest recipients with vasoactive medications, mechanical ventilation, dialysis, and molecular adsorbent recirculating system requirements. Volume analysis revealed inferior outcomes (hazard ratio [HR] 1.68; 95% CI 1.11 to 2.51) in low-volume centers (<5 annual cases). Identifiable risk factors (previous transplantation, elevated serum sodium, hemodialysis, mechanical ventilation, body weight < 6 kg, and low center volume) increased risk of mortality.
Conclusions:
This analysis demonstrates that the use of advanced critical care in children and infants with liver failure is justified because OLT can be performed on the sickest children and acceptable outcomes achieved. It is an appropriate use of a scarce donor allograft in a child who would otherwise succumb to a terminal liver disease.
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