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Early Living Donor Liver Transplant Is Associated With Improved Graft- and Patient-Survival Outcomes in Children With
Marshall W Wallace1, Cameron M Arkin1, Anastasia M Kahan1
1Division of Pediatric Surgery, Department of Surgery, University of Utah, Salt Lake City, Utah, USA.
Insights
Proactive living donor liver transplant (LDLT) for biliary atresia (BA) in children with low Pediatric End-Stage Liver Disease (PELD) scores significantly improves graft and patient survival. Early LDLT offers better outcomes compared to deceased donor liver transplant (DDLT).
Area of Science:
- Pediatric Hepatology
- Transplant Surgery
- Organ Transplantation
Background:
- Biliary atresia (BA) is the leading cause of pediatric liver transplantation.
- Pediatric End-Stage Liver Disease (PELD) scores dictate deceased donor liver transplant (DDLT) priority.
- Donor shortages often lead to transplantation at advanced disease stages.
Purpose of the Study:
- To investigate the hypothesis that early, low PELD, living donor liver transplant (LDLT) improves outcomes in pediatric BA patients.
- To compare graft and patient survival rates between DDLT and LDLT stratified by PELD scores.
Main Methods:
- Retrospective review of pediatric BA liver transplant cases from the SRTR database.
- Comparison of DDLT versus LDLT, stratified into low PELD (≤12) and high PELD groups.
- Kaplan-Meier and Cox-proportional hazards analyses for patient and graft survival.
Main Results:
- Low PELD LDLT recipients had better pre-transplant markers (lower INR, bilirubin) and less need for life support.
- Kaplan-Meier analysis demonstrated the highest 5-year graft and patient survival in the low PELD LDLT group (p<0.01).
- Cox modeling indicated low PELD LDLT was independently associated with reduced graft loss (aHR 0.45) and mortality (aHR 0.43).
Conclusions:
- A proactive LDLT strategy in pediatric BA is linked to enhanced long-term graft and patient survival.
- Considering low PELD LDLT can improve early transplant access for children with BA.
- Early LDLT should be explored to optimize outcomes in pediatric BA liver transplantation.
Introduction:
Biliary atresia (BA) is the most common indication for pediatric liver transplantation. Pediatric end-stage liver disease (PELD) scores primarily determine deceased donor liver transplant (DDLT) waitlist priority. Due to persistent donor supply-demand mismatch, children typically have advanced disease and high PELD scores at the time of DDLT. Proactive living donor liver transplant (LDLT) may facilitate transplantation before critical illness. We hypothesized that early, low PELD, LDLT is associated with improved graft and patient survival in children with BA.
Methods:
We retrospectively reviewed children undergoing liver transplantation for BA in the SRTR database, comparing DDLT to LDLT, stratified by PELD. Early transplant was defined as transplant with a PELD ≤ 12. Four groups were analyzed: low PELD LDLT, low PELD DDLT, high PELD LDLT, and high PELD DDLT. Kaplan-Meier and Cox-proportional hazards analyses evaluated patient- and graft-survival.
Results:
4733 children meeting inclusion criteria were included (n = 249 Low PELD LDLT, n = 1152 Low PELD DDLT, n = 708 High PELD LDLT, n = 2624 High PELD DDLT). Prior to transplant, Low PELD LDLT recipients had lower INR and bilirubin levels, and required less life support (p < 0.01). Kaplan-Meier analyses showed the highest 5-year graft and patient survival in the Low PELD LDLT (p < 0.01). Cox modeling revealed an independent association between low PELD LDLT and decreased graft loss (adjusted HR 0.45, p < 0.01) and mortality (adjusted HR 0.43, p = 0.03).
Conclusions:
A proactive approach to LDLT in children with BA is associated with improved long-term graft and patient survival. Low PELD LDLT should be considered to increase early transplant access for children with BA.
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