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Ultra-Low Weight < 5 Versus 5-9.9-kg Pediatric Liver Transplant Recipients: Characteristics and Intraoperative
Lori A Aronson1, Kim My Li1, Alexander J Bondoc1
1Cincinnati Children's Hospital and Medical Center, Cincinnati, Ohio, USA.
Insights
Pediatric liver transplantation (PLT) in ultra-low weight infants (<5kg) showed increased vasopressor use, suggesting hemodynamic instability. However, outcomes like survival and hospital stay were similar to slightly heavier infants (5-9.9kg).
Area of Science:
- Hepatology
- Pediatric Surgery
- Critical Care Medicine
Background:
- Pediatric liver transplantation (PLT) survival has improved, yet outcomes for infants under 10kg, especially those under 5kg (ultra-low weight or ULW), remain poorly understood.
- Information on intraoperative management and outcomes for ULW PLT recipients is scarce.
Purpose of the Study:
- To compare intraoperative vasopressor use between ULW (<5kg) and 5-9.9kg pediatric liver transplant recipients.
- To evaluate differences in liver disease etiology and associated outcomes between these weight groups.
Main Methods:
- A single-center retrospective review of PLT recipients weighing less than 10kg between 2009 and 2022.
- Data collected included demographics, diagnosis, intraoperative vasoactive infusions, blood loss, ventilation, and intensive care unit (ICU) and hospital length of stay (LOS).
Main Results:
- ULW infants (<5kg) had a lower average weight (4.53kg vs. 7.30kg) and age at transplant (3.36 months vs. 7.90 months) compared to the 5-9.9kg group.
- While no significant differences were found in anhepatic time, blood loss, or transfusions, ULW infants showed a trend towards higher vasopressor doses, particularly at the end of the procedure (p=0.06).
- One-year patient and graft survival rates were high (94% and 91%, respectively), with portal vein thrombosis (PVT) occurring more frequently in the <5kg cohort.
Conclusions:
- The etiology of liver failure differs between ULW and 5-9.9kg PLT recipients, with neonatal acute liver failure being more common in ULW infants.
- ULW infants (<5kg) may experience greater hemodynamic instability requiring increased vasopressor support, although this did not correlate with longer hospital stays or ventilation times.
- Etiology, rather than just size or age, might influence pressor requirements and PVT risk in ULW infants undergoing PLT.
Background:
Survival in pediatric liver transplantation (PLT) has significantly improved in infants under 1 year, but < 10 kg and < 6 months continue to have poor outcomes with a paucity of information on ultra-low weight (ULW) infants (< 5 kg). We compared intraoperative vasopressor use in < 5 kg versus 5-< 9.9 kg PLT recipients.
Methods:
We conducted a single-center retrospective review of all PLT recipients < 10 kg at time of transplant from 2009 to 2022, excluding multi-organ transplantation. We collected data on demographics, diagnosis, intraoperative vasoactive infusions, blood loss and requirements, and abdominal closure timing. Outcomes data include total mechanical ventilation, intensive care and hospital length of stay days, 1-year patient and graft survival and thrombotic complications.
Results:
ULW < 5 kg and 5-9.9 kg patients showed average weight of 4.53 versus 7.30 kg (p-value < 0.0001) and average age of transplant 3.36 versus 7.90 months (p-value 0.0002). The most common etiology of liver disease for ULW versus 5-9.9 kg was neonatal acute liver failure (3 of 5) versus biliary atresia (41 of 63). No significant difference in anhepatic time, abdominal closure, blood products transfused/kg, estimated blood loss/kg was noted. Total days of mechanical ventilation, ICU and hospital LOS were similar between groups. ULW trends toward higher doses of vasopressors during PLT, most notably at end of case compared to 5-9.9 kg (p = 0.06). Overall, 1-year graft and patient survival were 91% and 94%, respectively. HAT and PVT did not appear to be associated with VIS by phase of surgery, but PVT occurred relatively more in the < 5 kg group (2 vs. 4) and HAT in the 5-9.9 kg group (0 vs. 3).
Conclusions:
Results show etiology of liver failure differs and < 5 kg trends to an increased amount of vasopressor use, especially at end of case, suggesting more hemodynamic instability requiring support; however, this did not correlate with measured hospital metrics. Split graft PLT recipients have more blood loss and require more transfusions. PVT was observed more in the < 5 kg cohort. Etiology, not just size or early age, may contribute to the higher and sustained pressor requirements and possible PVT risk in ULW infants.
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