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An analysis of hepatic retransplantation in children
K A Newell1, J M Millis, D S Bruce
1Section of Transplantation, University of Chicago, Illinois 60637, USA.
Insights
Pediatric liver retransplantation outcomes are significantly worse than primary transplants. Young children (<3 years) retransplanted with reduced-size grafts face poorer survival, prompting a shift in clinical practice.
Area of Science:
- Pediatric Hepatology
- Transplant Surgery
- Organ Transplantation
Background:
- Limited organ donor supply necessitates reevaluating liver retransplantation in children.
- Historically, pediatric liver retransplantation was offered broadly, irrespective of illness severity.
- This study examines outcomes and predictive factors for pediatric hepatic retransplantation.
Purpose of the Study:
- To assess the outcomes of pediatric hepatic retransplantation.
- To identify factors predicting success or failure in pediatric liver retransplantation.
- To evaluate the institution's approach to retransplantation in children.
Main Methods:
- Retrospective review of hospital records for 314 children (<15 years) undergoing 441 liver transplants (Oct 1984 - Dec 1995).
- Analysis of patient and allograft survival rates post-primary and re-transplantation.
- Univariate and multivariate analyses to identify factors influencing survival.
Main Results:
- Overall patient and allograft survival rates at 1 and 5 years were 77.1% and 67.1% (patient), and 65.6% and 56.5% (allograft).
- Retransplantation significantly decreased patient and allograft survival rates (P<0.0001).
- Younger age at retransplantation (<3 years) and use of reduced-size allografts were associated with worse outcomes (P<0.05).
Conclusions:
- Primary liver allograft failure is a significant challenge in pediatric transplantation.
- Pediatric liver retransplantation yields significantly poorer results compared to primary transplants.
- Avoiding retransplantation with reduced-size grafts in young children (<3 years) may improve outcomes.
Background:
The limited supply of organ donors has led some groups to reconsider the role of retransplantation. Historically, except for children with malignancies, extrahepatic sources of sepsis, or severe irreversible neurologic injuries, our institution has offered all children with failing liver grafts the option of retransplantation regardless of their current severity of illness. The purpose of this study was to examine the outcome of hepatic retransplantation in children in an attempt to identify factors predictive of outcome and to assess the results of our approach to retransplantation.
Methods:
Between October 1984 and December 1995, 314 children less than 15 years of age underwent a total of 441 liver transplants. Data were obtained retrospectively by review of hospital records.
Results:
With a mean follow-up period of 5.3+/-2.7 years, the overall patient survival rates at 1 and 5 years were 77.1% and 67.1%, respectively. Primary allograft survival rates were 65.6% and 56.5%, respectively. Of the 137 patients who developed failure of their primary allograft, 92 underwent retransplantation (29.3% of all primary transplants). Both patient and allograft survival rates were significantly decreased after retransplantation (P<0.0001 versus primary transplants). Univariate and multivariate analysis of retransplanted patients revealed only two factors that were statistically related to patient and graft survival: age at the time of retransplantation (P<0.02 univariate and P<0.05 multivariate) and retransplantation with a reduced-size allograft (P<0.005 univariate and P<0.05 multivariate). In this series, the effect on patient survival of differences in medical condition as reflected by United Network for Organ Sharing (UNOS) status approached, but did not achieve, significance (P=0.08 for UNOS 1 versus UNOS 2 and 3). UNOS status did not affect graft survival. Neither the cause of primary allograft loss or the timing of retransplantation relative to the first transplant were related to outcome.
Conclusions:
These data demonstrate that the failure of primary hepatic allografts remains a major problem in pediatric liver transplantation and that the overall results of retransplantation were significantly worse than those associated with primary transplants. We have identified a group of children who experienced a significantly worse outcome after retransplantation. This group consisted of children less than 3 years of age retransplanted using reduced-size grafts. Based on this finding, we now attempt to avoid retransplanting young children with reduced-size grafts. By using this approach, we hope to be able to offer children the option of retransplantation with improved results and simultaneously minimize the negative impact on patients awaiting primary transplants.