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Liver transplantation in the first three months of life
E S Woodle1, J M Millis, S K So
1Department of Surgery, University of Chicago, Illinois 60637, USA. swoodle@surgery.bsd.uchicago.edu
Insights
Liver transplantation in infants under 3 months old shows good survival rates, but rejection is common. Early referral for these infants is recommended for successful outcomes.
Area of Science:
- Pediatric Hepatology
- Transplant Surgery
- Neonatal Medicine
Background:
- Traditional age-based classifications for pediatric liver transplant recipients may not adequately address the unique needs of infants under 3 months.
- Infants in the first 3 months of life present distinct clinical features that warrant separate consideration in liver transplantation.
Purpose of the Study:
- To characterize the outcomes of liver transplantation in infants younger than 3 months of age.
- To analyze the specific challenges and successes of this distinct pediatric liver transplant population.
Main Methods:
- Retrospective analysis of liver transplant data from three major pediatric transplant centers (University of Chicago, Stanford University, UCLA).
- Inclusion criteria: infants transplanted within the first 3 months of life.
- Data collected on patient demographics, etiology of liver disease, graft types, and post-transplant outcomes.
Main Results:
- Twenty-three liver transplants were performed in infants under 3 months, representing 37% of the US experience (1988-1994).
- Common etiologies included idiopathic hepatitis (52%) and iron storage disease (17%).
- One-year patient and graft survival rates were 60%; two-year rates were 60% and 42%, respectively. Rejection occurred in 42% of patients.
Conclusions:
- Liver transplantation in infants under 3 months yields acceptable short- and long-term survival rates.
- Significant rates of rejection necessitate careful management, while vascular thrombosis rates are not excessive.
- The distinct etiology of end-stage liver disease in this age group underscores the need for prompt referral and transplantation.
Background:
Pediatric liver transplant recipients have traditionally been grouped according to age. Age-based classification schemes are useful in identifying clinical problems in selected age groups and also for developing solutions to these problems. Although infants in the first 3 months of life have not traditionally been considered a distinct age group, several features of these infants may distinguish them from other pediatric liver transplant recipients.
Methods:
The experience with liver transplantation in infants during the first 3 months of life in three large pediatric liver transplant programs (University of Chicago, Stanford University, and UCLA) was analyzed in order to characterize this group.
Results:
A total of 23 liver transplants were performed at these three centers in children younger than 3 months of age. This group of patients comprised approximately 37% of the U.S. experience between 1988 and 1994 according to United Network for Organ Sharing statistics. Age distribution at the time of transplantation included the following: <1 month, 28%; 1-2 months, 35%; and 2-3 months, 36%. Median age at the time of transplantation was 37 days (range, 7-90 days), and mean age was 57+/-30 days. Mean weight at the time of transplantation was 3.8+/-1.0 kg. Etiology of liver disease included idiopathic hepatitis, 52%; iron storage disease, 17%; and other causes, 31%. Types of liver allografts used included cadaveric, 85% (reduced size, 60%, and full-size, 25%); living donor, 15%; ABO-identical, 65%; and ABO-compatible, 35%. Actuarial patient and graft survival rates were 60% and 60% at 1 year and 60% and 42% at 2 years, respectively. Median follow-up was 1.5 years. Rejection occurred in 42% of patients, with a median time to first rejection of 13 days. Of these patients, 28% required steroids only and 14% required OKT3. Three patients (14%) were retransplanted at a median time to retransplantation of 1.6 years. Vascular thrombosis occurred in three patients (14%).
Conclusions:
Liver transplantation performed in infants younger than 3 months of age (1) provides acceptable short- and long-term patient and graft survival, (2) is associated with significant rates of rejection, and (3) is not associated with excessive rates of vascular thrombosis. The etiology of end-stage liver disease occurring in the first 3 months of life is distinct from that in other pediatric liver transplant recipient age groups. These infants should be referred promptly for liver transplantation as reasonable survival can be expected.