In conclusion, living-donor liver transplantation using HRLLS grafts offers a safe and useful option for treating smaller infants.

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Liver transplantation is now an established treatment for children with end-stage liver disease. Left lateral segment (LLS) grafts are most commonly used in split and living donor liver transplantation in children. In very small children, LLS grafts can be too large, and further nonanatomical reduction has recently been introduced to mitigate the problem of large-for-size grafts. However, the implantation of LLS grafts can be a problem in infants and very small children because of the thickness of the grafts, and these techniques do not address problems related to thickness. We herein describe a technique for reducing the thickness of living donor left lateral grafts and successful transplantation in a 2.8-kg infant with acute liver failure. The lack of size-matched pediatric liver grafts has led to the development of reduced, split, and living donor liver transplantation. These techniques have expanded the potential donor pool and decreased waiting-list mortality for children. 1 Transplantation in children who weigh less than 5 kg remains a problem because the left lateral segment (LLS) from an adult may be too large when the graft-to-recipient weight ratio is greater than 4.0% and thus may result in a large-for-size graft and its associated morbidity. 2 Further reduced LLS grafts that can be transplanted safely without compromise to patient survival have been introduced for these children to mitigate the problem of large-for-size grafts. 3 In very small children (neonates) who have no portal hypertension, hepatomegaly, or ascites, the abdominal cavity may be small, and the anteroposterior thickness of the graft remains a problem. 4,5 Abdominal closure may require a temporary Silastic mesh, and this is associated with complications. We have developed a modified LLS reduction by which the thickness of the graft is addressed and transplantation is allowed in very small infants. The clinical study protocol was approved by the institutional review committee. CASE PRESENTATIONA 23-day-old Asian girl weighing 2.8 kg who presented with deteriorated liver function was admitted to our hospital. The laboratory study showed a total bilirubin level of 22.7 mg/dL, a prothrombin time/international normalized ratio of 10.0, an alanine aminotransferase level of 500 U/L, and a serum ammonia level of 217 lmol/L. The investigations for infectious and inherited metabolic pathogenesis were all negative. The patient was diagnosed with neonatal acute Abbreviations: LHV, left hepatic vein; LLS, left lateral segment; LPV, left portal vein; MHV, middle hepatic vein; P2, segment II portal vein; P3, segment III portal vein; PV, portal vein; RHV, right hepatic vein; RPV, right portal vein.

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An IL-2 receptor antagonist, basiliximab, decreases the frequency of ACR in liver transplant (LT) recipients as induction therapy. The aim of this study was to evaluate the effectiveness of basiliximab against SRR as rescue therapy in pediatric LT patients with ALF. Forty pediatric ALF patients underwent LT between November 2005 and July 2013. Among them, seven patients suffering from SRR were enrolled in this study. The median age at LT was 10 months (6-12 months). SRR was defined as the occurrence of refractory rejection after more than two courses of steroid pulse therapy. Basiliximab was administered to all patients. The withdrawal of steroids without deterioration of the liver function was achieved in six patients treated with basiliximab therapy without patient mortality, although one patient developed graft loss and required retransplantation for veno-occlusive disease. The pathological examinations of liver biopsies in the patients suffering from SRR revealed severe centrilobular injuries, particularly fibrosis within one month after LT. We demonstrated the effectiveness and safety of rescue therapy consisting of basiliximab for SRR in pediatric LT recipients with ALF.