Background Infants have the highest waitlist mortality of all liver transplant candidates. Deceased-donor split liver transplantation, a technique that provides both an adult and pediatric graft, may be the best way to decrease this disproportionate mortality. Yet concern for an increased risk to adult split recipients has discouraged its widespread adoption. We aimed to determine the current risk of graft failure in adult recipients following split liver transplantation. Study Design United Network for Organ Sharing (UNOS) data from 62,190 first-time adult recipients of deceased-donor liver transplants (1995–2010) were analyzed (889 split grafts). Bivariate risk factors (p<0.2) were included in cox proportional hazards models of the effect of transplant type on graft failure. Results Split liver recipients had an over-all hazard-ratio (HR) of graft failure of 1.26 (p<.001) compared to whole liver recipients. The split liver HR was 1.45 (p<.001) in the pre-MELD era (1995–2002), and 1.10 (p=.28) in the MELD era (2002–2010). Interaction analyses suggested an increased risk of split graft failure in Status 1 recipients and those given an exception for hepatocellular carcinoma (HCC). Excluding higher-risk recipients, split and whole grafts had similar outcomes (HR .94, p=.59). Conclusions The risk of graft failure is now similar between split and whole liver recipients in the vast majority of cases – demonstrating that the expansion of split liver allocation may be possible without increasing the overall risk of long-term graft failure in adult recipients. Further prospective analysis should examine if selection bias may account for the possible increase in risk for recipients with HCC or designated Status 1.

The care of pediatric liver transplant recipients has traditionally included postoperative mechanical ventilation. In 2005, we started extubating children undergoing liver transplantation in the operating room according to standard criteria for extubation used for general surgery cases. We reviewed our single-center experience to determine our rates of immediate extubation and practice since that time. The records of 84 children who underwent liver transplantation from 2005 to 2011 were retrospectively reviewed. The immediate extubation rate increased from 33% during 2005-2008 to 67% during 2009-2011. Immediate extubation did not result in an increased reintubation rate in comparison with delayed extubation in the intensive care unit (ICU). Patients undergoing immediate extubation had a trend toward a shorter mean ICU stay as well as a significantly decreased overall hospital length of stay. Our findings suggest that there is a learning curve for instituting immediate extubation in the operating room after liver transplantation and that the majority of pediatric liver recipients can safely undergo immediate extubation. Liver Transpl 21:57-62, 2015. V C 2014 AASLD.Received December 5, 2013; accepted September 14, 2014.In 1997, studies reported an increasing frequency of immediate extubation of adult liver transplant recipients in the operating room. 1,2 Subsequent studies showed no increase in reintubation rates, decreased postoperative days in the intensive care unit (ICU), and decreased associated costs with immediate extubation. 2 Despite this increase in the fast-tracking of adult liver transplant recipients, common management in pediatric liver transplantation has continued to include postoperative ventilation. 3 A recently presented abstract examining the Studies of Pediatric Liver Transplantation database demonstrated that among the 25 centers queried, those centers with an overall shorter hospital stay and lower costs had a shorter duration of postoperative intubation (2.7 days) in comparison with other centers (6.5 days). The authors concluded that early extubation may result in a decreased length of stay. 4 In 2005, we began immediately extubating pediatric liver transplant recipients if all team members were comfortable with that plan. The current study sought to (1) examine our rates of immediate extubation, (2) identify factors associated with immediate extubation or postoperative ventilation, and (3) evaluate postoperative outcomes after this practice change. PATIENTS AND METHODSApproval for the study and a waiver for consent were obtained from the institutional review board. We performed a retrospective review of the medical records of all pediatric liver transplant recipients from January 2005 through December 2011 at our institution. Patients with preoperative ventilator requirements were subsequently excluded from the analysis. Three patients were included in the data set twice for Abbreviations: BMI, body mass index; ICU, intensive care unit; MELD, Model for End-Stage Liver Disease; PELD, Pedia...

Background Infants have the highest waitlist mortality of all liver transplant candidates. While previous studies have demonstrated that young children may be at increased risk when receiving partial grafts from adult and adolescent deceased donors (DD), with few size-matched organs available, these grafts have increasingly been used to expand the pediatric donor pool. We aimed to determine the current adjusted risk of graft failure and mortality in young pediatric recipients of DD partial livers, and to determine if these risks have changed over time. Methods We analyzed 2,683 first-time DD liver-alone recipients under the age of 2 years in the UNOS database (1995-2010), including 1,118 DD partial livers and 1,565 DD whole organs. Transplant factors associated with graft loss on bivariate analyses (p<0.1) were included in multivariable proportional hazards models of graft and patient survival. Interaction analysis was used to examine risks over time (time-periods:1995-2000, 2001-2005, 2006-2010). Results While there were significant differences in crude graft survival by graft type in 1995-2000 (p<.001), graft survival between partial and whole grafts was comparable in 2001-2005 (p=.43) and 2006-2010 (p=.36). Furthermore, while the adjusted hazards of partial graft failure and mortality were 1.40 (1.05-1.89) and 1.41 (.95-2.09) respectively in 1995-2000, the adjusted risk of graft failure and mortality was comparable between partial and whole organs in 2006-2010 (Graft failure HR .81 95%CI .56-1.18; Mortality HR 1.02 95%CI .66-1.71). Conclusions Deceased-donor partial liver transplantation has become less risky over time, and now has comparable outcomes to whole liver transplantation in infants and young children.

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