Acute liver failure in children—Is living donor liver transplantation justified?

Abstract

ObjectivesLiving donor liver transplantation (LDLT) in patients with acute liver failure (ALF) has become an acceptable alternative to transplantation from deceased donors (DDLT). The aim of this study was to analyze outcomes of LDLT in pediatric patients with ALF based on our center’s experience.Material and methodsWe enrolled 63 children (at our institution) with ALF who underwent liver transplantation between 1997 and 2016. Among them 24 (38%) underwent a LDLT and 39 (62%) received a DDLT. Retrospectively analyzed patient clinical data included: time lapse between qualification for transplantation and transplant surgery, graft characteristics, postoperative complications, long-term results post-transplantation, and living donor morbidity. Overall, we have made a comparison of clinical results between LDLT and DDLT groups.ResultsFollow-up periods ranged from 12 to 182 months (median 109 months) for LDLT patients and 12 to 183 months (median 72 months) for DDLT patients. The median waiting time for a transplant was shorter in LDLT group than in DDLT group. There was not a single case of primary non-function (PNF) in the LDLT group and 20 out of 24 patients (83.3%) had good early graft function; 3 patients (12.5%) in the LDLT group died within 2 months of transplantation but there was no late mortality. In comparison, 4 out of 39 patients (10.2%) had PNF in DDLT group while 20 patients (51.2%) had good early graft function; 8 patients (20.5%) died early within 2 months and 2 patients (5.1%) died late after transplantation. The LDLT group had a shorter cold ischemia time (CIT) of 4 hours in comparison to 9.2 hours in the DDLT group (p<0.0001).ConclusionsLDLT is a lifesaving procedure for pediatric patients with ALF. Our experience showed that it may be performed with very good results, and with very low morbidity and no mortality among living donors when performed by experienced teams following strict procedures.

Long‐term Outcomes of Pediatric Living Versus Deceased Donor Liver Transplantation Recipients: A Systematic Review and Meta‐analysis

“…The baseline characteristics of the included studies are presented in Table 1. ( 5‐28 ) All of these studies were included in the systematic review; however, 15 studies with overlapping cohorts were excluded from the main meta‐analyses but may have been included in the sensitivity analyses. Outcome data were reported as 3‐year, 5‐year, and 10‐year posttransplantation patient and graft survival in acute and chronic liver failure.…”

“…The time origin of the survival analysis was not specified in 11 studies. ( 5,7­9,12,13,15,16,22,23,28 ) Three studies reported starting the analysis from the time of transplantation, one from the time of listing, and one from the time of donor evaluation.…”

“…If outcomes for recipients of a whole liver or split liver were reported, we utilized only survival from whole liver recipients to maintain uniformity with other studies that only reported whole liver DDLT. ( 5‐28 )…”

Minding the gap—Providing quality transplant care for South African children with acute liver failure

“…However, our annual transplant rates for PALF have increased dramatically over the last 5 years, comprising 26% of all transplants in 2019—more than double most rates in international transplant programs 3,4 . The reasons for our higher than average transplant rates most likely reflect our “open‐door” policy for accepting referrals for any child in need of a liver transplant (irrespective of payer status); a broad referral base that includes children from all parts of South Africa and neighboring countries; and our efforts to increase the donor pool by using technical variant grafts from living donors, deceased donor reduced or split liver grafts, and performing ABO‐incompatible transplants, all of which avoid treatment delay 23,24 . Despite these considerations, it should be noted that the increased referral rate is a recent development and still in evolution.…”

Pediatric acute liver failure: Reexamining key clinical features, current management, and research prospects

“…This study also demonstrated improved graft quality from the LDLT compared with the DDLT, which also had higher rates of graft primary nonfunction. [ 29 ] Similarly, a 2016 Brazilian retrospective, single‐center study of 115 patients with PALF showed that LDLT was associated with a higher long‐term survival rate (72.4%) compared with DDLT (40.0%) as well as lower incidences of primary nonfunction. [ 30 ] The study also demonstrated improved waitlist mortality after the initiation of LDLT.…”