Incidence, impact, and treatment of portal and hepatic venous complications following pediatric liver transplantation: A single-center 12 year experience

Abstract

PVT or PVS and HVOO are known causes of graft and patient loss after pediatric liver transplantation. Increased incidences of these complications have been reported in partial livers including DDSLT or LDLT. From 1997 to 2008, 241 consecutive pediatric patients received 271 hepatic grafts at a single center. Median follow-up is 1856 days. Surgical technique, demographics, lab values, and radiologic imaging procedures were obtained utilizing OTTR to evaluate the relationship of portal and hepatic complications with risk factors, patient and graft survival. Grafts were composed of 115/271 (42.4%) partial livers of which 90 (33.2%) were DDSLT and 25 (9.2%) LDLT. Of 271 patients, 156 (57.6%) received whole-sized grafts. There were six PVC in five patients with one patient requiring retransplantation (0.34%) and no patient deaths. Utilizing all three hepatic vein orifices on the recipient hepatic vena cava and the donor hepatic vein cut short enables a wide hepatic outflow tract unlikely to twist. None of the 241 patients developed early or late complications of the hepatic vein. None of the last 128 consecutive patients who received 144 grafts over seven and a half yr have developed either early or late complications of the hepatic or portal vein. Partial-graft actuarial survival was similar to whole-graft survival (87.2% vs. 85.3% at one yr; 76.6% vs. 80.2 at three yr; p = 0.488). Likewise, patient survival was similar between partial grafts and whole grafts (93.8% vs. 93.1% at one yr; 89.8% vs. 87.2% at three yr; p = 0.688) with median follow-up of 1822 (+/-1334) days. Patients receiving partial livers were significantly younger and smaller than patients receiving whole livers (p < 0.001). Portal and hepatic venous complications may have negative effects on patient or graft survival after pediatric liver transplantation. In our series, there was one graft and no patient loss related to portal or hepatic venous complications after pediatric liver transplantation over 12 yr.

Analysis of factors associated with portal vein thrombosis in pediatric living donor liver transplant recipients

“…Heffron et al reported a PVC incidence of 2.2% for a cohort of 271 patients (156 full size grafts and 115 partial liver grafts). The BW values for patients receiving whole liver and partial grafts were 34.9 and 16.7 kg, respectively.…”

Long-term medical management of the pediatric patient after liver transplantation: 2013 practice guideline by the American Association for the Study of Liver Diseases and the American Society of Transplantation

“…The main causes of graft loss in the first week include primary nonfunction, hepatic artery thrombosis (HAT) or portal vein thrombosis (PVT), systemic sepsis, and multiorgan failure (<10%). Other significant complications are acute rejection (AR; 50%), chronic rejection (CR; 10%), biliary leaks and strictures (5%‐25%), viral infections [especially cytomegalovirus (CMV) and Epstein‐Barr virus (EBV)], acute kidney injury, and fluid imbalance . The 1‐year patient survival rate is 90%, and the survival rate is 75% at 15 to 20 years with good quality of life .…”

Pediatric transplantation: preventing thrombosis

“…The approach to thrombosis prevention remains largely empirical, and practices vary widely between centers. Hardikar et al [25] prospectively evaluated a standardized perioperative protocol in 40 transplant recipients which incorporated regular AT concentrate to maintain levels > 70%, daily fresh frozen plasma (FFP) 15 mL kg À1 to maintain protein C/S levels, and low-dose unfractionated heparin (UFH) [28] USA P/C LT 0-18 PGE1, ASA HAT 2.7% Heffron (2010) [75] USA P/C LT 0-18 PGE1, ASA PVT < 1% Ikegami (2006) [76] Japan P/C LDLT All LMWH, AT, protease inhibitor, PGE1, FFP HAT 5.4%…”