AN ANALYSIS OF HEPATIC RETRANSPLANTATION IN CHILDREN

Background The limited supply of organ donors has Bed some groups to r econsider the role of retransplantation. Historically, except for chil dren with malignancies, extrahepatic sources of sepsis, or severe irre versible neurologic injuries, our institution has offered all children with failing liver grafts the option of retransplantation regardless of their current severity of illness. The purpose of this study was to examine the outcome of hepatic retransplantation in children in an at tempt to identify factors predictive of outcome and to assess the resu lts of our approach to retransplantation. Methods. Between October 198 4 and December 1995, 314 children less than 15 years of age underwent st total of 441 liver transplants. Data were obtained retrospectively by review of hospital records. Results, With a mean follow-up, period of 5.3+/-2.7 years, the overall patient survival rates at 1 and 5 year s were 77.1% and 67.1%, respectively, Primary allograft survival rates were 65.6% and 56.5%, respectively. Of the 137 patients who developed failure of their primary allograft, 92 underwent retransplantation (2 9.3% of all primary transplants). Both patient and allograft survival rates were significantly decreased after retransplantation (P<0.0001 v ersus primary transplants). Univariate and multivariate analysis of re transplanted patients revealed only two factors that were statisticall y related to patient and graft survival: age at the time of retranspla ntation (P<0.02 univariate and P<0.05 multivariate) and retransplantat ion with a reduced-size allograft (P<0.005 univariate and P<0.05 multi variate), In this series, the effect on patient survival of difference s in medical condition as reflected by United Network for Organ Sharin g (UNOS) status approached, but did not achieve, significance (P=0.08 for UNOS 1 versus UNOS 2 and 3), UNOS status did not affect graft surv ival. Neither the cause of primary allograft loss or the timing of ret ransplantation relative to the first transplant were related to outcom e. Conclusions. These data demonstrate that the failure of primary hep atic allografts remains a major problem in pediatric liver transplanta tion and that the overall results of retransplantation were significan tly worse than those associated with primary transplants, We have iden tified a group of children who experienced a significantly worse outco me after retransplantation. This group consisted of children less than 3 years of age retransplanted using reduced-size grafts. Based on thi s finding, we now attempt to avoid retransplanting young children with reduced size grafts. By using this approach, we hope to be able to of fer children the option of retransplantation with improved results and simultaneously minimize the negative impact on patients awaiting prim ary transplants.