PEDIATRIC LIVER-TRANSPLANTATION - FROM THE FULL-SIZE LIVER GRAFT TO REDUCED, SPLIT, AND LIVING-RELATED LIVER-TRANSPLANTATION

Between 1984 and 1996, the authors performed 499 liver transplants in 416 children less than 15 years old. The overall patient survival at 1 0 years was 76.5%. It was 71.3% for the 209 children grafted in 1984-1 990; 78.5% for biliary atresia (n = 286), 87.3% for metabolic diseases (n = 59), and 72.7% for acute liver failure(n = 22). The 5-year survi val was 73.6% for the 209 children grafted in 1984-1990 and 85% for th e 206 grafted in 1991-1996. Scarcity of size-matched donors led to the development of innovative techniques: 174 children who electively rec eived a reduced liver as a first graft in our center had a 5-year surv ival of 76% while 168 who received a full-size graft had a survival of 85% (NS). Results of the European Split Liver Registry showed 6-month graft survival similar to results obtained with full-size grafts coll ected by the European Liver Transplant Registry. Extensive use of thes e techniques allowed the mortality while waiting to be reduced from 16 .5% in 1984-1990 to 10% in 1991-1992. It rose again to 17% in 1993, le ading the authors to develop a program of living related liver transpl antation (LRLT). The legal and ethical aspects are analyzed. Between J uly 1993 and October 1997, the authors performed 53 LRLTs with 90% sur vival. In elective cases, a detailed analysis was made of the 45 child ren listed for LRLT between July 1993 and March 1997 and the 79 regist ered on the cadaveric waiting list during the same period. Mortality w hile waiting was 2% and 14.5% for the LRLT and cadaveric lists, respec tively. The retransplantation rate was 4.6% and 16.1% for LRLT and cad averic transplants, respectively. Overall post-transplant survival was 88% and 82% for children who received a LRLT or a cadaveric graft, re spectively. Overall survival from the date of registration was 86% and 70% (P < 0.05) for LRLT or cadaveric LT respectively. The 2-year post -transplant survival in children less than 1 year of age at transplant ation was 88.8% and 80.3% with a LRLT or cadaveric graft, respectively ; patient survival after 3 months post-transplant was 95.8% and 91.9% for stable children waiting at home, 93.7% and 93.7% in children hospi talized for complications of their disease, and 89.5% and 77.7% for ch ildren hospitalized in an intensive care unit at the time of transplan tation for children who received a LRLT or cadaveric graft, respective ly. It is concluded that LRLT seems to be justified for multidisciplin ary teams having a large experience with reduced and split liver graft ing.