Retrospective Cohort Study
Copyright ©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Transplant. Mar 18, 2024; 14(1): 87752
Published online Mar 18, 2024. doi: 10.5500/wjt.v14.i1.87752
Pediatric and adult liver transplantation in Bahrain: The experiences in a country with no available liver transplant facilities
Hasan M Isa, Fatema A Alkharsi, Jawad K Khamis, Sawsan A Hasan, Zainab A Naser, Zainab N Mohamed, Afaf M Mohamed, Shaikha A Altamimi
Hasan M Isa, Fatema A Alkharsi, Sawsan A Hasan, Zainab A Naser, Zainab N Mohamed, Department of Pediatrics, Salmaniya Medical Complex, Manama 26671, Bahrain
Hasan M Isa, Department of Pediatrics, Arabian Gulf University, Manama 26671, Bahrain
Jawad K Khamis, Department of Medicine, Salmaniya Medical Complex, Manama 26671, Bahrain
Afaf M Mohamed, Public Health Directorate, Ministry of Health, Manama 26671, Bahrain
Shaikha A Altamimi, The Overseas Office, Supreme Committee for Treatment Abroad, Ministry of Health, Manama 26671, Bahrain
Author contributions: Isa HM was the main contributor in study design, literature review, data analysis, drafting manuscript, and over-sight for all phases of the project and the final approval of the version to be published; Alkharsi FA was responsible for literature review, data collection, data analysis, drafting and revising manuscript; Khamis JK, Hasan SA, and Naser ZA were responsible for literature review, data collection, drafting and revising manuscript; Mohamed ZN was responsible for data collection, drafting and revising manuscript; Mohamed AM and Altamimi SA were responsible for data collection and revising manuscript; All the authors have read and approved the final manuscript.
Institutional review board statement: The study was conducted in accordance with the principles of Helsinki Declaration of 1975 (revised 2013), and it was ethically approved by the Research and Research Ethics Committee, Salmaniya Medical Complex, Government hospitals, Kingdom of Bahrain (IRB number: 87151122, November 15, 2022).
Informed consent statement: Consent was not needed as the study was retrospective without exposure to the patients’ data.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Data sharing statement: Data are available upon reasonable request.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Hasan M Isa, MBChB, Associate Professor, Consultant Physician-Scientist, Department of Pediatrics, Salmaniya Medical Complex, Road No. 2904, Al Salmaniya Area, P.O. Box: 12, Manama 26671, Bahrain. halfaraj@hotmail.com
Received: October 7, 2023
Peer-review started: October 7, 2023
First decision: November 17, 2023
Revised: November 29, 2023
Accepted: December 19, 2023
Article in press: December 19, 2023
Published online: March 18, 2024
Processing time: 160 Days and 2.4 Hours
Abstract
BACKGROUND

Liver transplantation (LT) is a life-saving procedure for patients with end-stage liver disease and has become the standard and most effective treatment method for these patients. There are many indications for LT that vary between countries and settings. The outcome of LT depends on the available facilities and surgical expertise, as well as the types of liver graft donors available.

AIM

To assess the clinical characteristics of patients from Bahrain who underwent LT overseas, and analyze factors affecting their survival.

METHODS

In this retrospective cohort study, we reviewed the medical records and overseas committee registry information of all pediatric and adult patients who were sent overseas to undergo LT by the Pediatric and Medical Departments of Salmaniya Medical Complex and Bahrain Defence Force Hospital via the Overseas Treatment Office, Ministry of Health, Kingdom of Bahrain, between 1997 and 2023. Demographic data, LT indication, donor-recipient relationship, overseas LT center, graft type, post-LT medications, and LT complications, were collected. Outcomes measured included the overall and 5-year LT survival rate. Fisher’s exact, Pearson χ2, and Mann-Whitney U tests were used to compare the pediatric and the adults’ group in terms of clinical characteristics, donor-recipient relationship, medication, complications, and outcome. Survival analysis was estimated via the Kaplan-Meier’s method. Univariate and multivariate analyses were used to detect predictors of survival.

RESULTS

Of the 208 eligible patients, 170 (81.7%) were sent overseas to undergo LT while 38 (18.3%) remained on the waiting list. Of the 170 patients, 167 (80.3%) underwent LT and were included in the study. The majority of the patients were Bahraini (91.0%), and most were males (57.5%). One-hundred-and-twenty (71.8%) were adults and 47 (28.3%) were children. The median age at transplant was 50.0 [interquartile range (IQR): 14.9–58.4] years. The main indication for pediatric LT was biliary atresia (31.9%), while that of adult LT was hepatitis C-related cirrhosis (35.0%). Six (3.6%) patients required re-transplantation. Most patients received a living-related liver graft (82%). Pediatric patients received more living and related grafts than adults (P = 0.038 and P = 0.041, respectively), while adult patients received more cadaveric and unrelated grafts. Most patients required long-term immunosuppressive therapy after LT (94.7%), of which tacrolimus was the most prescribed (84.0%), followed by prednisolone (50.7%), which was prescribed more frequently for pediatric patients (P = 0.001). Most patients developed complications (62.4%) with infectious episodes being the most common (38.9%), followed by biliary stricture (19.5%). Tonsilitis and sepsis (n = 12, 8.1% for each) were the most frequent infections. Pediatric patients experienced higher rates of infection, rejection, and early poor graft function than adult patients (P < 0.001, P = 0.003, and P = 0.025, respectively). The median follow-up time was 6.5 (IQR: 2.6–10.6) years. The overall survival rate was 84.4%, the 5-year survival rate, 86.2%, and the mortality rate, 15.6%. Younger patients had significantly better odds of survival (P = 0.019) and patients who survived had significantly longer follow-up periods (P < 0.001).

CONCLUSION

Patients with end-stage liver disease in Bahrain shared characteristics with those from other countries. Since LT facilities are not available, an overseas LT has offered them great hope.

Keywords: Overseas liver transplantation; End-stage liver disease; Liver transplant facilities; Liver donor; Biliary atresia; Hepatitis C

Core Tip: The clinical characteristics, management, and outcomes of patients from Bahrain with end-stage liver disease who underwent an overseas liver transplantation (LT) have not been studied previously. In this retrospective cohort study, we found that biliary atresia in children and hepatitis C infection in adults were the main indications. This was comparable to literature from neighboring countries and worldwide. Most patients received living-related grafts. The overall survival rate was 84.4% and was significantly better in younger patients. Therefore, in countries where LT facilities are not available, an overseas LT can offer great hope for this group of patients.