Published online Mar 18, 2023. doi: 10.5500/wjt.v13.i3.96
Peer-review started: December 2, 2022
First decision: December 13, 2022
Revised: December 22, 2022
Accepted: March 6, 2023
Article in press: March 6, 2023
Published online: March 18, 2023
Settings of pediatric liver transplantation (PLT) in end-stage chronic liver disease (ESCLD) and acute liver failure (ALF) are divergent. ALF recipients are transplanted within a narrow window of opportunity, whereas ESCLD recipients are usually transplanted electively.
Outcomes of PLT in ALF and ESCLD were previously described by different centers but to the best of our knowledge, they were not compared to establish if there is a difference in post-PLT survival and complication rates between these two groups.
To determine if there is a difference in post-operative complications and survival outcomes between the ALF and ESCLD in PLT.
This was a retrospective observational study of all primary PLTs performed at a single center between 2000 and 2019. ALF and ESCLD groups were compared for the pretransplant recipient, donor and operative parameters, and post-operative outcomes including graft and patient survival.
During the 20-year study period, 232 primary PLTs were performed at our center; 195 were transplanted for ESCLD and 37 were transplanted for ALF. The ALF recipients were significantly older (median 8 years vs 5.4 years; P = 0.031) and heavier (31 vs 21 kg; P = 0.011). Living donor grafts were used more in the ESCLD group (34 vs 0; P = 0.006). There was no difference between the two groups concerning vascular complications and rejection, but there were more bile leaks in the ESCLD group. Post-transplant patient survival was considerably superior in the ESCLD group: 1-, 5-, and 10-year survival rates were 97.9%, 93.9%, and 89.4% correspondingly compared to 78.3%, 78.3%, and 78.3% in the ALF group (P = 0.007). However, there was no difference in 1-, 5-, and 10-year graft survival rates between the ESCLD and ALF groups - 90.7%, 82.9%, and 77.3% vs 75.6%, 72.4%, and 66.9% (P = 0.119).
Post-PLT survival in ALF patients is inferior to ESCLD patients. This may be due to several factors including uncertainty of the underlying pathology in most ALF patients and the more critical clinical status of ALF candidates in the immediate pre-transplant period. Survival post-PLT in the ALF group was adversely affected in the 1st year and then stabilized, while post-PLT survival in the ESCLD group showed a gradual decline over the study period.
Future research should address the dilemma of identifying the underlying pathology in a considerable portion of ALF candidates and should also try to overcome liver graft shortage by identifying methods to widen the graft pool.