Pediatric and adult liver transplantation in Bahrain: The experiences in a country with no available liver transplant facilities

Table 1 Clinical characteristics of patients underwent liver transplantation

Patient demography	Total, n = 167 (100)	Pediatric, n = 47 (28.1)	Adult, n = 120 (71.8)	P value
Sex				0.492a
Male	96 (57.5)	25 (53.2)	71 (59.7)
Female	71 (42.5)	22 (46.8)	49 (40.8)
Nationality				< 0.001a
Bahraini	152 (91.0)	36 (76.6)	116 (96.7)
Non-Bahraini	15 (9.0)	11 (23.4)	4 (3.3)
Governorate				0.369b
Northern	73 (43.7)	21 (44.7)	52 (43.3)
Capital	35 (20.9)	6 (12.8)	29 (24.2)
Southern	34 (20.4)	12 (25.5)	22 (18.3)
Muharraq	25 (15.0)	8 (17.0)	17 (14.2)
Age at transplant (yr)	50.0 (14.9-58.4)	3.7 (1.0-9.0)	55.2 (48.4-60.5)	< 0.001c
Weight at transplant (kg), (n = 83)	52 (15.0-70.0)	11.0 (7-23)	69 (52-80)	< 0.001c
Height at transplant (cm), (n = 75)	163 (138-169)	82.0 (69-120)	167 (159-172)	< 0.001c
Presence of associated diseases1	130/162 (80.3)	25 (53.2)	105/115 (91.3)	< 0.001a
Previous liver biopsy	67/145 (46.2)	20/46 (43.5)	47/99 (47.5)	0.722a
Previous surgeries	52/145 (35.9)	17/46 (37.0)	35/99 (35.4)	0.855a
Kasai procedure	11/145 (7.6)	10/46 (21.7)	1/99 (1.0)	< 0.001a
Other surgeries	45/145 (31.0)	10/46 (21.7)	35/99 (35.4)	0.124a
Family history of liver disease	38/145 (26.2)	17/46 (37)	21/99 (21.2)	0.067a
Follow up duration (yr)	6.5 (2.6-10.6)	8.1 (1.3-10.6)	6.1 (3.3-10.3)	0.976c
Number of overseas visits	3 (2.0-8.0)	4 (2.0-10.0)	3 (2.0-6.0)	0.299c

^aFisher’s exact test.

^bPearson’s χ² test.

^cMann-Whitney U test.

¹Supplementary Table 1. Data are presented as number and percentage or median and interquartile range. Boldface indicates a statistically significant difference with P < 0.05.

Table 2 Indications of liver transplantation in pediatrics and adults in Bahrain

Indications of liver transplantationa	Total, n (%)
Pediatric indications	47 (28.1)
Biliary atresia	15 (31.9)
Progressive familial intrahepatic cholestasis	9 (19.1)
Metabolic diseasesb	7 (14.9)
Alagille’s syndrome	3 (6.4)
Autoimmune hepatitis	3 (6.4)
Primary sclerosing cholangitis	3 (6.4)
Cystic fibrosis liver disease	2 (4.3)
Hepatocellular carcinoma	2 (4.3)
Cytomegalovirus hepatitis	2 (4.3)
Othersc	8 (17.0)
Adult indications	120 (71.9)
Hepatitis C-related cirrhosis	42 (35.0)
Nonalcoholic steatohepatitis	19 (15.8)
Hepatocellular carcinoma	18 (15.0)
Primary sclerosing cholangitis	17 (14.2)
Hepatitis B virus	15 (12.5)
Cryptogenic cirrhosis	13 (10.8)
Autoimmune hepatitis	9 (7.5)
Alcoholic liver cirrhosis	4 (3.3)
Othersd	5 (4.2)

^aSome patients had more than one indication for liver transplantation. Data are presented as number and percentage.

^bUrea cycle defect (n = 3) [argininosuccinic aciduria type 1 (n = 2) and ornithine transcarbamylase deficiency (n = 1)], propionic academia (n = 2), tyrosinemia, and Wilson’s disease (n = 1 each).

^cCholedocal cyst type 4 (n = 2), hereditary hemorrhagic telangiectasia, neonatal hepatitis, liver metastasis due to Wilms tumor, cryptogenic, Crigler Najjar syndrome type 1, and neonatal hemochromatosis (n = 1 each).

^dCholangiocarcinoma, hereditary hemorrhagic telangectasia, bilharzial liver disease, biliary atresia, and unspecified viral hepatitis (n = 1 each).

Table 3 Donor-recipient relationship of patients underwent liver transplantation

Donor	Total LT, n = 150/173 (86.7)	Pediatrics, n = 48/49 (98.0)	Adults, n = 102/124 (82.3)	P value
Related living donors	123 (82)	44 (91.7)	79 (76.5)	0.041a
1st degree	65 (52.8)	29 (65.9)	36 (45.6)	0.020b
2nd degree	19 (15.5)	3 (6.8)	16 (20.3)
3rd degree	21 (17.1)	10 (22.7)	11 (13.9)
4th degree	17 (13.8)	2 (4.5)	15 (18.9)
Unspecified relation	1 (0.8)	0 (0.0)	1 (1.3)
Unrelated donors	27 (18)	4 (8.3)	23 (22.5)	0.041a
Living	12 (8.0)	3 (6.3)	9 (8.8)	0.753a
Cadaveric	15 (10.0)	1 (2.1)	14 (13.7)	0.038a

^aFisher’s exact test.

^bPearson’s χ² test.

Data are presented as number and percentage. Boldface indicates a statistically significant difference with P < 0.05. The six patients who underwent re-transplantation surgery had different donor types. LT: Liver transplantation.

Table 4 Medications used after liver transplantation

Medicationsa	Total, n = 150/167 (89.8)	Pediatrics, n = 44/47 (93.6)	Adults, n = 106/120 (88.3)	P valueb
Immunosuppressive medications	142 (94.7)	40 (90.9)	102 (96.2)	0.234
Tacrolimus	126 (84.0)	38 (86.4)	88 (83.0)	0.807
Prednisolone	76 (50.7)	32 (72.7)	44 (41.5)	0.001
Mycophenolic acid	73 (48.7)	14 (31.8)	59 (55.7)	0.012
Cyclosporine A	13 (8.7)	4 (9.1)	9 (8.5)	1.000
Azathioprine	8 (5.3)	5 (11.4)	3 (2.8)	0.048
Everolimus	7 (4.7)	0 (0.0)	7 (6.6)	0.106
Baziliximab	1 (0.7)	1 (2.3)	0 (0.0)	0.293
Dietary supplementations	109 (72.7)	37 (84.1)	72 (67.9)	0.046
Calcium	77 (51.3)	18 (40.9)	59 (55.7)	0.110
Vitamin D	63 (42.0)	22 (50.0)	41 (38.7)	0.210
Magnesium	35 (23.3)	20 (45.5)	15 (14.2)	< 0.001
Multivitamin	32 (21.3)	27 (61.4)	5 (4.7)	< 0.001
Folic acid	30 (20.0)	14 (31.8)	16 (15.1)	0.026
Iron	22 (14.7)	11 (25.0)	11 (10.4)	0.040
Biotin	4 (2.7)	4 (9.1)	0 (0.0)	0.007
Carnitine	2 (1.3)	2 (4.5)	0 (0.0)	0.085
Antiviral (valganciclovir)	23 (15.3)	20 (45.5)	3 (2.8)	< 0.001
Antibiotics	20 (13.3)	18 (40.9)	2 (1.9)	< 0.001
Aminoglycosides	15 (10.0)	15 (34.1)	0 (0.0)	< 0.001
Co-trimoxazole	12 (8.0)	10 (22.7)	2 (1.9)	< 0.001
Antifungal medications	9 (6.0)	8 (18.2)	1 (0.9)	< 0.001
Fluconazole	7 (4.7)	6 (13.6)	1 (0.9)	0.003
Amphotericin B	2 (1.3)	2 (4.5)	0 (0.0)	0.085
Other medications	135 (90.0)	38 (86.4)	97 (91.5)	0.375
Proton pump inhibitors	96 (64.0)	21 (47.7)	75 (70.8)	0.009
Urosodeoxycholic acid	91 (60.7)	27 (61.4)	64 (60.4)	1.000
N-acetylcysteine	66/118 (55.9)	10/29 (34.5)	56/89 (62.9)	0.010
Aspirin	57 (38.0)	22 (50.0)	35 (33.0)	0.065

^aSome patients received more than one medication.

^bFisher’s exact test.

Data are presented as number and percentage. Boldface indicates a statistically significant difference with P < 0.05.

Table 5 Complications during or after liver transplantation

Complicationsa	Total, n = 93/149 (62.4)	Pediatrics, n = 33/46 (71.7)	Adults, n = 60/103 (58.3)	P valueb
Infection episodes	58 (38.9)	29 (63.0)	29 (28.2)	< 0.001
Tonsillitis	12 (8.1)	10 (21.7)	2 (1.9)	< 0.001
Sepsis	12 (8.1)	3 (6.5)	9 (8.7)	0.755
Acute gastroenteritis	11 (7.4)	7 (15.2)	4 (3.9)	0.035
Cytomegalovirus	7 (4.7)	7 (15.2)	0 (0.0)	< 0.001
Fever of unclear cause	7 (4.7)	1 (2.2)	6 (5.8)	0.437
Pneumonia	7 (4.7)	5 (10.9)	2 (1.9)	0.029
Other infections1	31 (20.8)	16 (34.8)	15 (14.6)	0.016
Biliary stricture	29 (19.5)	5 (10.9)	24 (23.3)	0.115
Rejection	15 (10.1)	10 (21.7)	5 (4.9)	0.003
Early poor graft function	9 (6.0)	6 (13.0)	3 (2.9)	0.025
Incisional hernia	9 (6.0)	3 (6.5)	6 (5.8)	1.000
Surgical wound complications	8 (5.4)	2 (4.3)	6 (5.8)	1.000
Bleeding	4 (2.7)	2 (4.3)	2 (1.9)	0.587
Hepatic artery complications	2 (1.3)	1 (2.2)	1 (0.9)	0.524
Portal vein thrombosis	2 (1.3)	1 (2.2)	1 (0.9)	0.524
Gastric perforation	2 (1.3)	2 (4.3)	0 (0.0)	0.094
Chylous ascites	2 (1.3)	1 (2.2)	1 (0.9)	0.524
Other complications2	9 (6.0)	3 (6.5)	6 (5.6)	1.000

^aSome patients had more than one complication.

^bFisher’s exact test.

Data are presented as number and percentage. Boldface indicates a statistically significant difference with P < 0.05.

¹In pediatrics: Herpetic gingivostomatitis (n = 3), herpes zoster infection and septic shock (n = 2 each), bronchitis, chickenpox, conjunctivitis, atopic dermatitis, candidal stomatitis, Epstein-Barr virus infection, hepatitis, lymphadenitis, colitis, cholangitis, and viremia (n = 1 each). In adults: Lymphadenitis (n = 3), septic shock and cellulitis (n = 2 each), bronchitis, candidiasis, peritonitis, pulmonary tuberculosis, hepatic abscess, and herpes zoster infection (n = 1 each).

²In pediatrics: Post liver transplant lymphoproliferative disorder, pancreatitis, and diabetes mellitus (n = 1 each). In adults: Post liver transplant lymphoproliferative disorder and myoglobulinemia of unknown significance (n = 2 each), post-transplant dialysis and pleural effusion (n = 1 each).

Table 6 Analysis of outcome in pediatric and adult liver transplantation

Variable	Survived, n = 141 (84.4)	Died, n = 26 (15.6)	P value
Sex			0.130a
Male	85 (60.3)	11 (42.3)
Female	56 (39.7)	15 (57.7)
Nationality			0.471a
Bahraini	127 (90.1)	25 (96.2)
Non-Bahraini	14 (9.9)	1 (3.8)
Area of residency			0.118b
Northern	63 (44.7)	10 (38.5)
Capital	29 (20.6)	6 (23.1)
Southern	25 (17.7)	9 (34.6)
Muharraq	24 (17.0)	1 (3.8)
Age at liver transplant (yr)	48.8 (13.2-58.0)	57.5 (47.9-65.2)	0.019c
Age group			0.346a
Pediatric	42 (29.8)	5 (19.2)
Adult	99 (70.2)	21 (80.8)
Weight at transplant (kg), (n = 83)	52.0 (20.0-70.0)	8.0 (5.0-46.0)	0.144c
Height at transplant (cm), (n = 76)	163.0 (149.0-169.0)	138.0 (74.0-149.0)	0.101c
Presence of associated diseases	139 (98.6)	23 (88.5)	0.255a
Yes	109 (78.4)	21 (91.3)
No	30 (21.6)	2 (8.7)
Type of graft (n = 150)	137 (97.2)	13 (50.0)	0.364a
Living	122 (89.1)	13 (100)
Cadaveric	15 (10.9)	0 (0.0)
Donor-recipient relationship (n = 150)	137 (97.2)	13 (50.0)	0.704a
Related donors	113 (82.5)	10 (76.9)
Unrelated donors	24 (17.5)	3 (23.1)
Indications of liver transplantation
Hepatitis C virus	37 (26.2)	5 (19.2)	0.623a
Primary sclerosing cholangitis	18 (12.8)	2 (7.7)	0.743a
Nonalcoholic steatohepatitis	15 (10.6)	4 (15.4)	0.503a
Hepatic cellular carcinoma	14 (9.9)	6 (23.1)	0.092a
Biliary atresia	13 (9.2)	3 (11.5)	0.718a
Hepatitis B virus	13 (9.2)	2 (7.7)	1.000a
Autoimmune hepatitis	11 (7.8)	1 (3.8)	0.694a
Metabolic diseases	7 (5.0)	0 (0.0)	0.597a
Intra- or post-LT complications (n = 150)	138 (97.9)	11 (42.3)	0.537a
Yes	85 (61.6)	8 (72.7)
No	53 (38.4)	3 (27.7)
Post-LT N-acetylcysteine use	50/66 (75.8)	46/52 (88.5)	0.098
Liver transplant countries			0.582b
Middle East	86 (61.0)	19 (73.1)
Asia & Pacific	51 (36.2)	8 (30.7)
Europe	4 (2.8)	0 (0.0)
North America	3 (2.1)	0 (0.0)
Follow-up duration (yr)	7.5 (3.9-10.6)	1.5 (0.3-3.2)	< 0.001c

^aFisher’s exact test.

^bPearson’s χ² test.

^cMann-Whitney U test.

Data are presented as number and percentage or median and interquartile range. Boldface indicates a statistically significant difference with P < 0.05. LT: Liver transplantation.

Table 7 Univariate and multivariate analysis of the selected predictors of outcome of liver transplantation

Variable	Univariate analysis		Multivariate analysis
	Odds ratio (95%CI)	P value	Odds ratio (95%CI)	P value
Male sex	0.483 (0.207-1.128)	0.093	0.617 (0.127-2.999)	0.549
Bahraini nationality	0.363 (0.046-2.886)	0.338	2.001 (0.124-32.414)	0.625
Governorate (Northern vs others)	0.774 (0.328-1.823)	0.558	0.912 (0.179-4.652)	0.912
Age at LT (yr)	0.980 (0.960-1.001)	0.059	1.047 (0.955-1.148)	0.329
Age group (pediatrics vs adults)	0.561 (0.198-1.588)	0.276	0.073 (0.001-8.750)	0.284
Weight at LT (kg)	1.009 (0.990-1.029)	0.362	1.047 (0.965-1.136)	0.268
Height at LT (cm)	1.007 (0.994-1.022)	0.293	1.000 (0.969-1.032)	0.989
Presence of associated diseases	0.346 (0.077-1.560)	0.167	1.131 (0.136-9.415)	0.909
Related versus unrelated donor	1.865 (0.225-15.447)	0.563	1.979 (0.149-26.338)	0.605
Hepatitis C virus	1.494 (0.526-4.249)	0.451	0.275 (0.026-2.914)	0.284
Biliary atresia	0.779 (0.206-2.949)	0.713	1.474 (0.124-17.462)	0.759
Presence of complications	0.601 (0.153-2.368)	0.467	0.222 (0.020-2.458)	0.220
LT countries (Middle East versus others)	2.096 (0.784-5.602)	0.140	2.699 (0.383-19.017)	0.319

CI: Confidence interval; LT: Liver transplant.