Practice Essentials
Liver transplantation is a treatment, used in appropriately selected patients, for acute and chronic liver failure due to any cause. It is not indicated if an acceptable alternative is available or if contraindications are present (eg, some cases of malignancy, terminal conditions, poor expected quality of outcome). There are approximately 500 candidates on the liver transplantation waitlist. Children aged 1‐5 years and 11 years or older made up the largest age groups, 30% each, followed by ages younger than 1 year, 22.4%, and 6‐10 years, 14.6%.
The number of pediatric liver transplants peaked at 613 in 2008 and was 573 in 2016. The majority of transplants were from deceased donors (90%). Live donor transplants have also decreased from a peak of 79 in 2015 to 62 in 2016, with most from donors closely related to the recipients. Recipients younger than 6 years old received 14% of livers from living donor.
Outcomes have shown continued improvement over the past decade among recipients of both deceased and living donor livers. Graft failure rates for deceased and live donor liver transplantation are summarized in Table 1 below. By primary diagnosis, metabolic disease and cholestatic biliary atresia were associated with the best patient survival. The 5-year mortality rate for deceased donor transplant recipients was 12.1% and the leading cause of death was infection (2.0%), followed by cardio/cerebrovascular complications (1.5%).
Table 1. Graft Failure Rates (Open Table in a new window)
| Period |
Deceased Donor |
Living Donor |
|---|---|---|
| 6 months | 8.9% | 4.4% |
| 1 year | 10.5% | 5.1% |
| 3 year | 16.1% | 8.5% |
| 5 year | 18.5% | 14.0% |
| 10 year | 29.9% | 18.4% |
Liver transplantation has been successfully extended to neonates.
Acute liver failure from hemochromatosis, leading to a histologic diagnosis of giant-cell hepatitis, is the primary indication for liver transplantation in the neonatal population. Neonates commonly receive left‐lateral segment grafts from infants and smaller children, although monosegment grafts have been used with some success. Encephalopathy cannot be easily evaluated in these patients and intracranial bleeding is common, portending poor outcome.
Because neonates do not have prior sensitization to the major blood group antigens, they can successfully accept ABO‐incompatible allografts without increased risk for patient or graft survival, biliary complications, vascular complications, or rejection. Although neonates appear to be more immunotolerant to transplanted organs, their immature immune systems combined with immunosuppression increases the risk for infectious complications.
A study comparing outcomes of 13,179 pediatric orthotopic liver transplantation (OTL) recipients found superior outcomes (p < 0.01) for OLT recipients younger than 2 years old. Additionally, in children less than 2 years old, the survival outcomes for ABO-incompatible and ABO-identical OLTs were the same: ABO-incompatible were 91.8% (1 year) and 88.4% (5 year), and ABO-identical were 91.5% (1 year) and 86.7% (5 year) (p = 0.94).
When a pediatric patient is likely to require a liver transplant, the medical management is generally divided into pretransplant and posttransplant periods, with the posttransplant period further separated into early and late time frames.
Medical treatment, surgery, and postsurgical care can be broken into 4 basic steps:
Candidate evaluation
Waiting period
Surgery
Postsurgical care
Go to Pediatric Fulminant Hepatic Failure for more complete information on this topic.