Liver unit reports higher than average success rate for children receiving living donor transplants

Ninety-six per cent of children who have received liver transplants from living relations are still alive five years after surgery, according to research published in the July issue of the British Journal of Surgery.

The findings by the Institute of Liver Studies at King's College Hospital, London, are based on the 50 living related liver transplants (LRLT) carried out on children by the hospital between 1993 and 2006. King's was the only UK centre to perform this ground-breaking procedure during that period.

They found that the survival rates for the 17 girls and 33 boys were 98 per cent one year after the transplant and 96 per cent after three and five years.

Ninety-eight per cent of the transplant grafts had survived after a year, 96 per cent after three years and 93 per cent after five years.

Both the year one patient and graft survival rates were higher than those recorded by other major LRLT transplant programmes in other countries.

"LRLT was developed to tackle the shortage of donor livers and to allow smaller children to receive life-saving transplants using liver segments provided by living adult donors" explains Professor Nigel Heaton from King's, one of the UK's leading liver surgeons.

"The first ever procedure took place in Brazil in 1988 and in 1990 a team from Chicago, USA, reported the first successful pilot programme. Since then it has been performed in a number of major paediatric liver transplant centres worldwide.

"LRLT accounted for 15 per cent of all liver transplants performed in Europe in 2004 and just under 10 per cent in the USA. It has also played an important role in Asian countries like Japan, Korea and Taiwan, where living donors are the only source of transplant grafts as they do not tend to use the organs of people who have died.

"The programme at King's College Hospital started in 1993 following approval from the hospital ethics committee, the Liver Advisory Group of the Royal College of Surgeons and the Department of Health."

The children who received transplants at King's ranged from six months to 13 years when they had their operations, with an average age of 18 months. Most of the donors were either the child's father (26 donors) or mother (23 donors) but one was an uncle. The donors ranged in age from 19 to 46 years, with an average of 33.

There were some side effects, as with any complex transplant surgery. Six per cent had blood clots in the hepatic artery, four per cent had blood clots in the portal vein and 14 per cent had bile duct complications.

Two of the children died, one five days after surgery, from a infection related to multi-organ failure, and one at 20 months, from a reoccurring liver tumour.

Three children had a second transplant. Two suffered chronic rejection and had to receive further transplants after four and ten years respectively. The third received a second transplant after developing bloods clots in the hepatic artery.

None of the relatives, who donated part of their liver after extensive health screening, died and they reported low levels of ill health. However, three did experience bleeding after surgery and wound pain was a significant complaint among donors, despite the use of epidural pain relief.

Two needed blood transfusions, one during surgery and one after three days. A third donor needed to be taken back into the theatre where a surface vessel was sutured to stem the bleeding.

"Early graft function was excellent in the majority of recipients and recovery was rapid" says Professor Heaton.

There is now considerable experience worldwide in LRLT and the risks to donors can be estimated more clearly.

International figures show that the 98 per cent recorded by surgeons at King's for the year one graft and survival rates exceed worldwide averages for major programmes, which ranged from 74 to 96 per cent and 78 to 94 per cent respectively.

An international review of published research papers up to February 2006 estimates that 4,600 LRLTs have been carried out in the USA and Europe since the technique was first developed. Thirteen donors have died as a direct result of the surgery and a further two deaths may have been related.

"LRLT is now established and its complications clearly documented" says Professor Heaton. "The current organ shortage and the growth of waiting lists have inevitably had an impact on the provision of suitable grafts for children and led to increasing demand for living donation.

"Medical advances mean that adult livers from dead donors can now be split so that they can be used for a greater number of recipients. However, LRLT can often be the only life-saving option for children with acute liver failure or tumours."

• Living related liver transplantation in children. Heaton et al. British Journal of Surgery. 95, pp 919-924. (July 2008).

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