While the number of children waiting for a liver transplant has doubled since 1993, children under five are the most likely to die while waiting for a liver transplant, according to background information in the article. The need for small-sized grafts coupled with a critical organ shortage have necessitated a turn to alternative sources for children with end-stage liver disease, including living donor liver transplantation (LDLT). In living donor liver transplantation a portion of an adult's healthy liver is transplanted into a child. This is feasible because of the child's smaller size and the ability of the adult liver to regenerate. Although living donor liver transplantation provides a valuable resource for transplantation, the authors note that it also poses some risk to an otherwise healthy donor. Therefore, it is crucial that the transplantation community carefully select candidates for living donor liver transplantation and evaluate the outcomes.
Mary T. Austin, M.D., of Vanderbilt University Medical Center, Nashville, Tenn., and colleagues analyzed data on all pediatric recipients of liver transplants from the United Network for Organ Sharing (UNOS) database from October 1, 1987 to May 24, 2004 to identify variables that would predict graft and patient outcome and to compare the outcomes achieved among the different donor types: deceased donor whole organ transplantations, deceased donor split organ transplantation and living donor liver transplantation.
During that period, 8,771 liver transplantations were performed in the U. S. on children with end-stage liver disease. Of those, 81 percent were deceased donor whole graft, eight percent were deceased donor split graft and 11 percent were living donor grafts. Of the 8,771 liver transplantations, 3,107 failed, with 1778 (57 percent) of these graft failures resulting in transplantation of another donor liver and 1,329 (43 percent) in the child's death. Thirty-seven percent of the deceased donor whole transplantations and 38 percent of deceased donor split transplantations resulted in graft failure compared with 27 percent of the living donor grafts.
The researchers analyzed the patient's pre-transplantation characteristics, including age, cause of liver disease, laboratory data, UNOS urgency status and medical condition, to determine whether the type of graft or differences in the pre-transplantation characteristics of the patients were responsible for the lower graft failure rate of living donor transplantations.
"We determined that graft and patient survival in the pediatric population is better with LDLT compared with deceased donor whole or split organ transplantation but not owing to the graft type itself," the authors write. "Several factors contribute to this difference including recipients who are not critically ill, who have shorter cold and warm ischemia times [the time the liver is not connected to a blood supply between procurement and transplantation], and who have fewer incidents of retransplantation with LDLT. Although LDLT poses risk to the donor, it is, as practiced, a valuable technique in pediatric transplantation to help overcome the critical organ shortage."
(Arch Surg. 2005; 140:465-471. Available post-embargo at www.archsurg.com.)
Editor's Note: This study was supported in part by the Health Resources and Services Administration, Washington, D.C.
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Journal
Archives of Surgery