Pediatric liver transplantation: A single center experience spanning 20 years

Background. Survival after liver transplantation has improved significantly over the last decade with pediatric recipients faring better than adults. The 20-year experience of pediatric liver transplantation at Children's Hospital of Pittsburgh is reported in terms of patient survival; graft survival in relation to age, gender, and immunosuppressive protocols; causes of death; and indications for retransplantation. Method. From March 1981 to April 1998, 808 children received liver transplants at Children's Hospital of Pittsburgh. All patients were followed until March 2001, with a mean follow-up of 12.2±3.9 years (median= 12.6; range=2.9-20). There were 405 female (50.2%) and 403 male (49.8%) pediatric recipients. Mean age at transplant was 5.3±4.9 years (mean=3.3; range 0.04-17.95), with 285 children (25.3%) being less than 2 years of age at transplant. Cyclosporine (CsA)-based immunosuppression was used before November 1989 in 482 children (50.7%), and the subsequent 326 recipients (40.3%) were treated with tacrolimus-based immunosuppression. Actuarial survival was calculated using the Kaplan-Meier statistical method. Differences in survival were calculated by log-rank analysis. Results. Overall patient survival at 1, 5, 10, 15 and 20 years was 77.1%, 72.6%, 69.4%, 65.8% and 64.4%, respectively. There was no difference in survival for male or female patients at any time point. At up to 10 years posttransplant, the survival for children greater than 2 years of age (79.5%, 75.7%, and 71.6% at 1, 5, and 10 years, respectively) was slightly higher than those at less than 2 years of age (72.6%, 66.9%, and 65.3% at 1, 5, and 10 years, respectively). However, at 15 and 20 years posttransplant, survival rates were similar (>2 years=67.3% and 65.8%; <2 years=64.1% and 64.1%). A significant difference in survival was seen in CsA-based immunosuppression (71.2%, 68.1%, 65.4%, and 61%) versus tacrolimus-based immunosuppression (85.8%, 84.7%, 83.3%, and 82.9%) at 1, 3, 5, and 10 years, respectively (P=0.0001). The maximum difference in survival was noted in the first 3 months between CsA and tacrolimus; thus, indicating there may have been other factors (nonimmunological factors) involved in terms of donor and recipient selection and technical issues. The mean annual death rate beyond 2 years posttransplant was 0.47%, with the mean annual death rate for patients who received tacrolimus-based immunosuppression being significantly lower than those who received CsA-based immunosuppression (0.14% vs. 0.8%; P=0.001). The most common etiologies of graft loss were hepatic artery thrombosis (33.4%), acute or chronic rejection (26.6%), and primary nonfunction (16.7%). Of note, retransplantation for graft loss because of acute or chronic rejection occurred only in those patients who received CsA-based immunosuppression. Conclusion. The overall 20-year actuarial survival for pediatric liver transplantation is 64%. Survival has increased by 20% in the last 12 years with tacrolimus-based immunosuppression. although this improvement may be the result of several factors, retransplantation as a result of acute or chronic rejection has been completely eliminated in patient treated with tacrolimus

Comparative Analysis of Hepatitis C Recurrence and Fibrosis Progression Between Deceased-Donor and Living-Donor Liver Transplantation: 8-Year Longitudinal Follow-Up

Background. Hepatitis C virus (HCV) recurrence is universal after liver transplantation (LT). Whether the progression of recurrent HCV is faster after live-donor LT (LDLT) compared with deceased-donor LT (DDLT) is debatable. Methods and Results. We retrospectively examined 100 consecutive LTs (65 DDLTs and 35 LDLTs) performed between July 2000 and July 2003. A total of 147 liver biopsies were performed between 6 months post-LT and last follow-up. Mean donor age and model for end-stage liver disease (MELD) score were significantly lower in LDLT (PϽ0.01). On a mean follow-up of 86.6Ϯ6.8 months, overall patient and graft survivals were 61% (51% DDLT vs. 77.1% LDLT; Pϭ0.026) and 56% (46.2% DDLT vs. 71.4% LDLT; Pϭ0.042), respectively. Eight of 39 (20.5%) deaths (7 DDLT and 1 LDLT) and two of nine (22.2%) retransplants (one in each group) were related to recurrent HCV. Mean fibrosis scores for DDLT and LDLT were 1.9Ϯ1.7 and 1.6Ϯ1.4, respectively (Pϭ0.01). When donor age less than 50 years and MELD score less than 25 were matched among 64 patients (32 DDLT and 32 LDLT), the overall patient and graft survivals were 73.4% (68.8% DDLT vs. 78.1% LDLT; Pϭ0.439) and 71.9% (71.9% DDLT vs. 71.9% LDLT; Pϭ0.978), respectively. Conclusions. Long-term survival rates were better, and fibrosis scores were lower for LDLT. The survivals between LDLT and DDLT were comparable for patients with MELD score less than 25 and donor age less than 50 years