LIVING-RELATED LIVER TRANSPLANTATION FOR ACUTE LIVER FAILURE IN CHILDREN: A SINGLE-CENTER EXPERIENCE

Abstract

128 Acute liver failure (ALF) is a life-threatening event and carries a high mortality without liver transplantation. The mortality rate among children with ALF on the waiting list for liver transplantation is 20%. The shortage of donor organs limits the timely availability of livers for these children. Living-related donor liver transplantation (LRD-LTx) facilitates transplantation before children with ALF become unsalvageable. Herein we present our experience with LRD-LTx in children who required urgent transplantation for ALF. Methods: Between 12/95-7/97, 6 children underwent LRD-LTx for ALF, defined as severe impairment of liver function, with or without encephalopathy, in association with hepatocellular necrosis and in the absence of recognized underlying chronic liver disease. Etiology of liver failure, recipient and donor demographics, pretransplant clinical and laboratory data, operative details, complications, and 3-mo and 1-yr graft and patient survival were recorded. Donors were selected based on blood type, liver function, negative serologies (HBV, HCV, HIV), physical exam, and left lateral segment volume as assessed by CT. Donors gave informed consent. During work-ups of donors, all children were also listed for cadaveric organs. Donor and recipient operations were performed simultaneously. Results: Five boys and 1 girl received left lateral segment grafts from their parents. Their mean age was 4±2.8 yr (range, 1-9). ALF was due to Wilson's disease in 1 and sickle cell anemia in 1; in the other 4, the etiology was unknown. All patients were in the pediatric ICU; 2 were on life support. All had mental status changes (coma stages 1 to 4). Mean pretransplant liver function tests were: ALT, 972±565; AST, 1263±862; total bilirubin, 31.3±12.4; PT, 34.3±12.4 sec; INR, 8.46±5.4; fibrinogen, 109±23.9. The donors were 5 mothers and 1 father. Their mean age was 32.5±7.6 (range, 19-40). None of the donors required blood transfusion, and none had any early or late postoperative complications. Donors' mean hospital length of stay was 5 days. In five cases, the donated segments were matched grafts; 1 child received an ABO-incompatible mismatched graft. All grafts functioned immediately. There were no technical complications. The child whose ALF was due to sickle cell anemia developed Budd-Chiari syndrome 3 mos posttransplant and required retransplantation; he eventually died of vascular complications related to his primary disease. The child who received a mismatched graft from his father died of Aspergillus infection of the brain and subarachnoid hemorrhage at 22 days posttransplant with a functioning graft. Four children are alive and well at a mean follow-up of 420 days (range, 180-719). Conclusion: LRD-LTx for children with acute liver failure facilitates timely transplantation and reduces posttransplant morbidity and mortality without drawing upon cadaveric donor resources. The established safety record of LRD has lessened concern about donor coercion, rendering LRD-LTx in the acute setting ethically acceptable.