Outcomes and technical aspects of liver retransplantation with living donors in children

Good outcomes after repeated pediatric liver retransplantations: A justified procedure even in times of organ shortage

BACKGROUND

Pediatric liver transplantations generally represent advanced surgery for selected patients. In case of acute or chronic graft failure, biliary or vessel complications, a retransplantation (reLT) can be necessary. In these situations massive adhesions, critical patient condition or lack of good vessels for anastomosis often are problematic.

METHODS

Between 2008 and 2021, 208 pediatric patients received a liver transplantation at our center. Retrospectively, all cases with at least one retransplantation were identified and stored in a database. Indication, intra- and postoperative course and overall survival (OS) were analyzed.

RESULTS

Altogether 31 patients (14.9%) received a reLT. In 22 cases only one reLT was done, 8 patients received 2 reLTs and 1 patient needed a fourth graft. Median age for primary transplantation, first, second and third reLT was 14 (range: 1-192 months), 60.5 (range: 1-215 months), 58.5 (range: 14-131 months) and 67 months, respectively. Although biliary atresia (42%) and acute liver failure (23%) represented the main indications for the primary liver transplantation, acute and chronic graft failure (1st reLT: 36%, 2nd reLT: 38%), hepatic artery thrombosis (1st reLT: 29%, 2nd reLT: 25%, 3rd reLT: 100%) and biliary complications (1st reLT: 26%, 2nd reLT: 37%) were the most frequent indications for reLT. OS was 81.8% for patients with 1 reLT, 87.5% with 2 reLTs and 100% with 3 reLTs.

CONCLUSION

Pediatric liver retransplantation is possible with a good outcome even after multiple retransplantations in specialized centers. Nevertheless, careful patient and graft selection, as well as good preoperative conditioning, are essential.

Liver retransplantation: Timing is equally important

BACKGROUND AND AIM

To evaluate the effect of transplantation interval on patient and graft survival in liver retransplantation (reLT) using meta-analytical techniques.

METHODS

Literature search was undertaken until January 2022 to identify comparative studies evaluating patient survival rates, graft survival rates, and the interval time. Pooled hazard ratio (HR) or risk ratio (RR) and 95% confidence intervals (95% CI) were calculated with either the fixed or random effect model.

RESULTS

The 12 articles were included in this meta-analysis. The late reLT survival rate is better than the early reLT in the 30 days group, and there is no statistical significance in other time groups. The patient survival was significantly higher in late reLT than early reLT at 1 and 5 years (respectively: RR, 0.81 [95% CI, 0.73-0.89]; RR, 0.64 [95% CI, 0.46-0.88]). The graft survival was significantly higher in late reLT than early reLT at 1 year (RR, 0.75 [95% CI, 0.63-0.89]). The risk of death after reLT in early group was 1.43 times higher than that in late group (HR, 1.43 [95% CI, 1.21-1.71]).

CONCLUSIONS

Late reLT had significantly better survival rates than early reLT, and the transplantation interval was more reasonable to divide the early or late groups by 30 days.

Early Vs Late Liver Retransplantation: Different Characteristics and Prognostic Factors

BACKGROUND

East Asia is a known endemic area for hepatitis B, and living donor liver transplantation is mainly performed. Liver retransplantation (ReLT) is expected to become an increasing problem because of a shortage of organs. This study aimed to compare early and late ReLT with consideration of specific circumstances and disease background of East Asians.

METHODS

Between October 1996 and January 2015, 51 patients underwent ReLT; we performed a retrospective analysis of data obtained from medical records of the patients. Clinical characteristics, indication, causes of death, survival rate, and prognostic factors were investigated.

RESULT

The survival rate for early ReLT (n = 18) was 51.5% and that for late ReLT (n = 33) was 50.1% at 1 year postoperatively. Continuous venovenous hemodialysis and the use of mechanical ventilators were more frequent, and pre-retransplant intensive care unit stay and prothrombin time was longer in early ReLT than in late ReLT. Operation time was longer and the amount of intraoperative blood loss was greater in late ReLT than in early ReLT. Multivariate analysis showed that a higher C-reactive protein level increased mortality in early ReLT (P = .045), whereas a higher total bilirubin level increased the risk of death in late ReLT (P = .03).

CONCLUSION

Patients with early ReLT are likely to be sicker pre-retransplantation and require adequate treatment of the pretransplant infectious disease. On the other hand, late ReLT is likely to be technically more difficult and should be decided before the total bilirubin level increases substantially.

The outcomes of pediatric liver retransplantation from a living donor: a 17-year single-center experience

PURPOSE

Liver retransplantation is the only therapeutic option for patients with graft failure after liver transplantation. The aim of this study is to evaluate the outcomes of pediatric retransplantation from living donor at a single center.

METHODS

Between December 1998 to August 2015, retransplantation from a living donor was performed for 14 children (<18 years of age) at Kumamoto University Hospital. The characteristics of the retransplantation recipient and the clinicopathological factors between primary transplantation and retransplantation were analyzed to detect the prognostic factors.

RESULTS

In retransplantation, the operative time was longer and the amount of blood loss was greater in comparison to primary transplantation. The 1-, 3-, and 5-year survival rates from the date of retransplantation were 85.7, 85.7, and 78.6%, respectively. The rates of re-laparotomy after primary transplantation, bile leakage and postoperative bleeding after retransplantation were higher than after primary transplantation. Among the three patients who died after retransplantation, the operative time, the rate of re-laparotomy after primary transplantation and the incidence of gastrointestinal complications were higher in comparison to the surviving patients.

CONCLUSION

Pediatric retransplantation from a living donor is an acceptable procedure that could save the lives of recipients with failing allografts when organs from deceased donors are scarce. To ensure good results, it is essential to make an appropriate assessment of the cardiopulmonary function and the infectious state of the patients before Re-LDLT.