Application of Pediatric Donors in Split Liver Transplantation

Is There An Age Limit?

Wei Gao; Zhuolun Song; Nan Ma; Chong Dong; Xingchu Meng; Chao Sun; Hong Qin; Chao Han; Yang Yang; Fubo Zhang; Weiping Zheng; Zhongyang Shen


American Journal of Transplantation. 2020;20(3):817-824. 

In This Article


Perioperative Aspects

Histological examination of the 8 donor grafts at zero biopsy showed normal liver structure; in addition, all donors and recipients were free of cytomegalovirus (CMV), Epstein-Barr virus, and hepatitis B virus (HBV) infection. Ten of the 15 patients (recipients 3, 4, 5, 7, 8, 9, 12, 14, 15, and 16) who were diagnosed with BA underwent the Kasai procedure before liver transplant.

Among the recipients, the lowest GRWR was 1.5% and the highest GRWR was 5%. The GRWR in 1 recipient was <2% (recipient 7); the recipient recovered well without developing small-for-size syndrome. The GRWR in 2 recipients was >4% (recipients 13 and 16); the abdomens were closed in both recipients without tension, and postoperative ultrasound showed normal blood flow. The surgical procedure went smoothly without cardiac arrest or other intraoperative life-threatening events. Surgical aspects were given in Table 3.

Postoperative Graft and Recipient Recovery

The graft recovery was reflected by the values of alanine aransaminase (ALT), aspartate transaminase (AST) and total bilirubin (TBIL), whereas ICU and hospital stay durations reflected the recovery of recipients. The mean values of ALT, AST, and TBIL started to decrease from the second postoperative day and continued with a downward daily trend in most recipients (Table S2). Nevertheless, the values of ALT, AST, and TBIL in recipient 1 increased again on the sixth postoperative day (Figure 2A-C), and pathological liver biopsy examination indicated ischemic and hypoxic changes in the liver graft. The same pathological finding was seen in recipient 2, who showed a slow process of TBIL decline. Notably, both recipient 1 and recipient 2 received the same liver graft from donor 1, and the graft had a long cold ischemia time (11.2 hours). In addition, recipient 1 had the longest ICU stay (14 days) among all recipients, which may be attributed to the severity of his primary disease (PELD score: 37) before liver transplant.

Figure 2.

The recovery of liver grafts. (A) Alanine aminotransferase (ALT) on postoperative days 1 to 7. (B) Aspartate aminotransferase (AST) on postoperative days 1 to 7. (C) Total bilirubin (TBIL) on postoperative days 1 to 7

The value of TBIL in recipient 12 progressively increased after surgery (Figure 2C); this patient was diagnosed with postoperative cholangitis, and her ALT, AST, and TBIL levels returned to normal after treatment at the end of follow-up. Recipient 11 shared the same donor graft with recipient 12; recipient 11 also had a slow TBIL level drop compared with the other recipients. It was worth noting that the donor graft allocated to recipients 11 and 12 also underwent a longer cold ischemia time (10.8 hours) than our criterion.

Postoperative Complications

All recipients were strictly followed for >3 months. None of the recipients appeared to have life-threatening complications, such as primary nonfunction or surgery-related graft failure. Hepatic artery thrombosis (HAT) is one of the common complications in the early period of pediatric liver transplant, but none of the recipients developed HAT during our follow-up time. The only surgery-related complication was seen in recipient 5, who was diagnosed with portal vein stenosis 2 months after surgery on portography. This recipient was treated with percutaneous transhepatic balloon dilation, and the portal flow was significantly improved after treatments and stayed normal at the end of the follow-up period. Cold storage injury was histologically confirmed in 2 liver grafts from the same donor (donor 1), which had a long cold ischemia time. The most common short-term complication among these 16 recipients was CMV infection (62.5%) (Table 4); all the infected recipients were treated with ganciclovir, and CMV infection did not influence graft function and recipient outcomes. The levels of ALT, AST, and TBIL remained in the normal range in all recipients at the end of the follow-up time.

Comparison of Outcomes Between LLS and ERL Recipients

To further evaluate the prognostic difference between LLS and ERL recipients, we compared their graft and recipient outcomes. The level of ALT in LLS recipients was significantly lower than that in ERL recipients on the second, third, and fourth postoperative days (Figure 3A). The level of AST on postoperative days 2 and 3 was also significantly lower in LLS recipients compared with ERL recipients (Figure 3B). The level of 2 markers returned to baseline in both groups, and no statistical difference was seen at the end of first postoperative week. Apart from that, the values of TBIL (Figure 3C) and lengths of ICU and hospital stays, as well as postoperative complications, were similar between LLS and ERL recipients (Table S3).

Figure 3.

Comparison of postoperative graft recovery between left lateral segment and extended right lobe recipients. (A) Alanine aminotransferase (ALT) on postoperative days 1 to 7. (B) Aspartate aminotransferase (AST) on postoperative days 1 to 7. (C) Total bilirubin (TBIL) on postoperative days 1 to 7. *p < .05

Recipient and Graft Survival

The mean follow-up time for the 16 recipients was 8.0 ± 2.3 months. The graft and recipient survival rates were 100%.