Background: The risk of early surgical complications of liver transplantation (LT) is higher in children when compared with adults. The aims of the present retrospective study from a single center cohort/single surgeon were to identify the predictive factors for surgical complications after pediatric LT. Methods: All children receiving a first LT from October 1990 to October 2010 in our center were included. Results: Included 151 children (boys 55.0%), with a mean age of 4.8 +/- 4.8 years, and a mean weight of 17.9 +/- 14.4 kg. Thirty-seven patients were transplanted within the first year, and 59 patients had a body weight below 10 kg. The main initial liver disease was biliary atresia (49.0%). Living donor LT was performed in 39 cases (25.8%), cadaveric whole liver LT in 50 cases (33.1%), and cadaveric partial liver LT in 62 cases (41.1%). Early surgical complications included reoperation (37.8%), vascular complications (8.6%), i.e. arterial (3.3%) or portal thrombosis/stenosis (7.3%) within the first month, and biliary complications in the first 90 days occurred in 22.5% of the cases. The main indications for surgical revision were abdominal bleeding, treatment of a biliary complication, and bowel perforation. Multivariate analysis disclosed that only graft type (split and moreover from a living donor) was significantly and independently associated with the occurrence of biliary complication, and that indication for LT, period, graft type, and operative time were significantly and independently associated with the necessity of surgical revision. Conclusion: Our results emphasize that surgical complications are frequent and strongly depend on patient/graft characteristics.

BackgroundLiver transplantation (LT) is a standard-of-care therapeutic modality for selected patients with life-threatening liver disease, including children. In addition to specific clinical characteristics of pediatric LT recipients due to initial liver disease (and related comorbidities) and level of liver failure, early postoperative outcome may be dependent on the surgical technique used, related to the type of organ donor and graft. Therefore, the aims of the present retrospective study from a large single centre cohort were to identify the prognostic factors for both 1-year patient and graft survival.MethodsBetween October 1990 and October 2010, 151 children underwent a first LT in our centre.ResultsThe mean age was 5.3 ± 7.4 years, and the main indication was biliary atresia (BA) (49.0%). Living donor liver transplantation (LDLT) was performed in 39 cases (25.8%). Cadaveric liver graft was a whole liver in 50 cases (33.1%) and a partial liver (reduced or split) in 62 cases (41.1%). One-year patient and graft survival rates were 88.7% and 86.1%, respectively. Multivariate analysis disclosed that initial liver disease, location at time of LT, donor/recipient (D/R) delta age, early post-transplant hemodialysis and initial immunosuppression (induction) were significantly associated with patient survival and that D/R delta age, primary non-function, early post-transplant hemodialysis and initial immunosuppression (induction) were significantly associated with graft survival.ConclusionThe results of our single-centre experience of pediatric LT emphasize that early patient and graft survivals depend on pre-operative/operative factors such as initial liver disease, D/R delta age and immunosuppressive regimen. Awareness of these factors can help in the decision making for children requiring LT.

Au cours de la transplantation hépatique en pédiatrie, la réperfusion du greffon est souvent associée à une altération brutale de la coagulation qui peut aboutir à une majoration du saignement. L’analyse ROTEM pourrait apporter une évaluation fiable et rapide de la fonction hémostatique [1] et guider la prise en charge transfusionnelle de ces patients [2], en particulier les apports en fibrinogène [3]. Nous avons inclus de façon rétrospective 30 enfants qui ont bénéficié d’une transplantation hépatique dans notre hôpital depuis 3 ans. Cette série comprend 11 filles et 19 garçons, d’âge moyen 7,3 ans (extrêmes 1–17). Leurs pathologies initiales étaient principalement : une atrésie des voies biliaires (n = 12) et des maladies métaboliques (n = 9). Pour tous les patients, trente minutes après la réperfusion du greffon, une analyse ROTEM (incluant ExTEM, InTEM et FibTEM) était réalisée en même temps qu’un bilan biologique classique (bilan de coagulation et analyses biochimiques). Parallèlement, des paramètres cliniques tels que la température, la pression artérielle et le bilan transfusionnel étaient relevés. Une corrélation significative a été retrouvée entre la fibrinogénémie et les amplitudes à 10 minutes (A10) (r = 0,62 ; p < 0,01) et maximale (MCF) (r = 0,53 ; p < 0,01) sur le FibTEM. Pour un seuil de fibrinogène à 1,5 g/L, l’aire sous la courbe ROC pour l’A10 était à 0,81 (IC 95 % [0,68–0,93]. Un A10 < 6 mm prédisait un fibrinogène < 1,5 g/L avec des valeurs prédictives positive de 83 % et négative de 69 %. Le taux de plaquettes était significativement corrélé avec le temps de formation du caillot (CFT) (r = –0,57 ; p < 0,01) et l’angle α (r = 0,61 ; p < 0,01) sur l’ExTEM. Aucune corrélation n’a été retrouvée entre les paramètres cliniques, l’acidose ou la calcémie ionisée et les résultats du ROTEM (Fig. 1). L’analyse ROTEM semble fournir une évaluation fiable et rapide de l’état de la coagulation au cours de la transplantation hépatique en pédiatrie, et pourrait améliorer la prise en charge transfusionnelle de ces patients. Un A10 abaissé sur le FibTEM pourrait être une indication suffisante pour transfuser rapidement du fibrinogène sans attendre le résultat biologique classique. De la même façon, un CFT allongé et un angle α réduit sur l’ExTEM pourrait orienter vers une transfusion plaquettaire.

This randomized, comparative study assessed the long-term efficacy and tolerability of thymoglobulin (TMG) induction in 93 liver transplant patients with an initial regimen of tacrolimus (Tac), mycophenolate mofetil (MMF), and steroids. Forty-four patients were randomly allocated to the TMG+ group, and 49 patients were randomly allocated to the TMG− group. In both groups, Tac was given orally at the initial daily dose of 0.075 mg/kg twice daily, and MMF was given at the initial daily dose of 2 g/day. Steroid withdrawal was planned at 3 months after liver transplantation. The results were evaluated with respect to acute rejection incidence, patient and graft survival, graft function, and medical complications until 5 years or death for all patients. No significant differences were found between groups for the incidence of acute rejection at 5 years (11.4% versus 14.3%), 5-year patient survival (77.3% versus 87.8%), graft function, or postoperative renal function. One patient in the TMG− group underwent retransplantation. There was no difference between groups with respect to the incidence of medical complications, excepted for a higher rate of leukopenia in the TMG+ group, during the 5-year follow-up. In conclusion, the results of this prospective randomized study suggest that the addition of TMG to a triple immunosuppressive regimen (Tac, MMF, and steroids) did not modify the incidence of acute rejection episodes or long-term survival and was responsible for increased leukopenia rates. Liver Transpl 15:1426–1434, 2009. © 2009 AASLD.