Deceased donor liver transplantation in infants and small children: are partial grafts riskier than whole organs?

Abstract

Infants have the highest wait-list mortality of all liver transplant candidates. Although previous studies have demonstrated that young children may be at increased risk when they receive partial grafts from adult and adolescent deceased donors (DDs), with few size-matched organs available, these grafts have increasingly been used to expand the pediatric donor pool. We aimed to determine the current adjusted risks of graft failure and mortality in young pediatric recipients of partial DD livers and to determine whether these risks have changed over time. We analyzed 2683 first-time recipients of DD livers alone under the age of 24 months in the United Network for Organ Sharing database (1995-2010), which included 1118 partial DD livers and 1565 whole DD organs. Transplant factors associated with graft loss in bivariate analyses (P < 0.1) were included in multivariate proportional hazards models of graft and patient survival. Interaction analysis was used to examine risks over time (1995-2000, 2001-2005, and 2006-2010). Although there were significant differences in crude graft survival by the graft type in 1995-2000 (P < 0.001), graft survival rates with partial and whole grafts were comparable in 2001-2005 (P = 0.43) and 2006-2010 (P = 0.36). Furthermore, although the adjusted hazards for partial graft failure and mortality were 1.40 [95% confidence interval (CI) = 1.05-1.89] and 1.41 (95% CI = 0.95-2.09), respectively, in 1995-2000, the adjusted risks of graft failure and mortality were comparable for partial and whole organs in 2006-2010 [hazard ratio (HR) for graft failure = 0.81, 95% CI = 0.56-1.18; HR for mortality = 1.02, 95% CI = 0.66-1.71]. In conclusion, partial DD liver transplantation has become less risky over time and now has outcomes comparable to those of whole liver transplantation for infants and young children. This study supports the use of partial DD liver grafts in young children in an attempt to significantly increase the pediatric organ pool.

Figure 1

Kaplan-Meier Analysis of graft survival comparing (Left) Reduced, Split and Whole Grafts before and after the introduction of PELD (Pre PELD 1995-2/2002, Post PELD 3/2002-2010); (Right) Partial versus Whole Grafts by Time Period (1995-2000, 2001-2005, 2006-2010).