Survival after reduced-size liver transplantation is dependent on pretransplant status

Orthotopic liver transplantation (OLT) in children is characterized by unique problems including a shortage of compatible-size donors resulting in long waiting periods, significant deterioration while waiting, and death before transplantation. To improve the chances of obtaining an organ for the sickest patients, reduced-size liver transplantation (RSLT) was offered to all hospital-bound children starting in July 1988. Since then, 68 OLTs were performed in 58 children. Thirty-six RSLTs were done in 30 children (42% of total 86 OLT, 53% since 1988). The mean weight of the RSLT patients was 13.5±10.4 kg versus 23.8±21.9 kg in the full-size (FSLT) group (P<.05). Twenty-five of 39 transplants (71.4%) done in children<10 kg were RSLTs in comparison to only 10 of 47 (21.3%) in patients>10 kg (P<.0005). Since 1988, 25 of 34 (73.5%) of all transplants in children<10 kg have been RSLTs. Average donor to recipient weight ratio in the RSLT group was 4.21:1 versus 1.17:1 in the FSLT group (P<.0001). RSLT was done as a primary procedure in 26 patients and as a retransplant in 10. Mean blood product replacement was significantly higher in the RSLT group both intraoperatively (515.7±490.9 v 177.2±278.3 mL/kg, P<.005) and during the first 24 hours postoperation (50.5±81.8 mL/kg v 16.4±28.5 mL/kg, P<.05). Primary graft nonfunction was lower in the RSLT group (9.1% in RSLT, 14% in the FSLT group, P=NS) despite longer cold ischemia times (10.2±2.8 v 8.5±3.1 hours, P<.05) in RSLT. Arterial thrombosis rate was 7.8% in FSLT and 11.4% in RSLT (NS). Postoperative bleeding requiring reoperation, bile leak, hematoma, and intraabdominal abscess were more frequent in the RSLT group (54.7% v 30%, P>.05). Survival rate of stable patients (status 1 and 2) was similar whether they received a RSLT or a FSLT first (73.3 v 79.0, P>.05). Survival for ICU patients (status 3 and 4) was similar whether a reduced or full size graft was used first (50% v 80%, P>.05). Mortality on the waiting list decreased from 29.2% to 5.6% (P<.05) since RSLTs were started. Only 1 out of 10 patients who received RSLTs as secondary procedures survived (11.1%). Deaths occured from 1 to 48 days following the second transplant (mean, 21.4±21.6 days), and causes of death included severe cytomegalovirus sepsis (2), myocardial infarction (1), bacterial sepsis (3), multiorgan failure (3), and primary nonfunction (1). Only one of the deaths was attributable to failure of the reduced-size graft to function. We conclude that primary elective RSLT results in equally good survival as FSLT and significantly reduces mortality on the waiting list with only minimal additional morbidity. Our policy at the present time is to offer early RSLT to all children on the waiting list.