Complications following pediatric liver transplantation - a change of paradigm

Abstract

Until recently, the postoperative course of pLT was complicated most frequently by surgical complications such as arterial or portal vein thrombosis and severe infections, leading to both graft and patient loss. The objective of this study is to demonstrate a significant shift in pLT-related complications to a dominance of CNI-associated side effects. Therefore, a retrospective chart review of 50 children (31 boys, 19 girls) was performed who underwent pLT between 2005 and 2011. Most common indications were biliary atresia in 52% and acute liver failure in 10%. Age at pLT ranged from 21 days-19years (median: 21 months), body weight was 3.6-79 kg (median 9.9 kg). Immunosuppressive regimen was based on tacrolimus (TAC) and tapered prednisolone. Full-size post-mortem grafts were transplanted in 28%, split grafts (left-lateral, left lobe or right lobe) and living- donation grafts in 36% each. Range of PELD was 0-41 (median: 16). Patient and graft survival rates improved over the last decades having reached 100% at the UKT from 2005-2011. The number of VCs with currently 18% (including HAT in only 1 patient) as well as the rate of rejections and infections decreased over the last years. BCs remain a constant problem occurring in 18 patients (36%), of which 28% were biliary anastomotic strictures. A literature review was done to show the development in the spectrum and number of complications in previous periods of pLT. In our study, 94 (69%) out of 136 complications were associated with CNI-treatment of which hypertension (64%) and nephrotoxicity (28%) were most prevalent. Other CNI-related side-effects included hematological or neuropsychiatric disorders, GI-symptoms, diabetes, food allergy or failure to thrive which at times required a discontinuation from CNIs and the introduction of alternative therapeutic regimens. This indicates that future management of patients after pLT needs to increasingly focus on strategies to reduce CNI-toxicity including the individual minimization and weaning, the use of alternative ISDs with beneficial toxicity profiles (MMF, mTOR inhibitors) or the combination of CNI with adjunctive drugs (e.g. HCTZ) to ensure adequate development and improved quality of life.