Recent improvement in survival outcomes and reappraisal of prognostic factors in pediatric living donor liver transplantation.

BACKGROUND Living donor liver transplantation (LDLT) is a significant advancement for the treatment of children with end-stage liver disease given the shortage of deceased donors. The ultimate goal of pediatric LT is to achieve complete donor safety and zero recipient mortality. METHODS We conducted a retrospective, single center assessment of the outcomes as well as the clinical factors that may influence graft and patient survival after primary LDLTs conducted between 1994 and 2020. A Cox's proportional hazards model was used for multivariate analysis. The trends for independent prognostic factors were analyzed according to the treatment era, i.e. I (1994~2002), II (2003~2011), and III (2012~2020). RESULT Primary LDLTs were conducted on 287 children during the study period. Biliary atresia (52%), acute liver failure (ALF) (26%) and monogenic liver disease (11%) were the leading indications. There were 45 graft losses (16%) and 27 patient deaths (7%) in this population during the study period. During era I (n=81), the cumulative survival rates at one and five years after LDLT were 90.1% and 81.5% for patients, and 86.4% and 77.8% for grafts, respectively. During era II (n=113), the corresponding rates were 92.9% and 92% for patients, and 89.4% and 86.7% for grafts. During era III (n=93), the corresponding rates were 100% and 98.6% for patients, and 98.9% and 95.4% for grafts. By multivariate analysis, primary diagnosis ALF, bloodstream infection, posttransplant lymphoproliferative disease, and chronic rejection were found to be negative prognostic indicators for patient survival. CONCLUSION Based on generalized care guidelines and our center-oriented experiences, comprehensive advances in appropriate donor selection, refinement of surgical techniques, and meticulous medical management may eventually realize a zero-mortality rate in pediatric LDLT.