Who needs a liver transplant? (new disease specific indications)
- aDepartment of Paediatric Liver, King’s College Hospital, Denmark Hill, London SE5 9RS, UK, bLiver Transplantation Unit, King’s College Hospital
- Dr Baker.
Improvements in surgical techniques and the availability of reliable immunosuppression have produced excellent results for othotopic liver transplantation (OLT). Eighty to 90% five year survival can be expected even for infants. The success of OLT has resulted in many more patients being considered, but with pressure to use OLT as a substitute for good clinical management of liver disease.
Results of OLT for children
Individual cases of successful OLT are currently alive and well with normal liver functions up to 24 years after the procedure, but significant cohorts did not survive until cyclosporin A became generally available in 1986. Survival curves have steadily improved but retain the same basic characteristics—most mortality in the first three months and the slope almost horizontal by one year; thereafter, annual graft and patient loss are less than 1% and 0.5% respectively. Thus, the long term prognosis appears to be good following OLT (table1)1-16 but factors such as nephropathy and malignancy may have a much greater influence later in the course of follow up than our current experience.
Pre-OLT factors influencing outcome include nutritional state, severity of decompensation of liver functions, and aetiology. Age appears only to be important for newborns. Timing of transplantation is important. If performed too early children may be denied a period of good quality life by death or graft function worse than the diseased liver, while transplantation in poor condition jeopardises the chance of recovery.11
Chronic liver diseases and cirrhosis
Accepted non-disease specific indicators in children of need for OLT are derived from adult experience, including failure of synthetic function with a low serum albumin or prolongation of INR (international normalised ratio), or recurrent or uncontrollable variceal haemorrhage, deterioration of liver function after variceal haemorrhage, intractable ascites, or spontaneous bacterial peritonitis, hepatorenal or hepatopulmonary syndromes, and, rarely in children, chronic encephalopathy. Table …