Paediatric liver transplant patients have good long-term survival prospects
Twenty-year survival is possible in almost 80 percent of children who had a liver transplant and were given cyclosporine as their primary immunosuppressive regimen, according to a study presented at the annual meeting of the European Association for the Study of the Liver (EASL) International Liver Congress™ (ILC) 2016 in Barcelona, Spain.
Of the 128 consecutive children (median age 2.5 years) who underwent a cadaveric transplant (n=47 for whole liver, n=77 for partial liver, n=4 for split-liver) between 1988 and 1993, 100 survived for 20 years or more after the transplant. [EASL-ILC 2016, abstract PS038]
Overall survival rates were 84, 82, 80, and 79 percent at 5, 10, 15, and 20 years, respectively after transplantation. Graft survival rates were 73, 72, 67, and 65 percent at the same respective time points.
“Until now, there has been no good answer as to how long children could be expected to live after liver transplantation. While each child receiving a transplant is unique and every procedure is different, this study provides robust evidence on the average expected survival rates, an important consideration for the parents of children who undergo this complicated procedure,” said Dr. Josefina Martinelli from the Paediatric Liver Unit, Assistance Publique-Hôpitaux de Paris, Paris, France, and lead author of the study.
The most common complications after transplant were infection which affected 59 percent of the patients, followed by acute and chronic rejection (44 and 37 percent, respectively).
Most patients (n=123) were given cyclosporine or steroids as primary immunosuppressive therapy, 47 of whom switched to tacrolimus a mean 10 years after transplant. The other five patients were given tacrolimus or steroids as initial immunosuppressive therapy. Five patients are no longer on immunosuppressive therapy, beginning from 8 to 26 years after the transplant.
At the time of the study, cyclosporine was the primary immunosuppressive agent used in paediatric liver transplant patients. Currently, the primary regimen is tacrolimus-based rather than cyclosporine, said Dr. Emmanuel Gonzales, Professor at the Pediatric Liver Unit, Paris Sud University, Paris, France, and one of the authors of the study.
Twenty six patients underwent retransplantation, causes of which included primary graft dysfunction, ischaemic cholangiopathy (with or without hepatic artery thrombosis), and chronic rejection.
“Retransplantation was not identified as a risk factor for poor outcome [lower survival rate] in univariate analysis,” said Gonzales.
Two patients underwent renal transplantation, one is currently on dialysis, 20 have arterial hypertension, and three are insulin-dependent diabetics. Three patients in the tacrolimus group required treatment for lymphoproliferative disorders. Thirty eight percent of patients did not reach their target height, though final height was considered acceptable for the majority of patients despite steroid use, said Gonzales.
According to Gonzales, chronic kidney disease is a common complication following liver transplants, affecting about 35 percent of long-term survivors.
“We believe that early posttransplant mortality could be decreased through living-related liver transplantation, improvement of pretransplantation care [eg, nutritional support, early Kasai procedure]. New combined immunosuppressive regimens may lower renal drug toxicity, while less or no steroids may improve growth,” he said. He also called for longitudinal studies that followed children who had undergone liver transplants up to adulthood, as well as prospective studies that evaluated new immunosuppressive regimens that were more efficient and less toxic.