title: Pediatric liver transplantation. A single center experience spanning 20 years.
abstract: BACKGROUND
  Survival after liver transplantation has improved significantly over the last decade with pediatric recipients faring better than adults. The 20-year experience of pediatric liver transplantation at Children's Hospital of Pittsburgh is reported in terms of patient survival; graft survival in relation to age, gender, and immunosuppressive protocols; causes of death; and indications for retransplantation.
  
  
  METHODS
  From March 1981 to April 1998, 808 children received liver transplants at Children's Hospital of Pittsburgh. All patients were followed until March 2001, with a mean follow-up of 12.2+/-3.9 years (median=12.6; range=2.9-20). There were 405 female (50.2%) and 403 male (49.8%) pediatric recipients. Mean age at transplant was 5.3+/-4.9 years (mean=3.3; range 0.04-17.95), with 285 children (25.3%) being less than 2 years of age at transplant. Cyclosporine (CsA)-based immunosuppression was used before November 1989 in 482 children (50.7%), and the subsequent 326 recipients (40.3%) were treated with tacrolimus-based immunosuppression. Actuarial survival was calculated using the Kaplan-Meier statistical method. Differences in survival were calculated by log-rank analysis.
  
  
  RESULTS
  Overall patient survival at 1, 5, 10, 15, and 20 years was 77.1%, 72.6%, 69.4%, 65.8%, and 64.4%, respectively. There was no difference in survival for male or female patients at any time point. At up to 10 years posttransplant, the survival for children greater than 2 years of age (79.5%, 75.7%, and 71.6% at 1, 5, and 10 years, respectively) was slightly higher than those at less than 2 years of age (72.6%, 66.9%, and 65.3% at 1, 5, and 10 years, respectively). However, at 15 and 20 years posttransplant, survival rates were similar (>2 years=67.3% and 65.8%; <2 years=64.1% and 64.1%). A significant difference in survival was seen in CsA-based immunosuppression (71.2%, 68.1%, 65.4%, and 61%) versus tacrolimus-based immunosuppression (85.8%, 84.7%, 83.3%, and 82.9%) at 1, 3, 5, and 10 years, respectively (P=0.0001). The maximum difference in survival was noted in the first 3 months between CsA and tacrolimus; thus, indicating there may have been other factors (nonimmunological factors) involved in terms of donor and recipient selection and technical issues. The mean annual death rate beyond 2 years posttransplant was 0.47%, with the mean annual death rate for patients who received tacrolimus-based immunosuppression being significantly lower than those who received CsA-based immunosuppression (0.14% vs. 0.8%; P=0.001). The most common etiologies of graft loss were hepatic artery thrombosis (33.4%), acute or chronic rejection (26.6%), and primary nonfunction (16.7%). Of note, retransplantation for graft loss because of acute or chronic rejection occurred only in those patients who received CsA-based immuno-suppression.
  
  
  CONCLUSIONS
  The overall 20-year actuarial survival for pediatric liver transplantation is 64%. Survival has increased by 20% in the last 12 years with tacrolimus-based immunosuppression. Although this improvement may be the result of several factors, retransplantation as a result of acute or chronic rejection has been completely eliminated in patients treated with tacrolimus.
authors.affiliation: Department of Surgery, Thomas E. Starzl Transplantation Institute, Children's Hospital of Pittsburgh, Pennsylvania 15213, USA.
authors.forename: Ashok
authors.initials: A
authors.lastname: Jain
authors.forename: George
authors.initials: G
authors.lastname: Mazariegos
authors.forename: Randeep
authors.initials: R
authors.lastname: Kashyap
authors.forename: Beverly
authors.initials: B
authors.lastname: Kosmach-Park
authors.forename: T E
authors.initials: TE
authors.lastname: Starzl
authors.forename: John
authors.initials: J
authors.lastname: Fung
authors.forename: Jorge
authors.initials: J
authors.lastname: Reyes
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D002423:Cause of Death; D002648:Child; D002675:Child, Preschool; D005260:Female; D006085:Graft Survival; D006776:Hospitals, Pediatric; D006801:Humans; D008107:Liver Diseases / Q000145:classification / Q000601:surgery; D016031:Liver Transplantation / Q000401:mortality* / Q000502:physiology* / Q000706:statistics & numerical data; D008232:Lymphoproliferative Disorders / Q000453:epidemiology; D008297:Male; D010414:Pennsylvania; D011183:Postoperative Complications / Q000145:classification / Q000453:epidemiology; D012086:Reoperation; D012189:Retrospective Studies; D015996:Survival Rate; D013997:Time Factors