Liver transplantation for children--the Red Cross Children's Hospital experience.
Liver transplantation for infants and children has been available in South Africa at a single centre, the only established service in Sub-Saharan Africa, for more than a decade. Current concerns have shifted from an initial target of early post-transplant survival to quality of life in the long-term.


METHODS
Since 1985, 225 infants and children have been assessed, with 146 accepted for transplantation. Sixty-nine have had 71 orthotopic liver transplants (OLTx). Biliary atresia was the most frequent diagnosis (54%) followed by acute liver failure (ALF) (15%). Waiting list mortality has remained high (23%), particularly for the ALF group (50%). Forty-three were reduced size transplants with donor: recipient weight ratios ranging from 2:1 to 11:1. Twenty-seven were <10 kg.


RESULTS
Fifty (74%) survive 1 month-12 years post-transplant. Actuarial survival after 1996 since HBV core antibody positive donor livers were refused and prophylactic IV ganciclovir used has been >82%. Early post-OLTx mortality was low (5%), one primary non-function, one IVC thrombosis, one PV thrombosis, but late morbidity and mortality (20%) was mainly due to viral infection: de novo hepatitis B (five patients, three deaths), EBV-related post-transplantation lymphoproliferative disease (PTLPD) (eight patients, six deaths) and CMV disease (11 patients, five deaths). Tuberculosis prophylaxis, required in six cases, resulted in major morbidity in two and mortality in one. Poor compliance played a significant role in seven deaths. Hypertension requiring medication along with some compromise of renal function has been present in all but two patients. However, all those of school-going age (25) attend school normally and remain in good health and only three of the survivors have abnormal liver function tests.


CONCLUSIONS
Successful liver transplantation is possible in a developing country with limited resources. Scarcity of virus-free donors (HBV and HIV) leading to waiting list mortality and infrequent re-transplantation along with long-term consequences of immunosuppression (infection, lymphoma and renal toxicity) remain problems. Intense education of the caregiver and close follow-up, particularly of those living at long distances has partly addressed the compliance problem.
Millar
A J W
AJ
Department of Paediatric Surgery, Paediatrics, Medicine and Surgery, Red Cross Children's Hospital, Institute of Child Health and Medical Research Council Liver Research Centre, University of Cape Town, Cape Town, South Africa. amillar@ich.uct.ac.za
Spearman
W
W
McCulloch
M
M
Goddard
E
E
Raad
J
J
Rode
H
H
Kahn
D
D
Cywes
S
S
D000206:Actuarial Analysis; D000293:Adolescent; D000998:Antiviral Agents / Q000627:therapeutic use; D001656:Biliary Atresia / Q000453:epidemiology; D002648:Child; D002675:Child, Preschool; D005260:Female; D005500:Follow-Up Studies; D015774:Ganciclovir / Q000627:therapeutic use; D006776:Hospitals, Pediatric; D006801:Humans; D007223:Infant; D017114:Liver Failure, Acute / Q000453:epidemiology; D016031:Liver Transplantation / Q000401:mortality / Q000706:statistics & numerical data*; D008137:Longitudinal Studies; D008297:Male; D009894:Opportunistic Infections / Q000453:epidemiology; D009929:Organ Size; D010349:Patient Compliance / Q000706:statistics & numerical data; D012011:Red Cross; D013019:South Africa / Q000453:epidemiology; D016019:Survival Analysis; D014019:Tissue Donors / Q000706:statistics & numerical data; D014850:Waiting Lists
D000998:Antiviral Agents; D015774:Ganciclovir