Liver transplantation in very small infants

Background: This study examines the results of liver transplantation (LT) in children 5 kg or less. Reports suggest an increased morbidity and mortality in children weighing 5 kg or less as compared to larger children. However, over half of all children needing LT are <1 year old. Improving outcomes in very small children is a major goal of liver transplantation. Methods: All children under 21 years of age transplanted from January 1990 to June 2005 were included in this study. One hundred sixty-eight primary liver transplants were done: 61 in children less than one year of age and 20 in infants weighing 5 kg or less at LT (2 to 5 kg). These 20 infants underwent 23 transplants. Whole organs were used in 39% of transplants, and reduced or split grafts were used in 61%. Arterial reconstruction using aortic conduits was done in 22%. Analysis included Fischer's exact or Chi square test for non-parametric analysis while patient survival was calculated using the Kaplan-Meier method test with differences in survival assessed using the log rank test. Results: Five-year survival for infants 5 kg or less was 74%, and graft survival was 60%, which was not different from patients transplanted that were >5 kg. There were three perioperative deaths, one from primary graft non-function, and two from portal vein thrombosis. There were no bile leaks or hepatic artery thromboses. Bacterial, fungal, and viral infections made up the vast majority of the postoperative complications (65%), with viral infections resulting in two graft losses requiring re-transplantation. Rejection occurred in 25% of patients, of which one required OKT3. Five of the 23 liver transplants in infants less than 5 kg were done prior to 1996, with a five-year graft survival of only 20%. Improvements in technique and postoperative care after 1996 led to improved graft and patient survival of 77% and 86% respectively. Conclusions: Liver transplantation for infants weighing less than 5 kilograms can be technically challenging but can have equivalent graft and patient survival when compared to larger children requiring liver transplantation. Infants should not be denied liver transplantation based on weight alone.