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Journal of Indian Association of Pediatric Surgeons
     Journal of Indian Association of Pediatric Surgeons
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EDITORIAL
Year : 2011  |  Volume : 16  |  Issue : 1  |  Page : 1
 

Pediatric liver transplantation in India: Its time has come


President, Indian Association of Pediatric Surgeons, Director and Sr. Consultant Pediatric Surgeon/Urologist, Narayana Hrudayalaya Woman and Child Institute, 258/A, Bommasandra Industrial Area, Anekal Taluk, Bangalore - 560 034, India

Date of Web Publication3-Jan-2011

Correspondence Address:
Ashley L. J. D'Cruz
President, Indian Association of Pediatric Surgeons, Director and Sr. Consultant Pediatric Surgeon/Urologist, Narayana Hrudayalaya Woman and Child Institute, 258/A, Bommasandra Industrial Area, Anekal Taluk, Bangalore - 560 034
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9261.74510

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How to cite this article:
D'Cruz AL. Pediatric liver transplantation in India: Its time has come. J Indian Assoc Pediatr Surg 2011;16:1

How to cite this URL:
D'Cruz AL. Pediatric liver transplantation in India: Its time has come. J Indian Assoc Pediatr Surg [serial online] 2011 [cited 2019 Dec 11];16:1. Available from: http://www.jiaps.com/text.asp?2011/16/1/1/74510


Liver transplantation is an established treatment for children with end-stage liver disease (ESLD). Dr. Starzl performed the first successful liver transplant in a child in 1967 and, since then, with improvements in the surgical technique and with better immunosuppression, over 90% graft and patient survival has become possible today in most centers. In India, the first pediatric liver transplants were performed in 1998 and since then many centers have established successful programs. Most are live donor transplants. Because of the various logistic and cultural reasons, there has been no progress in harvesting and sharing of deceased donor organs.

It is virtually impossible, in the absence of reliable data for pediatric liver disease, to obtain an accurate estimate of the number of children with ESLD in India who may benefit from a liver transplantation. According to the Studies of Pediatric Liver Transplantation (SPLIT) data (SPLIT is a group of participating centers in North America and Canada), more than 300 children are registered for liver transplant every year and more than 280 receive a first liver transplant. The primary diagnosis is cholestasis (53.3%), of which 39.4% were children with biliary atresia. Fulminant liver failure was the primary diagnosis in 13.4%, metabolic disease in 14.5% and cirrhosis in 8.1%. With increasing numbers being added to the registry, the number of patients with rare forms of liver disease has increased significantly, meriting special attention.

With no well-established deceased donor program in our country, except two, all 28 pediatric liver transplants performed by our team have been from living donors. Information from SPLIT data available for 2,738 donors show that 85.6% are deceased donors and that 13.3% are living related donors. The data also show that with a significant increase in the use of cadaveric split grafts, the number of living related donors has declined steadily in the recent years.

The perception among referring physicians that a certain optimal age and/or weight are a prerequisite for successful pediatric transplantation is not necessarily true. In our series, the majority were below 10 kg of weight at transplantation. With improvements in technique and growing experience, the portal vein and hepatic artery thrombosis, perceived as having a high incidence in very small children, has not been a problem. According to the SPLIT data, 33.5% were transplanted before their first birthday and 9% before the age of 6 months.

The health of the children before transplants is crucial to a successful transplant. Almost all of the children in our series with a diagnosis of biliary atresia were severely malnourished and had co-morbid diseases like portal hypertension and pulmonary infections and two patients had pulmonary hypertension. Many had recurring cholangitis prior to admission, needing hospitalization, and, in some cases, intensive care unit (ICU) care. Five patients, two post-Kasai, two fulminants and one older boy with cirrhosis, died in the hospital from these complications while being worked-up for transplantation. In comparison, the SPLIT registry data showed that 84.9% of the patients were receiving nutritional intake by mouth and only 43% needed ICU/hospital care before transplantation.

Systemic infections are common in pediatric patients with liver disease because of their poor nutritional status. Many have repeated admissions to hospitals and become colonized with resistant bacteria, and those with biliary atresia are prone to cholangitis. It is for this reason that a detailed and exhaustive pre-transplant infection screen is carried out in all recipients. Our experience is reported in this issue of the Journal, which will illustrate many of these observations.

Pediatric liver transplant sits on the pinnacle of pediatric surgical endeavor. Apart from benefits to children with ESLD, it catalyzes the development of pediatric intensive care, laboratory services, immunobiology and the management of serious infections. Pediatric liver transplant has arrived in our country and my fervent hope is that pediatric surgeons will lead from the front in taking it forward.




 

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