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South African Medical Journal

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Liver transplantation at Red Cross War Memorial Children's Hospital

CWN Spearman, M McCulloch, AJW Millar, H Burger, A Numanoglu, E Goddard, P Gajjar, C Davies, E Muller, F McCurdie, D Kemm, S Cywes, H Rode, D Kahn

Abstract


The liver transplant programme for infants and children at Red Cross War Memorial Children's Hospital is the only established paediatric service in sub-Saharan Africa. Referrals for liver transplant assessment come from  most provinces within Smith Africa as well as neighbouring countries.

Patients and methods. Since 1987, 81 children (range 6 months - 14 years) have had 84liver transplants with biliary atresia being the most frequent diagnosis. The indications for transplantation include biliary atresia (48), metabolic (7), fulminant hepatic failure (10), redo transplants (3) and other (16). Four combined liver/kidney transplants have been performed. Fifty-three were reduced-size transplants with donor/recipient weight ratios  ranging from 2:1 to 11:1 and .32 children weighed less than 10 kg.

Results. Sixty patients (74%) survived 3 months -14 years post transplant. Overall cumulative 1- and 5-year patient survival figures are 79% and 70% respectively. However, with the introduction of prophylactic intravenous ganciclovir and the exclusion of hepatitis B virus (HBV) IgG core Ab-positive donors, the 1-year patient survival is 90% and the projected 5-year  paediatric survival is> 80%. Early(< 1 month) postliver- transplantmortality was low. Causes include primary malfunction (1), inferior vena cava   thrombosis (1), bleeding oesophageal ulcer (1), sepsis (1) and cerebral oedema (1). Late morbidity and mortality was mainly due to infections: de novo hepatitis B (5 patients, 2 deaths), Epstein--Barr virus (EBV)related post-transplantation lymphoproliferative disease (12 patients, 7 deaths) and cytomegalovirus (CMV) disease (10 patients, 5 deaths). Tuberculosis (TB) treatment in 3 patients was complicated by chronic rejection (1) and TB-drug-induced subfulminant liver failure (1).

Conclusion. Despite limited resources, a successful paediatric programme has been established with good patient and graft survival figures and excellent quality of life. Shortage of donors because of infection with HBV and human immunodeficiency virus (HIV) leads to significant waiting-list mortality and infrequent transplantation.




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