Feasibility and limits of split liver transplantation from pediatric donors - An Italian multicenter experience

Objective: To report the results of a multicenter experience of split liver transplantation (SLT) with pediatric donors. Summary Background Data: There are no reports in the literature regarding pediatric liver splitting; further; the use of donors weighing <40 kg for SLT is currently not recommended. Methods: From 1997 to 2004, 43 conventional split liver procedures from donors aged < 15 years were performed. Nineteen donors weighing <= 40 kg and 24 weighing >40 kg were used. Dimensional matching was based on donor-to-recipient weight ratio (DRWR) for left lateral segment (LLS) and on estimated graft-to-recipient weight ratio (eGRWR) for extended right grafts (ERG). In 3 cases, no recipient was found for an ERG. The celiac trunk was retained with the LLS in all but 1 case. Forty LLSs were transplanted into 39 children, while 39 ERGs were transplanted into 11 children and 28 adults. Results: Two-year patient and graft survival rates were not significantly different between recipients of donors <= 40 kg and >40 kg, between pediatric and adult recipients, and between recipients of LLSs and ERGs. Vascular complication rates were 12% in the <= 40 kg donor group and 6% in the >40 kg donor group (P = not significant). There were no differences in the incidence of other complications. Donor ICU stay >3 days and the use of an interposition arterial graft were associated with an increased risk of graft loss and arterial complications, respectively. Conclusions: Splitting of pediatric liver grafts is an effective strategy to increase organ availability, but a cautious evaluation of the use of donors <= 40 kg is necessary. Prolonged donor ICU stay is associated with poorer outcomes. The maintenance of the celiac trunk with LLS does not seem detrimental for right-sided grafts, whereas the use of interposition grafts for arterial reconstruction should be avoided.