Journal of Gastrointestinal Surgery

, Volume 23, Issue 12, pp 2411–2420 | Cite as

Short- and Long-Term Outcomes After Live-Donor Transplantation with Hyper-Reduced Liver Grafts in Low-Weight Pediatric Recipients

  • Micaela RaicesEmail author
  • Matias Eduardo Czerwonko
  • Victoria Ardiles
  • Gustavo Boldrini
  • Daniel D’Agostino
  • José Marcó del Pont
  • Juan Pekolj
  • Juan Mattera
  • Claudio Brandi
  • Miguel Ciardullo
  • Eduardo de Santibañes
  • Martin de Santibañes
Original Article



To evaluate short- and long-term outcomes after live-donor liver transplantation (LT) with hyper-reduced grafts in low-weight pediatric recipients.

Summary Background Data

LT is an established curative therapy for children with end-stage chronic liver disease or acute liver failure. A major problem in pediatric LT has been the lack of size-matched donor organs. The disadvantage of the use of large-for-size grafts is the insufficient tissue oxygenation and graft compression, which result in poor outcomes. The shortage of suitable donors is most notable in children under 10 kg. To overcome such obstacle, in situ hyper-reduced live-donor liver grafts have been introduced. Available articles in the literature are based on small samples and are deficient in long-term follow-up.


A single-cohort, retrospective analysis was conducted including 59 pediatric patients under 10 kg who underwent hyper-reduced (in situ “a la carte” left lateral segment reduction) live-donor LT (LDLT) between February 1994 and February 2018.


The most frequent cause of liver failure was biliary atresia (70%). Median recipient weight was 8 kg. Vascular complications were confirmed in 15% of the sample, while 45% presented biliary complications. Median follow-up time was 40.3 months. Ten-year overall survival rate was 74%. Pediatric end-stage liver disease score > 23 was associated with a higher risk of post-operative complications.


LDLT can be undertaken in children with body weight < 10 kg achieving good results in high-volume centers by experienced surgeons.


Liver failure PELD Mortality Graft failure Biliary leak 


Author Contribution

Category 1:

Conception and design of study: MDS, MR, and MEC.

Acquisition of data: MDS, MR, MEC, VA, and GB.

Analysis and/or interpretation of data: MDS, MR, MEC, DD, JMDP, JP, JM, CB, MC, and EDS.

Category 2:

Drafting the manuscript: MDS, MR, and MEC.

Revising the manuscript critically for important intellectual content: MDS, MR, MEC, VA, GB, DD, JMDP, JP, JM, CB, MC, and EDS.

Category 3:

Approval of the version of the manuscript to be published (the names of all authors must be listed): MDS, MR, MEC, VA, GB, DD, JMDP, JP, JM, CB, MC, and EDS.

Compliance with Ethical Standards

Informed consent was obtained from all patients before surgery and the Hospital Italiano Ethics Committee gave ethical approval to perform this study (Protocol No. 3699). The study protocol has been registered on database (identifier NCT03594864).

Supplementary material

11605_2019_4188_MOESM1_ESM.docx (25 kb)
ESM 1 (DOCX 24 kb)


  1. 1.
    Perito ER, Roll G, Dodge JL, et al. Split liver transplantation and pediatric waitlist mortality in the United States: potential for improvement. Transplantation. . Epub ahead of print April 21, 2018. Scholar
  2. 2.
    Akdur A, Kirnap M, Ozcay F, et al. Large-for-size liver transplant: a single-center experience. Exp Clin Transplant. 2015;13 Suppl 1:108–110.PubMedGoogle Scholar
  3. 3.
    Kim WR, Lake JR, Smith JM, et al. OPTN/SRTR 2015 Annual Data Report: Liver. Am J Transplant. 2017;17 Suppl 1:174–251.CrossRefGoogle Scholar
  4. 4.
    de Santibañes E, McCormack L, Mattera J, et al. Partial left lateral segment transplant from a living donor. Liver Transpl. 2000;6:108–112.CrossRefGoogle Scholar
  5. 5.
    Ardiles V, Ciardullo MA, D’Agostino D, et al. Transplantation with hyper-reduced liver grafts in children under 10 kg of weight. Langenbecks Arch Surg. 2013;398:79–85.CrossRefGoogle Scholar
  6. 6.
    Kanazawa H, Sakamoto S, Fukuda A, et al. Living-donor liver transplantation with hyperreduced left lateral segment grafts: a single-center experience. Transplantation. 2013;95:750–754.CrossRefGoogle Scholar
  7. 7.
    Ciardullo M, Andreani O, Mattera J, et al. Reducción Hepática en el Trasplante Ortotopico de Higado. Nuestra Experiencia. Revista Argentina de Cirugía. Retrieved January 10, 2019, from: 1990.
  8. 8.
    PELD Calculator - OPTN. Retrieved December 12, 2018 from:
  9. 9.
    Clavien PA, Barkun J, de Oliveira ML, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009;250:187–196.CrossRefGoogle Scholar
  10. 10.
    Porrett PM, Hsu J, Shaked A. Late surgical complications following liver transplantation. Liver Transpl. 2009;15:S12–S18.CrossRefGoogle Scholar
  11. 11.
    Cauley RP, Vakili K, Potanos K, et al. Deceased donor liver transplantation in infants and small children: are partial grafts riskier than whole organs? Liver Transpl. 2013;19:721–729.CrossRefGoogle Scholar
  12. 12.
    Kitajima T, Sakamoto S, Sasaki K, et al. Impact of graft thickness reduction of left lateral segment on outcomes following pediatric living donor liver transplantation. Am J Transplant. . Epub ahead of print April 19, 2018. Scholar
  13. 13.
    Thomas N, Thomas G, Verran D, et al. Liver transplantation in children with hyper-reduced grafts - a single-center experience. Pediatr Transplant. 2010;14:426–430.CrossRefGoogle Scholar
  14. 14.
    McDiarmid SV, Anand R, Martz K, et al. A multivariate analysis of pre-, peri-, and post-transplant factors affecting outcome after pediatric liver transplantation. Ann Surg. 2011;254:145–154.CrossRefGoogle Scholar
  15. 15.
    Desai CS, Sharma S, Gruessner A, et al. Effect of small donor weight and donor-recipient weight ratio on the outcome of liver transplantation in children. Pediatr Transplant. 2015;19:366–370.CrossRefGoogle Scholar
  16. 16.
    Bismuth H, Houssin D. Reduced-sized orthotopic liver graft in hepatic transplantation in children. Surgery. 1984;95:367–370.PubMedGoogle Scholar
  17. 17.
    Houssin D, Soubrane O, Boillot O, et al. Orthotopic liver transplantation with a reduced-size graft: an ideal compromise in pediatrics? Surgery. 1992;111:532–542.PubMedGoogle Scholar
  18. 18.
    Shehata MR, Yagi S, Okamura Y, et al. Pediatric Liver Transplantation Using Reduced and Hyper-Reduced Left Lateral Segment Grafts: A 10-Year Single-Center Experience. Am J Transplant. 2012;12:3406–3413.CrossRefGoogle Scholar
  19. 19.
    Kasahara M, Fukuda A, Yokoyama S, et al. Living donor liver transplantation with hyperreduced left lateral segments. J Pediatr Surg. 2008;43:1575–1578.CrossRefGoogle Scholar
  20. 20.
    Arnon R, Annunziato R, Miloh T, et al. Liver transplantation in children weighing 5 kg or less: Analysis of the UNOS database. Pediatr Transplant. 2011;no–no.Google Scholar
  21. 21.
    Chung PHY, Chan SC, Mok VWK, et al. Recipient body size does not matter in pediatric liver transplantation. J Pediatr Surg. 2014;49:1734–1737.CrossRefGoogle Scholar
  22. 22.
    Hsu EK, Shaffer ML, Gao L, et al. Analysis of Liver Offers to Pediatric Candidates on the Transplant Wait List. Gastroenterology. 2017;153:988–995.CrossRefGoogle Scholar
  23. 23.
    Linecker M, Krones T, Berg T, et al. Potentially inappropriate liver transplantation in the era of the “sickest first” policy - A search for the upper limits. J Hepatol. . Epub ahead of print November 11, 2017. Scholar
  24. 24.
    Venick RS, Farmer DG, Soto JR, et al. One Thousand Pediatric Liver Transplants During Thirty Years: Lessons Learned. J Am Coll Surg. 2018;226:355–366.CrossRefGoogle Scholar
  25. 25.
    Oh SH, Kim KM, Kim DY, et al. Long-term outcomes of pediatric living donor liver transplantation at a single institution. Pediatr Transplant. 2010;14:870–878.CrossRefGoogle Scholar
  26. 26.
    Bourdeaux C, Tri TT, Gras J, et al. PELD score and posttransplant outcome in pediatric liver transplantation: a retrospective study of 100 recipients. Transplantation. 2005;79:1273–1276.CrossRefGoogle Scholar
  27. 27.
    Barshes NR, Lee TC, Udell IW, et al. The pediatric end-stage liver disease (PELD) model as a predictor of survival benefit and posttransplant survival in pediatric liver transplant recipients. Liver Transpl. 2006;12:475–480.CrossRefGoogle Scholar
  28. 28.
    Shneider BL, Neimark E, Frankenberg T, et al. Critical analysis of the pediatric end-stage liver disease scoring system: a single center experience. Liver Transpl. 2005;11:788–795.CrossRefGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2019

Authors and Affiliations

  • Micaela Raices
    • 1
    Email author
  • Matias Eduardo Czerwonko
    • 1
  • Victoria Ardiles
    • 1
  • Gustavo Boldrini
    • 2
  • Daniel D’Agostino
    • 2
  • José Marcó del Pont
    • 3
  • Juan Pekolj
    • 1
  • Juan Mattera
    • 1
  • Claudio Brandi
    • 4
  • Miguel Ciardullo
    • 1
  • Eduardo de Santibañes
    • 1
  • Martin de Santibañes
    • 1
  1. 1.Department of General Surgery, Division of HPB Surgery and Liver Transplant UnitHospital Italiano de Buenos AiresBuenos AiresArgentina
  2. 2.Department of Pediatrics, Division of Pediatric GastroenterologyHospital Italiano de Buenos AiresBuenos AiresArgentina
  3. 3.Department of Pediatrics, Division of Pediatric Infectious DiseasesHospital Italiano de Buenos AiresBuenos AiresArgentina
  4. 4.Department of General Surgery, Division abdominal wall and reconstructive microsurgeryHospital Italiano de Buenos AiresBuenos AiresArgentina

Personalised recommendations