Department of Gastroenterology, Hepatology and NutritionFaculty of Medicine Vanderbilt University Medical Center Nashville TN Division of Gastroenterology and Hepatology University of Washington Seattle WA E.M. Uleryk Consulting Mississauga ON Canada Department of Pediatrics Mount Sinai HospitalUniversity of Toronto Toronto ON Canada Faculty of Medicine University of Manitoba Winnipeg MB Canada Multiorgan Transplant Toronto General HospitalUniversity of Toronto Toronto ON Canada Department of Medicine Sunnybrook Health Sciences Centre Toronto ON Canada University of Toronto Toronto ON Canada Institute for Health Policy, Management and Evaluation University of Toronto Toronto ON Canada.
Liver Transpl. 2022 Mar;28(3):437-453. doi: 10.1002/lt.26250. Epub 2021 Oct 18.
Living donor liver transplantation (LDLT) emerged in the 1980s as a viable alternative to scarce cadaveric organs for pediatric patients. However, pediatric waitlist mortality remains high. Long-term outcomes of living and deceased donor liver transplantation (DDLT) are inconsistently described in the literature. Our aim was to systematically review the safety and efficacy of LDLT after 1 year of transplantation among pediatric patients with all causes of liver failure. We searched the MEDLINE, Medline-in-Process, MEDLINE Epub Ahead of Print, Embase + Embase Classic (OvidSP), and Cochrane (Wiley) from February 1, 1947 to February 26, 2020, without language restrictions. The primary outcomes were patient and graft survival beyond 1 year following transplantation. A meta-analysis of unadjusted and adjusted odds and hazard ratios was performed using a random-effects model. A total of 24 studies with 3677 patients who underwent LDLT and 9098 patients who underwent DDLT were included for analysis. In patients with chronic or combined chronic liver failure and acute liver failure (ALF), 1-year (odds ratio [OR], 0.68; 95% confidence interval [CI], 0.53-0.88), 3-year (OR, 0.73; 95% CI, 0.61-0.89), 5-year (OR, 0.71; 95% CI, 0.57-0.89), and 10-year (OR, 0.42; 95% CI, 0.18-1.00) patient and 1-year (OR, 0.50; 95% CI, 0.35-0.70), 3-year (OR, 0.55; 95% CI, 0.37-0.83), 5-year (OR, 0.5; 95% CI, 0.32-0.76), and 10-year (OR, 0.26; 95% CI, 0.14-0.49) graft survival were consistently better in LDLT recipients compared with those in DDLT recipients. In patients with ALF, no difference was seen between the 2 groups except for 5-year patient survival (OR, 0.60; 95% CI, 0.38-0.95), which favored LDLT. Sensitivity analysis by era showed improved survival in the most recent cohort of patients, consistent with the well-described learning curve for the LDLT technique. LDLT provides superior patient and graft survival outcomes relative to DDLT in pediatric patients with chronic liver failure and ALF. More resources may be needed to develop infrastructures and health care systems to support living liver donation.
活体肝移植（LDLT）于 20 世纪 80 年代出现，成为小儿患者稀缺尸体供体器官的可行替代方案。然而，儿科患者的等待名单死亡率仍然很高。文献中对活体和已故供体肝移植（DDLT）的长期结果描述不一致。我们的目的是系统地回顾所有原因导致肝衰竭的小儿患者在接受 LDLT 后 1 年的安全性和疗效。我们从 1947 年 2 月 1 日至 2020 年 2 月 26 日，在 MEDLINE、Medline-in-Process、MEDLINE Epub Ahead of Print、Embase + Embase Classic（OvidSP）和 Cochrane（Wiley）上进行了无语言限制的检索。主要结局是移植后 1 年以上的患者和移植物存活率。使用随机效应模型对未调整和调整后的优势比和风险比进行了荟萃分析。共纳入 24 项研究，3677 例患者接受 LDLT，9098 例患者接受 DDLT。在慢性或合并慢性肝功能衰竭和急性肝衰竭（ALF）患者中，1 年（比值比[OR]，0.68；95%置信区间[CI]，0.53-0.88）、3 年（OR，0.73；95%CI，0.61-0.89）、5 年（OR，0.71；95%CI，0.57-0.89）和 10 年（OR，0.42；95%CI，0.18-1.00）的患者和 1 年（OR，0.50；95%CI，0.35-0.70）、3 年（OR，0.55；95%CI，0.37-0.83）、5 年（OR，0.5；95%CI，0.32-0.76）和 10 年（OR，0.26；95%CI，0.14-0.49）的移植物存活率在 LDLT 受者中均优于 DDLT 受者。在 ALF 患者中，两组之间除了 5 年的患者生存率（OR，0.60；95%CI，0.38-0.95）外，没有差异，LDLT 组更有利。按时代进行的敏感性分析显示，最近一组患者的生存率有所提高，这与 LDLT 技术的描述良好的学习曲线一致。在慢性肝功能衰竭和 ALF 的小儿患者中，LDLT 相对于 DDLT 提供了更好的患者和移植物存活率。可能需要更多的资源来发展基础设施和医疗保健系统，以支持活体肝捐赠。
