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65 - Liver transplantation

from Part VII - Transplantation

Published online by Cambridge University Press:  08 January 2010

By
Paolo Muiesan  and
Nigel D. Heaton
Edited by
Mark D. Stringer ,
Keith T. Oldham  and
Pierre D. E. Mouriquand
Paolo Muiesan
Affiliation:
Liver Transplant Surgical Services, Institute of Liver Studies, King's College Hospital, London, UK
Nigel D. Heaton
Affiliation:
Liver Transplant Surgical Services, Institute of Liver Studies, King's College Hospital, London, UK
Mark D. Stringer
Affiliation:
University of Otago, New Zealand
Keith T. Oldham
Affiliation:
Children's Hospital of Wisconsin
Pierre D. E. Mouriquand
Affiliation:
Debrousse Hospital, Lyon
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Summary

Historical aspects

Over the past 40 years, orthotopic liver transplantation (OLT) has evolved from an experimental procedure to a routine treatment of end-stage liver failure in children. The first attempt at pediatric liver transplantation by Thomas Starzl in 1963 was not successful but 4 years later he reported the first survivor. These early liver transplants were in high-risk recipients and hemorrhage, coagulopathy, and poor graft function resulted in significant intraoperative and early postoperative mortality. Prednisolone and azathioprine were the primary immunosuppressive drugs but some regimens included combinations of cyclophosphamide, anti-lymphocyte globulin, splenectomy, total body irradiation, and thymectomy. Despite advances in surgical techniques, 1-year survival after liver transplantation remained poor and by 1978 was only 30%.

The introduction of the immunosuppressant, cyclosporin, into clinical practice in 1979 transformed the outcome after OLT. Cyclosporin acts by blocking lymphocyte production of interleukin-2 and other cytokines thereby reducing the incidence and severity of acute cellular rejection. The combination of cyclosporin and corticosteroids resulted in a marked increase in graft and patient survival and reduced the need for long-term use of high dose steroids with their attendant side effects. The National Institute of Health consensus conference in 1983 concluded that liver transplantation for end-stage liver disease deserved broad application as a therapeutic option rather than an experimental procedure.

The development of newer immunosuppressive drugs, refinements in operative techniques, improved organ preservation and donor management and advances in anesthetic and intensive care have contributed further to improvements in recipient survival.

Type
Chapter
Information
Pediatric Surgery and Urology
Long-Term Outcomes
 , pp. 858 - 883
Publisher: Cambridge University Press
Print publication year: 2006

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