THE JOURNAL OF PEDIATRICS EDITORIALS VOLUME 134, NUMBER 3 259 Liver transplantation is a lifesaving treatment for children with irreversible liver disease. The dramatic improve- ment in patient and graft survival since 1980 has occurred as a result of the de- velopment of more effective immuno- suppressive agents and surgical tech- niques, which increase the variety of donor options for patients awaiting transplantation. With the success of liver transplantation, the waiting list for transplantation has markedly expand- ed, yet the number of available trans- plant donor organs has remained un- changed over the past 5 years. 1 Approximately 4000 patients under- went liver transplantation in the Unit- ed States in 1997, 13% of whom were under 18 years of age. Yet more than 9000 patients were on the waiting list at the end of 1997 and more than 11,000 patients are on the waiting list as of the end of 1998. A 10-fold in- crease in the average waiting time has developed as a consequence of the dis- crepancy between number of donors and the number of potential transplant recipients. 1,2 The increased waiting time is particularly critical for children with biliary atresia or metabolic liver disease, who account for almost 60% of children younger than 5 years awaiting liver transplantation. 1 These patients often have rapidly progress- ing disease and experience severe mal- nutrition or significant developmental delay while awaiting liver transplanta- tion, both of which affect posttrans- plantation outcome. 3-6 T The long- and short-term outcome of living-donor liver transplantation J Pediatr 1999;134:259-61. Copyright © 1999 by Mosby, Inc. 0022-3476/99/$8.00 + 0 9/18/96792 See related article, p. 280. CAD Cadaveric liver transplantation LDT Living-donor liver transplantation
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PII: S0022-3476(99)70445-2VOLUME 134, NUMBER 3
259
Liver transplantation is a lifesaving treatment for children with irreversible liver disease. The dramatic improve- ment in patient and graft survival since 1980 has occurred as a result of the de- velopment of more effective immuno- suppressive agents and surgical tech- niques, which increase the variety of donor options for patients awaiting transplantation. With the success of liver transplantation, the waiting list for transplantation has markedly expand-
ed, yet the number of available trans- plant donor organs has remained un- changed over the past 5 years.1
Approximately 4000 patients under- went liver transplantation in the Unit- ed States in 1997, 13% of whom were under 18 years of age. Yet more than 9000 patients were on the waiting list at the end of 1997 and more than 11,000 patients are on the waiting list as of the end of 1998. A 10-fold in- crease in the average waiting time has developed as a consequence of the dis- crepancy between number of donors
and the number of potential transplant recipients.1,2 The increased waiting time is particularly critical for children with biliary atresia or metabolic liver disease, who account for almost 60% of children younger than 5 years
awaiting liver transplantation.1 These patients often have rapidly progress- ing disease and experience severe mal- nutrition or significant developmental delay while awaiting liver transplanta- tion, both of which affect posttrans- plantation outcome.3-6
TThe long- and short-term outcome of living-donor liver transplantation
J Pediatr 1999;134:259-61. Copyright © 1999 by Mosby, Inc.
0022-3476/99/$8.00 + 0 9/18/96792
CAD Cadaveric liver transplantation LDT Living-donor liver transplantation
EDITORIALS THE JOURNAL OF PEDIATRICS
MARCH 1999
Living donor liver transplantation was introduced to address the in- creased demand for donor organs. The surgical procedures to undertake LDT were developed from the experience acquired with cadaveric organ re- duced-sized liver allografts. In 1997, LDT accounted for only 1.5% of the total liver transplants done in the Unit- ed States.1 Consequently, LDT has not alleviated the organ shortage problem. Nevertheless, LDT has had a signifi- cant impact; LDT accounts for >10% of pediatric liver transplantation.
In this issue of The Journal, Reding et al7 compared the outcome of children who underwent LDT with that of chil- dren who underwent cadaveric liver transplantation at the Saint-Luc Uni- versity Clinics at the University of Lou- vain Medical School in Brussels. The authors reviewed 110 children listed for primary elective liver transplantation, 68 listed for CAD transplant and 42 scheduled for LDT. One year after transplantation, the patient and graft survival rates were not different be- tween the 2 groups, 87% and 75% for the CAD group and 92% and 90% for the LDT group. The absence of statisti- cally significant difference between the groups may reflect a β error because the power of the analysis to detect a 10% improved survival rate was only 37%. The pretransplant mortality rate was much higher for patients listed for CAD compared with those scheduled for LDT (15% vs 2%). The increased pre- transplant mortality rate for those awaiting CAD suggests that LDT re- cipients received an allograft when they were in better clinical condition.
The operative procedures undertak- en in living donor hepatectomy involve technical and personal risks to the donor. Donor mortality rate from living donor hepatectomies is <0.2%, and overall significant complication rates range from 15% to 20%, including bil- iary leaks, gastrointestinal complica- tions, and a rare vascular injury to the remaining donor liver. Minor complica- tions in 10% to 20% of patients increase
the overall risk of this procedure to ~35%.8-10 In the study by Reding et al,7
3 of the 41 donors had biliary leaks on the cut surface of the liver that healed spontaneously, and there were no other major complications. As shown by Reding et al, the risk of donor partial hepatectomy is low when the operative procedures are done in centers experi- enced with hepatic resection and re- duced-size transplantation.
The specific recipient vascular and biliary technical risks of LDT are simi- lar to those seen with reduced-size or split liver transplantation. However, the donor procedure dictates the pres- ence of short vascular and biliary com- ponents, as well as limited visualization of the biliary anatomy in the donor liver. Hepatic arterial thrombosis was common (14% to 24%) before the use of microsurgical reconstructive tech- niques. Extensive experience has shown that direct microsurgical recon- struction of the donor hepatic artery is a reliable technique, with the risk of thrombosis less than that with whole organ or reduced-size transplanta- tion.11 In the series reported by Red- ing et al,7 hepatic artery thrombosis occurred exclusively in recipients of cadaveric transplants. The findings are initially surprising because the donor arterial vessels used for LDT are smaller than those used for CAD. However, the same group of investiga- tors has previously reported that recip- ients of LDT had lower serum hyaluronic acid levels, suggesting less endothelial injury, when compared with recipients of CAD.12 The recipi- ents of LDT in the series reported by Reding et al7 had much shorter organ ischemia time and consequently may have had less endothelial damage, thereby decreasing the risk for hepatic artery thrombosis.
Biliary complications remain the pri- mary risk in LDT. In the report by Reding et al,7 biliary complications oc- curred in 34% of recipients of LDT compared with 14% of patients who received cadaveric grafts. This is twice
the biliary complication rate experi- enced in the whole organ or reduced- size transplant experience. The highly variable anatomy of the biliary ele- ments to segments II, III, and IV of the liver contributes to the complexities of identifying and reconstructing biliary continuity. The short ischemic time seen in LDT suggests that this compli- cation is related to the biliary complex- ity and ductal size rather then ductal ischemia. Improved imaging with pre- operative magnetic resonance or intra- operative cholangiography may de- crease the incidence of missed biliary radicals as a source of early bile leak or late segmental biliary obstruction.
Biliary complications are rarely the sole cause of allograft loss but con- tribute significantly to the develop- ment of posttransplantation sepsis. Early recognition of cut-surface or anastomotic bile leaks greatly dimin- ishes their potential for sepsis. Re- ichert et al13 identified a 19% incidence of cut-surface parenchymal leaks and a 5% anastomotic leak rate on routine planned re-exploration on the seventh postoperative day.13 They recommend this practice to facilitate early identifi- cation and treatment of these compli- cations. We also follow and recom- mend this policy. It seems a prudent course until the incidence of biliary complications is decreased through in- creased experience and improved imaging to guide the biliary dissection.
The course of successful liver trans- plantation is divided into 4 distinct phases: pretransplant, liver transplan- tation and perioperative recovery, re- turn to functional health, and long- term outcome. At each phase of care, the patient and health care provider meet distinct challenges. LDT decreas- es the pretransplant mortality rate and permits transplantation to occur before the patient has severe malnutrition or complications of end-stage liver dis- ease. The evidence to date does not allow us to determine whether LDT influences long-term outcome for sur- vivors. Irrespective of the donor type,
260
VOLUME 134, NUMBER 3
critical issues remain, which have an impact on long-term outcome for liver transplant recipients. For both chil- dren and adults, increased serum lipid levels, elevated blood pressure, altered glucose metabolism, decreased renal function, and diminished bone accre- tion occur as a result of immunosup- pressive therapy or complications of therapy. Consequently, liver transplant recipients are at increased risk for os- teoporosis, chronic renal disease, and atherosclerotic heart disease.14-17 The potential impact on a child who re- ceived a liver transplant is distinct from that for an adult. For any degen- erative illness, the clinical condition moves at variable rates through a se- ries of stages, beginning with normal physiologic functioning through minor variation from the norm, perceived symptoms, early diagnosed disease, and finally to disabling illness. Long- term survivors are unlikely to have symptomatic or disabling disease dur- ing the first decade after liver trans- plantation. However, the longer poten- tial life span after liver transplantation in childhood may mean that patients live long enough to move from a stage of asymptomatic to disabling disease.
There is no doubt that LDT achieves the goal of successful transplantation in pediatric recipients. To determine the true value of LDT, health care providers must compare the cumula- tive risk of the donor’s pre-operative evaluation and operative procedure, with that of the recipient at the time of transplantation. Although donors re- ceive psychologic benefit from the transplantation of their relative or child, they do not receive any direct medical benefit from the operative pro- cedure. This unique relationship dis- tinguishes this operative procedure. The balance between the unique bene- fits of this procedure relative to its cu- mulative risks and the availability of suitable alternative cadaveric allografts
will determine the long-term role of this procedure. LDT does not solve the problem of maintaining health and graft function in long-term survivors of liver transplantation. The number of transplants done each year has in- creased slightly, from 3400 to about 4000 in the last 5 years, whereas the cumulative number of long-term sur- vivors has grown. Because of the in- creasing size of the population of long- term survivors, the total costs for maintaining graft function and health will soon exceed the total costs for pri- mary transplantation. Until graft toler- ance without immunosuppression is a reality, outcome will depend not only on options for transplantation but also on our ability to maintain graft func- tion and health in children who are long-term survivors.
John C. Bucuvalas, MD Division of Gastroenterology & Nutrition
Frederick C. Ryckman, MD Department of Pediatric Surgery
Children’s Hospital Medical Center Cincinnati, OH 45229
REFERENCES 1. United Network for Organ Sharing
Facts & Statistics. Available at: http://204.127.237.11. Accessed De- cember 20, 1998.
2. Bohnengel A. Annual report. Wor- thington (OH): Ohio Solid Organ Transplantation Consortium; 1997.
3. Shepherd R, Chin S, Cleghorn G, Patrick M, Ong T, Lynch S, et al. Mal- nutrition in children with chronic liver disease accepted for liver transplanta- tion. J Pediatr Child Health 1991;27: 295-9.
4. Moukarzel AA, Najm I, Vargas J, Mc- Diarmid SV, Busuttil RW, Ament ME. Effect of nutritional status on outcome of orthotopic liver transplantation in pediatric patients. Transplant Proc 1990;22:1560-3.
5. Schwering KL, Febo-Mandl F, Finke- nauer C, Rimé B, Hayez J-Y, Otte JB. Psychological and social adjustment after pediatric liver transplantation as a function of age at surgery and of time
elapses since transplantation. Pediatr Transplant 1997;1:138-45.
6. Wayman KI, Cox KL, Esquivel CO. Neurodevelopmental outcome of young children with extrahepatic bil- iary atresia 1 year after liver transplan- tation. J Pediatr 1997;131:894-8.
7. Reding R, de Ville de Goyet J, Del- beke I, Sokal E, Jamart J, Janssen M, et al. Pediatric liver transplantation with cadaveric or living related donors: comparative results in 90 elective re- cipients of primary grafts. J Pediatr 1999;134:280-6.
8. Grewal HP, Thistlewaite JR, Loss GE, Fisher JS, Cronin DC, Siegel CT, et al. Complications in 100 living-liver donors. Ann Surg 1998;228:214-9.
9. Yamaoka Y, Morimoto T, Inamoto T, Tanaka A, Honda K, Ikai I, Tanaka K, et al. Safety of the donor in living-re- lated liver transplantation—an analy- sis of 100 parental donors. Transplan- tation 1995;59:224-6.
10. Sterneck MR, Fischer L, Nischwitz U, Burdelski M, Kjer S, Latta A, et al. Se- lection of the living donor. Transplan- tation 1995;60:667-71.
11. Furata S, Ikegami T, Nakazawa Y, Hashikura Y, Matsunami H, Kawasaki S, et al. Hepatic artery reconstruction in living donor liver transplantation from the microsurgeon’s point of view. Liver Transplant Surg 1997;3:388-93.
12. Reding R, Wallemacq P, Moulin D, Manicourt D, Lambotte L, Jamart J, et al. Early hepatocyte, endothelial, and bile duct cell injury after pediatric liver transplantation from cadaveric or living-related donors. Transplantation 1998;65:681-5.
13. Reichert PR, Renz JF, Rosenthal P, Bacchetti P, Lim RC, Roberts JP, et al. Biliary complications of reduced-organ liver transplantation. Liver Transplant Surg 1998;4:343-9.
14. Bartosh SM, Alonso EM, Whitington PF. Renal outcomes in pediatric liver transplantation. Clin Transplant 1997; 5:354-60.
15. McDiarmid SV. Renal function in pe- diatric liver transplant patients. Kid- ney Int 1996;53(suppl):S77-84.
16. Meys E, Fontanges E, Fourcade N. Bone loss after orthotopic liver trans- plantation. Am J Med 1994;97:445-50.
17. Kobasigawa JA, Kasiske BL. Hyper- lipidemia in solid organ transplanta- tion. Transplantation 1997;63:331-8.
261
259
Liver transplantation is a lifesaving treatment for children with irreversible liver disease. The dramatic improve- ment in patient and graft survival since 1980 has occurred as a result of the de- velopment of more effective immuno- suppressive agents and surgical tech- niques, which increase the variety of donor options for patients awaiting transplantation. With the success of liver transplantation, the waiting list for transplantation has markedly expand-
ed, yet the number of available trans- plant donor organs has remained un- changed over the past 5 years.1
Approximately 4000 patients under- went liver transplantation in the Unit- ed States in 1997, 13% of whom were under 18 years of age. Yet more than 9000 patients were on the waiting list at the end of 1997 and more than 11,000 patients are on the waiting list as of the end of 1998. A 10-fold in- crease in the average waiting time has developed as a consequence of the dis- crepancy between number of donors
and the number of potential transplant recipients.1,2 The increased waiting time is particularly critical for children with biliary atresia or metabolic liver disease, who account for almost 60% of children younger than 5 years
awaiting liver transplantation.1 These patients often have rapidly progress- ing disease and experience severe mal- nutrition or significant developmental delay while awaiting liver transplanta- tion, both of which affect posttrans- plantation outcome.3-6
TThe long- and short-term outcome of living-donor liver transplantation
J Pediatr 1999;134:259-61. Copyright © 1999 by Mosby, Inc.
0022-3476/99/$8.00 + 0 9/18/96792
CAD Cadaveric liver transplantation LDT Living-donor liver transplantation
EDITORIALS THE JOURNAL OF PEDIATRICS
MARCH 1999
Living donor liver transplantation was introduced to address the in- creased demand for donor organs. The surgical procedures to undertake LDT were developed from the experience acquired with cadaveric organ re- duced-sized liver allografts. In 1997, LDT accounted for only 1.5% of the total liver transplants done in the Unit- ed States.1 Consequently, LDT has not alleviated the organ shortage problem. Nevertheless, LDT has had a signifi- cant impact; LDT accounts for >10% of pediatric liver transplantation.
In this issue of The Journal, Reding et al7 compared the outcome of children who underwent LDT with that of chil- dren who underwent cadaveric liver transplantation at the Saint-Luc Uni- versity Clinics at the University of Lou- vain Medical School in Brussels. The authors reviewed 110 children listed for primary elective liver transplantation, 68 listed for CAD transplant and 42 scheduled for LDT. One year after transplantation, the patient and graft survival rates were not different be- tween the 2 groups, 87% and 75% for the CAD group and 92% and 90% for the LDT group. The absence of statisti- cally significant difference between the groups may reflect a β error because the power of the analysis to detect a 10% improved survival rate was only 37%. The pretransplant mortality rate was much higher for patients listed for CAD compared with those scheduled for LDT (15% vs 2%). The increased pre- transplant mortality rate for those awaiting CAD suggests that LDT re- cipients received an allograft when they were in better clinical condition.
The operative procedures undertak- en in living donor hepatectomy involve technical and personal risks to the donor. Donor mortality rate from living donor hepatectomies is <0.2%, and overall significant complication rates range from 15% to 20%, including bil- iary leaks, gastrointestinal complica- tions, and a rare vascular injury to the remaining donor liver. Minor complica- tions in 10% to 20% of patients increase
the overall risk of this procedure to ~35%.8-10 In the study by Reding et al,7
3 of the 41 donors had biliary leaks on the cut surface of the liver that healed spontaneously, and there were no other major complications. As shown by Reding et al, the risk of donor partial hepatectomy is low when the operative procedures are done in centers experi- enced with hepatic resection and re- duced-size transplantation.
The specific recipient vascular and biliary technical risks of LDT are simi- lar to those seen with reduced-size or split liver transplantation. However, the donor procedure dictates the pres- ence of short vascular and biliary com- ponents, as well as limited visualization of the biliary anatomy in the donor liver. Hepatic arterial thrombosis was common (14% to 24%) before the use of microsurgical reconstructive tech- niques. Extensive experience has shown that direct microsurgical recon- struction of the donor hepatic artery is a reliable technique, with the risk of thrombosis less than that with whole organ or reduced-size transplanta- tion.11 In the series reported by Red- ing et al,7 hepatic artery thrombosis occurred exclusively in recipients of cadaveric transplants. The findings are initially surprising because the donor arterial vessels used for LDT are smaller than those used for CAD. However, the same group of investiga- tors has previously reported that recip- ients of LDT had lower serum hyaluronic acid levels, suggesting less endothelial injury, when compared with recipients of CAD.12 The recipi- ents of LDT in the series reported by Reding et al7 had much shorter organ ischemia time and consequently may have had less endothelial damage, thereby decreasing the risk for hepatic artery thrombosis.
Biliary complications remain the pri- mary risk in LDT. In the report by Reding et al,7 biliary complications oc- curred in 34% of recipients of LDT compared with 14% of patients who received cadaveric grafts. This is twice
the biliary complication rate experi- enced in the whole organ or reduced- size transplant experience. The highly variable anatomy of the biliary ele- ments to segments II, III, and IV of the liver contributes to the complexities of identifying and reconstructing biliary continuity. The short ischemic time seen in LDT suggests that this compli- cation is related to the biliary complex- ity and ductal size rather then ductal ischemia. Improved imaging with pre- operative magnetic resonance or intra- operative cholangiography may de- crease the incidence of missed biliary radicals as a source of early bile leak or late segmental biliary obstruction.
Biliary complications are rarely the sole cause of allograft loss but con- tribute significantly to the develop- ment of posttransplantation sepsis. Early recognition of cut-surface or anastomotic bile leaks greatly dimin- ishes their potential for sepsis. Re- ichert et al13 identified a 19% incidence of cut-surface parenchymal leaks and a 5% anastomotic leak rate on routine planned re-exploration on the seventh postoperative day.13 They recommend this practice to facilitate early identifi- cation and treatment of these compli- cations. We also follow and recom- mend this policy. It seems a prudent course until the incidence of biliary complications is decreased through in- creased experience and improved imaging to guide the biliary dissection.
The course of successful liver trans- plantation is divided into 4 distinct phases: pretransplant, liver transplan- tation and perioperative recovery, re- turn to functional health, and long- term outcome. At each phase of care, the patient and health care provider meet distinct challenges. LDT decreas- es the pretransplant mortality rate and permits transplantation to occur before the patient has severe malnutrition or complications of end-stage liver dis- ease. The evidence to date does not allow us to determine whether LDT influences long-term outcome for sur- vivors. Irrespective of the donor type,
260
VOLUME 134, NUMBER 3
critical issues remain, which have an impact on long-term outcome for liver transplant recipients. For both chil- dren and adults, increased serum lipid levels, elevated blood pressure, altered glucose metabolism, decreased renal function, and diminished bone accre- tion occur as a result of immunosup- pressive therapy or complications of therapy. Consequently, liver transplant recipients are at increased risk for os- teoporosis, chronic renal disease, and atherosclerotic heart disease.14-17 The potential impact on a child who re- ceived a liver transplant is distinct from that for an adult. For any degen- erative illness, the clinical condition moves at variable rates through a se- ries of stages, beginning with normal physiologic functioning through minor variation from the norm, perceived symptoms, early diagnosed disease, and finally to disabling illness. Long- term survivors are unlikely to have symptomatic or disabling disease dur- ing the first decade after liver trans- plantation. However, the longer poten- tial life span after liver transplantation in childhood may mean that patients live long enough to move from a stage of asymptomatic to disabling disease.
There is no doubt that LDT achieves the goal of successful transplantation in pediatric recipients. To determine the true value of LDT, health care providers must compare the cumula- tive risk of the donor’s pre-operative evaluation and operative procedure, with that of the recipient at the time of transplantation. Although donors re- ceive psychologic benefit from the transplantation of their relative or child, they do not receive any direct medical benefit from the operative pro- cedure. This unique relationship dis- tinguishes this operative procedure. The balance between the unique bene- fits of this procedure relative to its cu- mulative risks and the availability of suitable alternative cadaveric allografts
will determine the long-term role of this procedure. LDT does not solve the problem of maintaining health and graft function in long-term survivors of liver transplantation. The number of transplants done each year has in- creased slightly, from 3400 to about 4000 in the last 5 years, whereas the cumulative number of long-term sur- vivors has grown. Because of the in- creasing size of the population of long- term survivors, the total costs for maintaining graft function and health will soon exceed the total costs for pri- mary transplantation. Until graft toler- ance without immunosuppression is a reality, outcome will depend not only on options for transplantation but also on our ability to maintain graft func- tion and health in children who are long-term survivors.
John C. Bucuvalas, MD Division of Gastroenterology & Nutrition
Frederick C. Ryckman, MD Department of Pediatric Surgery
Children’s Hospital Medical Center Cincinnati, OH 45229
REFERENCES 1. United Network for Organ Sharing
Facts & Statistics. Available at: http://204.127.237.11. Accessed De- cember 20, 1998.
2. Bohnengel A. Annual report. Wor- thington (OH): Ohio Solid Organ Transplantation Consortium; 1997.
3. Shepherd R, Chin S, Cleghorn G, Patrick M, Ong T, Lynch S, et al. Mal- nutrition in children with chronic liver disease accepted for liver transplanta- tion. J Pediatr Child Health 1991;27: 295-9.
4. Moukarzel AA, Najm I, Vargas J, Mc- Diarmid SV, Busuttil RW, Ament ME. Effect of nutritional status on outcome of orthotopic liver transplantation in pediatric patients. Transplant Proc 1990;22:1560-3.
5. Schwering KL, Febo-Mandl F, Finke- nauer C, Rimé B, Hayez J-Y, Otte JB. Psychological and social adjustment after pediatric liver transplantation as a function of age at surgery and of time
elapses since transplantation. Pediatr Transplant 1997;1:138-45.
6. Wayman KI, Cox KL, Esquivel CO. Neurodevelopmental outcome of young children with extrahepatic bil- iary atresia 1 year after liver transplan- tation. J Pediatr 1997;131:894-8.
7. Reding R, de Ville de Goyet J, Del- beke I, Sokal E, Jamart J, Janssen M, et al. Pediatric liver transplantation with cadaveric or living related donors: comparative results in 90 elective re- cipients of primary grafts. J Pediatr 1999;134:280-6.
8. Grewal HP, Thistlewaite JR, Loss GE, Fisher JS, Cronin DC, Siegel CT, et al. Complications in 100 living-liver donors. Ann Surg 1998;228:214-9.
9. Yamaoka Y, Morimoto T, Inamoto T, Tanaka A, Honda K, Ikai I, Tanaka K, et al. Safety of the donor in living-re- lated liver transplantation—an analy- sis of 100 parental donors. Transplan- tation 1995;59:224-6.
10. Sterneck MR, Fischer L, Nischwitz U, Burdelski M, Kjer S, Latta A, et al. Se- lection of the living donor. Transplan- tation 1995;60:667-71.
11. Furata S, Ikegami T, Nakazawa Y, Hashikura Y, Matsunami H, Kawasaki S, et al. Hepatic artery reconstruction in living donor liver transplantation from the microsurgeon’s point of view. Liver Transplant Surg 1997;3:388-93.
12. Reding R, Wallemacq P, Moulin D, Manicourt D, Lambotte L, Jamart J, et al. Early hepatocyte, endothelial, and bile duct cell injury after pediatric liver transplantation from cadaveric or living-related donors. Transplantation 1998;65:681-5.
13. Reichert PR, Renz JF, Rosenthal P, Bacchetti P, Lim RC, Roberts JP, et al. Biliary complications of reduced-organ liver transplantation. Liver Transplant Surg 1998;4:343-9.
14. Bartosh SM, Alonso EM, Whitington PF. Renal outcomes in pediatric liver transplantation. Clin Transplant 1997; 5:354-60.
15. McDiarmid SV. Renal function in pe- diatric liver transplant patients. Kid- ney Int 1996;53(suppl):S77-84.
16. Meys E, Fontanges E, Fourcade N. Bone loss after orthotopic liver trans- plantation. Am J Med 1994;97:445-50.
17. Kobasigawa JA, Kasiske BL. Hyper- lipidemia in solid organ transplanta- tion. Transplantation 1997;63:331-8.
261
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