Liver transplant for paediatric acute liver failure: insights from a newly established paediatric liver transplant program in a developing country

Liver transplantation (LT) is the cure for medically refractory acute liver failure (ALF). In resource-limited settings, establishing a paediatric LT program for paediatric ALF (PALF) encounters unique challenges. This study describes the initial 5-year experience of the paediatric LT (PLT) program at the Colombo North Centre for Liver Diseases (CNCLD), Sri Lanka (March 2020 to March 2025). Data from all PALF cases (n = 35) were retrospectively analyzed. A total of 120 children were referred to LT and 35 (29%) were due to ALF. Median age was 8 years 9 months (range: 2 months – 13 years) and 63% were male. Common etiologies included Wilson disease (23%) and autoimmune liver disease (20%). Spontaneous recovery occurred in 43% (15) while 34% (12/35) underwent LT and 23% (8) died without LT. Of 12 transplant recipients, 8/12 received living donor liver transplants (LDLT) (5/8 related donors, 3/8 altruistic – Buddhist monks), and 4/12 received deceased donor liver transplants (DDLT). The median time from listing to transplant was 72 h. Post-transplant survival in one and three months was 75% and 66% respectively. There were three immediate post-LT deaths due to primary non-function of deceased donor grafts. PALF comprised a substantial proportion of referrals in Sri Lanka’s nascent PLT program. The majority of LT for PALF were LDLT with favorable outcomes compared to DDLT. Optimum utilization of a budding LT program with timely referrals and availability of altruistic donors have played key roles in the success of the PLT program in a resource limited setting. What is already known on this topic? Paediatric liver transplantation for acute liver failure is challenging and outcomes are less favourable compared to elective liver transplants. What this study adds? This study reports favourable liver transplant outcomes for PALF achieved through a budding liver transplant programme at a resource limited setting along with the unique factors which helped to overcome the challenges faced. How this study affects research, study, and practice? This study affects the practice of paediatric liver transplantation by encouraging the use of more living donors for PALF. Parents of the paediatric patients are younger, healthier, and committed to donate for their children while altruistic donors would bridge the donor gap. Further timely referrals of PALF with the trust earned by a budding LT programme would allow adequate time to escalate for emergency liver transplant which will result in good outcomes. Sri Lanka has a well-developed primary care structure. However specialized tertiary care services are still developing. Pediatric LT commenced almost decade after adult LT. This delay was due to lack of essential trained members in LT multidisciplinary (MDT) team in Sri Lanka. The key specialists; pediatric hepatologist, liver transplant surgeons and anesthetist were trained to commence the program and later interventional radiologist, pathologist and allied health staff such as nutritional therapists, transfusion specialists, pharmacists and physiotherapists with local and overseas experience were added. Trained MDT liver transplant team is the ground stone to build on a pediatric liver transplant team. Like the assembly of the MDT team, infrastructure was gradually established using the clinical success. Initially LT was performed in general theatres, ICU and wards. However later a dedicated unit was built for liver transplant. Trained MDT liver transplant team is the ground stone to build on a pediatric liver transplant team as the necessary infrastructure, consumables and patient aids can be developed subsequently. This study provides valuable insights for many beginners in paediatric liver transplantation to use a country’s unique strengths to uplift the health care systems to a modern level despite being at a resource limited setting.