Biliary complications in pediatric living donor liver transplantation: An international multicenter analysis of risk and prognostic factors

Biliary reconstruction is often considered the Achilles' heel of liver transplantation, yet risk factors and outcomes remain poorly defined, particularly in pediatric living donor liver transplantation (LDLT). This international multicenter study aims to identify predictors of biliary complications and evaluate their impact on long-term outcomes. 2,665 pediatric patients who underwent LDLT between January 2019 and December 2023 across 19 centers were included. Multivariable logistic regression was performed to identify risk factors, while time-dependent Cox models were used to assess impact on survival. The median recipient age was 11 months (IQR: 6.3-34.6) and biliary atresia was the most common diagnosis (59.7%). Bile leak and anastomotic stricture occurred in 3.6% (n=97) and 1.9% (n=51) of patients, respectively. For bile leak, higher donor BMI was an independent predictor (OR 1.09 per kg/m², 95% CI: 1.02-1.17). For anastomotic strictures, longer cold ischemia time was a significant predictor (OR 1.36 per hour, 95% CI: 1.03-1.79). Bile leak (aHR 4.39, 95% CI: 1.04-18.60) and biliary stricture (aHR 6.26, 95% CI: 1.58-24.80) were associated with worse graft survival. Patient survival was not significantly impacted by bile leak and stricture. Early complications more often required surgery, but survival and failure-to-rescue rates were similar regardless of treatment approach. Ultimately, bile leak and anastomotic stricture remain significant threats to graft survival. The identified risk factors offer insights for risk stratification and prevention strategies aimed at improving outcomes in children undergoing LDLT.

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Publication Details

Journal
Liver Transplantation
Published
2026-09-14
DOI
https://doi.org/10.1097/lvt.0000000000000998
Primary Topic
Organ Transplantation Techniques and Outcomes
Type
article
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article

Biliary complications in pediatric living donor liver transplantation: An international multicenter analysis of risk and prognostic factors

Elvan Onur Kırımker, Samir Abu‐Gazala, Stefan Schneeberger, Uta Herden et al.
Liver Transplantation
Organ Transplantation Techniques and Outcomes
article

Biliary complications in pediatric living donor liver transplantation: An international multicenter analysis of risk and prognostic factors

Elvan Onur Kırımker, Samir Abu‐Gazala, Stefan Schneeberger, Uta Herden, Nicolás Goldaracena, Moritz Schmelzle, Ian Leipnitz, Vidyadhar Padmakar Mali, Grzegorz Kowalewski, Vasanthakumar Gunasekaran, Katryn N. Furuya, Kaihang Wang, Lutz Fischer, Elizabeth B. Rand, Bryanna Domenick, Yuji Soejima, Dimitri A. Raptis, F. J. Krendl, Blayne A. Sayed, Kim Olthoff, Alfred Kow, Piotr Kaliciński, George V. Mazariegos, Stephen Dunn, Cornelius J. van Beekum, Dieter C. Broering, Vicky L. Ng, Deniz Balci, Debra L. Sudan, Itsuko Chih-Yi Chen, Yuan Liu, Mureo Kasahara, Mohamed Rela, Seisuke Sakamoto, Pierre-Alain Clavien, Chao-Long Chen, Omid Madadi-Sanjani, Silvio Nadalin, Hajime Uchida, Zhihao Li, Qiang Xia, Ashwin Rammohan
article en

Abstract

Biliary reconstruction is often considered the Achilles' heel of liver transplantation, yet risk factors and outcomes remain poorly defined, particularly in pediatric living donor liver transplantation (LDLT). This international multicenter study aims to identify predictors of biliary complications and evaluate their impact on long-term outcomes. 2,665 pediatric patients who underwent LDLT between January 2019 and December 2023 across 19 centers were included. Multivariable logistic regression was performed to identify risk factors, while time-dependent Cox models were used to assess impact on survival. The median recipient age was 11 months (IQR: 6.3-34.6) and biliary atresia was the most common diagnosis (59.7%). Bile leak and anastomotic stricture occurred in 3.6% (n=97) and 1.9% (n=51) of patients, respectively. For bile leak, higher donor BMI was an independent predictor (OR 1.09 per kg/m², 95% CI: 1.02-1.17). For anastomotic strictures, longer cold ischemia time was a significant predictor (OR 1.36 per hour, 95% CI: 1.03-1.79). Bile leak (aHR 4.39, 95% CI: 1.04-18.60) and biliary stricture (aHR 6.26, 95% CI: 1.58-24.80) were associated with worse graft survival. Patient survival was not significantly impacted by bile leak and stricture. Early complications more often required surgery, but survival and failure-to-rescue rates were similar regardless of treatment approach. Ultimately, bile leak and anastomotic stricture remain significant threats to graft survival. The identified risk factors offer insights for risk stratification and prevention strategies aimed at improving outcomes in children undergoing LDLT.

Liver Transplantation
Bahçeşehir University (TR), University Health Network (CA), Alfred I. duPont Hospital for Children (US), Children's Hospital of Philadelphia (US), University of Wisconsin–Madison (US), Shinshu University (JP), Innsbruck Medical University (AT), Ankara University (TR), University of Auckland (NZ), Universität Hamburg (DE), National University of Singapore (SG), Duke University (US), Shanghai Jiao Tong University (CN), Universität Innsbruck (AT), University of Zurich (CH), Renji Hospital (CN), King Faisal Specialist Hospital & Research Centre (SA), Hospital for Sick Children (CA), Medizinische Hochschule Hannover (DE), Kaohsiung Chang Gung Memorial Hospital (TW), University Medical Center Hamburg-Eppendorf (DE), Children's Memorial Health Institute (PL), Duke Medical Center (US), Children's Hospital of Pittsburgh (US), National Center For Child Health and Development (JP), National University Hospital (SG), University of Tübingen (DE)
Good health and well-being
Openalex Percentile: Top 9%
Organ Transplantation Techniques and Outcomes
DOISourceOpenAlex
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