Pediatric Liver Transplantation in Countries with Low Resources: Medical Issues Before and After Transplant

  • Vidyut Bhatia
  • Akshay Kapoor
  • Sarath Gopalan
  • Anupam Sibal
Reference work entry
Part of the Organ and Tissue Transplantation book series (OTT)


Liver transplantation is now a well-established therapy for children with acute liver, end-stage liver disease, and a variety of metabolic disorders. The first successful liver transplant in India was performed in an 18-month-old child with end-stage liver disease secondary to biliary atresia in November 1998 at Apollo Hospitals, New Delhi. That child remains well 17 years posttransplantation. Over the years, the indications have expanded, and successful living-related liver transplantation has been reported for acute liver failure and metabolic disorders such as Crigler-Najjar syndrome. Age and size are no longer barriers as babies as young as 6 months have been transplanted. Excellent survival figures have been reported in children weighing less than 7.5 kg. Fathers have now started to come forward as donors. Children from different parts of India and more than 20 countries have been transplanted. The average cost of a pediatric transplant in India is 23,000 to 27,000 USD. This is only about one fifth to one tenth the cost in the West. With 5-year survival rates of 90%, India has now become a major center for LT for international patients as well. With increasing acceptance of LT among the medical community and the public at large, there is now potential for the number of liver transplants to increase significantly so as to offer hope to the thousands of children who suffer from liver failure.


Liver transplant Biliary atresia Acute liver failure Immunosuppression Tolerance Hepatocyte transplantation Complications Posttransplant metabolic syndrome 


  1. Al-Hussaini A, Tredger JM, Dhawan A (2005) Immunosuppression in pediatric liver and intestinal transplantation: a closer look at the arsenal. J Pediatr Gastroenterol Nutr 41(2):152–165
  2. Banff Working Group on Liver Allograft P (2012) Importance of liver biopsy findings in immunosuppression management: biopsy monitoring and working criteria for patients with operational tolerance. Liver Transpl 18(10):1154–1170. CrossRefGoogle Scholar
  3. Bhatia V, Bavdekar A, Matthai J, Waikar Y, Sibal A (2014) Management of neonatal cholestasis: consensus statement of the Pediatric Gastroenterology Chapter of Indian Academy of Pediatrics. Indian Pediatr 51(3):203–210CrossRefPubMedGoogle Scholar
  4. Bhatia V, Bavdekar A, Yachha SK (2013) Management of acute liver failure in infants and children: consensus statement of the pediatric gastroenterology chapter, Indian academy of pediatrics. Indian Pediatr 50(5):477–482CrossRefPubMedGoogle Scholar
  5. Bhatia V, Sibal A (2013) Are fathers catching up with mothers in liver donation? Indian Pediatr 50(1):158CrossRefPubMedGoogle Scholar
  6. Cherian PT, Mishra AK, Bangaari A, Kota V, Sathyanarayanan M, Raya R, Rela M (2015) Better innovate than compromise: a novel hepatic outflow reconstruction technique in pediatric living donor liver transplantation. Pediatr Transplant 19(3):E56–E61. CrossRefPubMedGoogle Scholar
  7. Dagher M, Ng VL, Carpenter A, Rankin S, De Angelis M, Avitzur Y, Mouzaki M (2015) Overweight, central obesity, and cardiometabolic risk factors in pediatric liver transplantation. Pediatr Transplant 19(2):175–181. CrossRefPubMedGoogle Scholar
  8. Dell-Olio D, Kelly DA (2009) Calcineurin inhibitor minimization in pediatric liver allograft recipients. Pediatr Transplant 13(6):670–681. CrossRefPubMedGoogle Scholar
  9. Devarbhavi H, Dierkhising R, Kremers WK, Sandeep MS, Karanth D, Adarsh CK (2010) Single-center experience with drug-induced liver injury from India: causes, outcome, prognosis, and predictors of mortality. Am J Gastroenterol 105(11):2396–2404. CrossRefPubMedGoogle Scholar
  10. Duffy JP, Kao K, Ko CY, Farmer DG, McDiarmid SV, Hong JC, Venick RS, Feist S, Goldstein L, Saab S, Hiatt JR, Busuttil RW (2010) Long-term patient outcome and quality of life after liver transplantation: analysis of 20-year survivors. Ann Surg 252(4):652–661PubMedGoogle Scholar
  11. Fagiuoli S, Colli A, Bruno R, Craxi A, Gaeta GB, Grossi P, Mondelli MU, Puoti M, Sagnelli E, Stefani S, Toniutto P, Burra P, Group AST (2014) Management of infections pre- and post-liver transplantation: report of an AISF consensus conference. J Hepatol 60(5):1075–1089. CrossRefPubMedGoogle Scholar
  12. Feier FH, da Fonseca EA, Seda-Neto J, Chapchap P (2015) Biliary complications after pediatric liver transplantation: risk factors, diagnosis and management. World J Hepatol 7(18):2162–2170. CrossRefPubMedPubMedCentralGoogle Scholar
  13. Feltracco P, Barbieri S, Cillo U, Zanus G, Senzolo M, Ori C (2015) Perioperative thrombotic complications in liver transplantation. World J Gastroenterol 21(26):8004–8013. CrossRefPubMedPubMedCentralGoogle Scholar
  14. Ferrarese A, Zanetto A, Gambato M, Bortoluzzi I, Nadal E, Germani G, Senzolo M, Burra P, Russo FP (2016) Liver transplantation for viral hepatitis in 2015. World J Gastroenterol 22(4):1570–1581. CrossRefPubMedPubMedCentralGoogle Scholar
  15. Ganschow R, Nolkemper D, Helmke K, Harps E, Commentz JC, Broering DC, Pothmann W, Rogiers X, Hellwege HH, Burdelski M (2000) Intensive care management after pediatric liver transplantation: a single-center experience. Pediatr Transplant 4(4):273–279CrossRefPubMedGoogle Scholar
  16. Guru FR, Sibal A (2010) Liver transplant for Crigler-Najjar syndrome. Indian Pediatr 47(3):285–286PubMedGoogle Scholar
  17. Holty JE, Gould MK, Meinke L, Keeffe EB, Ruoss SJ (2009) Tuberculosis in liver transplant recipients: a systematic review and meta-analysis of individual patient data. Liver Transpl 15(8):894–906. CrossRefPubMedGoogle Scholar
  18. Holty JE, Sista RR (2009) Mycobacterium tuberculosis infection in transplant recipients: early diagnosis and treatment of resistant tuberculosis. Curr Opin Organ Transplant 14(6):613–618. CrossRefPubMedGoogle Scholar
  19. Huisman EJ, Trip EJ, Siersema PD, van Hoek B, van Erpecum KJ (2011) Protein energy malnutrition predicts complications in liver cirrhosis. Eur J Gastroenterol Hepatol 23(11):982–989. CrossRefPubMedGoogle Scholar
  20. Kapoor A, Sibal A (2015) Immunization issues in children undergoing liver transplantation. Indian Pediatr 52(8):716–717PubMedGoogle Scholar
  21. Kasahara M, Umeshita K, Inomata Y, Uemoto S, Japanese Liver Transplantation S (2013) Long-term outcomes of pediatric living donor liver transplantation in Japan: an analysis of more than 2200 cases listed in the registry of the Japanese Liver Transplantation Society. Am J Transplant 13(7):1830–1839. CrossRefPubMedGoogle Scholar
  22. Kaur S, Wadhwa N, Sibal A, Jerath N, Sasturkar S (2011) Outcome of live donor liver transplantation in Indian children with bodyweight <7.5 kg. Indian Pediatr 48(1):51–54CrossRefPubMedGoogle Scholar
  23. Kelly D, Jara P, Rodeck B, Lykavieris P, Burdelski M, Becker M, Gridelli B, Boillot O, Manzanares J, Reding R (2004) Tacrolimus and steroids versus ciclosporin microemulsion, steroids, and azathioprine in children undergoing liver transplantation: randomised European multicentre trial. Lancet 364(9439):1054–1061. CrossRefPubMedGoogle Scholar
  24. Kelly DA, Bucuvalas JC, Alonso EM, Karpen SJ, Allen U, Green M, Farmer D, Shemesh E, McDonald RA, American Association for the Study of Liver D, American Society of T (2013) Long-term medical management of the pediatric patient after liver transplantation: 2013 practice guideline by the American Association for the Study of Liver Diseases and the American Society of Transplantation. Liver Transpl 19(8):798–825. CrossRefPubMedGoogle Scholar
  25. Kerkar N, Yanni G (2016) ‘De novo’ and ‘recurrent’ autoimmune hepatitis after liver transplantation: a comprehensive review. J Autoimmun 66:17–24. CrossRefPubMedGoogle Scholar
  26. Madhwal S, Atreja A, Albeldawi M, Lopez R, Post A, Costa MA (2012) Is liver transplantation a risk factor for cardiovascular disease? A meta-analysis of observational studies. Liver Transpl 18(10):1140–1146. CrossRefPubMedGoogle Scholar
  27. Malhotra S, Sibal A, Bhatia V, Kapoor A, Gopalan S, Seth S, Jerath N, Wadhawan M, Gupta S (2015) Living related liver transplantation for biliary atresia in the last 5 years: experience from the first liver transplant program in India. Indian J Pediatr 82(10):884–889. CrossRefPubMedGoogle Scholar
  28. Mieli-Vergani G, Vergani D (2016) Sclerosing cholangitis in children and adolescents. Clin Liver Dis 20(1):99–111. CrossRefPubMedGoogle Scholar
  29. Mohan N, Karkra S, Jolly AS, Vohra V, Mohanka R, Rastogi A, Soin AS (2015) First living-related liver transplant to cure factor VII deficiency. Pediatr Transplant 19(6):E135–E138. CrossRefPubMedGoogle Scholar
  30. Montano-Loza AJ (2014a) Clinical relevance of sarcopenia in patients with cirrhosis. World J Gastroenterol 20(25):8061–8071. CrossRefPubMedPubMedCentralGoogle Scholar
  31. Montano-Loza AJ (2014b) Severe muscle depletion predicts postoperative length of stay but is not associated with survival after liver transplantation. Liver Transpl 20(11):1424. CrossRefPubMedGoogle Scholar
  32. Narasimhan KL, Chowdhry SK, Vaiphei K, Samujh R, Mahajan JK, Thapa BR, Rao KL (2001) Outcome of biliary atresia from Chandigarh: results of a prospective analysis. Indian Pediatr 38(10):1144–1148PubMedGoogle Scholar
  33. Nash KL, Collier JD, French J, McKeon D, Gimson AE, Jamieson NV, Wallwork J, Bilton D, Alexander GJ (2008) Cystic fibrosis liver disease: to transplant or not to transplant? Am J Transplant 8(1):162–169. PubMedGoogle Scholar
  34. Nijland ML, Kersten MJ, Pals ST, Bemelman FJ, Ten Berge IJ (2016) Epstein-barr virus-positive posttransplant lymphoproliferative disease after solid organ transplantation: pathogenesis, clinical manifestations, diagnosis, and management. Transplant Direct 2(1):e48. CrossRefPubMedGoogle Scholar
  35. Oh SH, Kim KM, Kim DY, Kim Y, Song SM, Lee YJ, Park SJ, Yoon CH, Ko GY, Sung KB, Hwang GS, Choi KT, Yu E, Song GW, Ha TY, Moon DB, Ahn CS, Kim KH, Hwang S, Park KM, Lee YJ, Lee SG (2014) Improved outcomes in liver transplantation in children with acute liver failure. J Pediatr Gastroenterol Nutr 58(1):68–73. CrossRefPubMedGoogle Scholar
  36. Okada N, Sanada Y, Hirata Y, Yamada N, Wakiya T, Ihara Y, Urahashi T, Miki A, Kaneda Y, Sasanuma H, Fujiwara T, Sakuma Y, Shimizu A, Hyodo M, Yasuda Y, Mizuta K (2015) The impact of rituximab in ABO-incompatible pediatric living donor liver transplantation: the experience of a single center. Pediatr Transplant 19(3):279–286. CrossRefPubMedGoogle Scholar
  37. Pandit A, Mathew LG, Bavdekar A, Mehta S, Ramakrishnan G, Datta S, Liu YF (2015) Hepatotropic viruses as etiological agents of acute liver failure and related-outcomes among children in India: a retrospective hospital-based study. BMC Res Notes 8:381. CrossRefPubMedPubMedCentralGoogle Scholar
  38. Polson J (2008) Assessment of prognosis in acute liver failure. Semin Liver Dis 28(2):218–225. CrossRefPubMedGoogle Scholar
  39. Poonacha P, Sibal A, Soin AS, Rajashekar MR, Rajakumari DV (2001) India’s first successful pediatric liver transplant. Indian Pediatr 38(3):287–291PubMedGoogle Scholar
  40. Ramachandran P, Safwan M, Reddy MS, Rela M (2015) Recent trends in the diagnosis and management of biliary atresia in developing countries. Indian Pediatr 52(10):871–879CrossRefPubMedGoogle Scholar
  41. Rao S, D’Cruz AL, Aggarwal R, Chandrashekar S, Chetan G, Gopalakrishnan G, Dunn S (2011) Pediatric liver transplantation: a report from a pediatric surgical unit. J Indian Assoc Pediatr Surg 16(1):2–7. CrossRefPubMedPubMedCentralGoogle Scholar
  42. Safwan M, Ramachandran P, Reddy MS, Shanmugam N, Rela M (2016) Living donor liver transplantation for biliary atresia – an Indian experience. Pediatr Transplant. Google Scholar
  43. Sakhuja V, Ramachandran R, Kohli HS, Jha V, Gupta KL, Rathi M, Joshi K, Nada R, Sharma A, Minz M (2013) Spectrum of lymphoproliferative disorders following renal transplantation in North India. Indian J Nephrol 23(4):287–291. CrossRefPubMedPubMedCentralGoogle Scholar
  44. Saland JM, Emre SH, Shneider BL, Benchimol C, Ames S, Bromberg JS, Remuzzi G, Strain L, Goodship TH (2006) Favorable long-term outcome after liver-kidney transplant for recurrent hemolytic uremic syndrome associated with a factor H mutation. Am J Transplant 6(8):1948–1952. CrossRefPubMedGoogle Scholar
  45. Sanghai SR, Shah I, Bhatnagar S, Murthy A (2009) Incidence and prognostic factors associated with biliary atresia in western India. Ann Hepatol 8(2):120–122PubMedGoogle Scholar
  46. Saraf V, Pande S, Gopalakrishnan U, Balakrishnan D, Menon RN, Sudheer OV, Dhar P, Sudhindran S (2015) Acute liver failure due to zinc phosphide containing rodenticide poisoning: Clinical features and prognostic indicators of need for liver transplantation. Indian J Gastroenterol Off J Indian Soc Gastroenterol 34(4):325–329. CrossRefGoogle Scholar
  47. Seda-Neto J, Antunes da Fonseca E, Pugliese R, Candido HL, Benavides MR, Carballo Afonso R, Neiva R, Porta G, Miura IK, Teng HW, Iwase FC, Rodrigues ML, Carneiro de Albuquerque LA, Kondo M, Chapchap P (2016) Twenty years of experience in pediatric living donor liver transplantation: focus on hepatic artery reconstruction, complications, and outcomes. Transplantation 100(5):1066–1072. CrossRefPubMedGoogle Scholar
  48. Shanmugam NP, Dhawan A (2011) Selection criteria for liver transplantation in paediatric acute liver failure: the saga continues. Pediatr Transplant 15(1):5–6. CrossRefPubMedGoogle Scholar
  49. Sibal A, Bhatia V, Gupta S (2013) Fifteen years of liver transplantation in India. Indian Pediatr 50(11):999–1000CrossRefPubMedGoogle Scholar
  50. Sindhi R (2003) Sirolimus in pediatric transplant recipients. Transplant Proc 35(3 Suppl):113S–114SCrossRefPubMedGoogle Scholar
  51. Singhal A, Srivastava A, Goyal N, Vij V, Wadhawan M, Bera M, Gupta S (2009) Successful living donor liver transplant in a child with Abernethy malformation with biliary atresia, ventricular septal defect and intrapulmonary shunting. Pediatr Transplant 13(8):1041–1047. CrossRefPubMedGoogle Scholar
  52. Soin A, Kumaran V, Mohanka R, Mehta N, Mohan N, Nundy S (2010) Bridge venoplasty: a new technique to simplify venous outflow reconstruction in living donor domino liver transplantation. Surgery 148(1):155–157. CrossRefPubMedGoogle Scholar
  53. Soin A, Pahari H, Goja S, Bhangui P, Rastogi A (2016) Targeting the Achilles’ heel of adult living donor liver transplant: corner-sparing sutures with mucosal eversion technique of biliary anastomosis. Liver Transpl 22(6):862–863. CrossRefPubMedGoogle Scholar
  54. Starzl TE, Esquivel C, Gordon R, Todo S (1987) Pediatric liver transplantation. Transplant Proc 19(4):3230–3235PubMedPubMedCentralGoogle Scholar
  55. Tandon P, Ney M, Irwin I, Ma MM, Gramlich L, Bain VG, Esfandiari N, Baracos V, Montano-Loza AJ, Myers RP (2012) Severe muscle depletion in patients on the liver transplant wait list: its prevalence and independent prognostic value. Liver Transpl 18(10):1209–1216. CrossRefPubMedGoogle Scholar
  56. Travasso C (2013) Immunisation coverage in India remains too low, study finds. BMJ 347:f5573. CrossRefPubMedGoogle Scholar
  57. Turner AP, Knechtle SJ (2013) Induction immunosuppression in liver transplantation: a review. Transplant Int Off J Eur Soc Organ Transplant 26(7):673–683. CrossRefGoogle Scholar
  58. Wadhawan M, Gupta S, Goyal N, Taneja S, Kumar A (2013) Living related liver transplantation for hepatitis B-related liver disease without hepatitis B immune globulin prophylaxis. Liver Transpl 19(9):1030–1035. CrossRefPubMedGoogle Scholar
  59. Wadhawan M, Gupta S, Goyal N, Vasudevan KR, Makki K, Dawar R, Sardana R, Lal N, Kumar A (2012) Cytomegalovirus infection: its incidence and management in cytomegalovirus-seropositive living related liver transplant recipients: a single-center experience. Liver Transpl 18(12):1448–1455. CrossRefPubMedGoogle Scholar
  60. Yazigi NA (2013) Long term outcomes after pediatric liver transplantation. Pediatr Gastroenterol Hepatol Nutr 16(4):207–218. CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Vidyut Bhatia
    • 1
  • Akshay Kapoor
    • 1
  • Sarath Gopalan
    • 1
  • Anupam Sibal
    • 1
    • 2
  1. 1.Apollo Center for Advanced PediatricsIndraprastha Apollo HospitalsNew DelhiIndia
  2. 2.Faculty of Medicine and Health SciencesMacquarie UniversitySydneyAustralia

Section editors and affiliations

  • Ashley L J D'Cruz
    • 1
  1. 1.Solid Organ Transplant ProgramNarayana Hrudayalaya Woman and Child InstituteBangaloreIndia

Personalised recommendations