Title: Impact of graft size matching on graft survival in pediatric whole liver transplantations in recipients with biliary atresia weighing less than 10 kg  

Source: Transplantation Proceedings 2026, Feb 27. [E–publication]

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Date of publication: February 2026

Publication type: Retrospective study

Abstract: Background: The size mismatch between a liver graft and the recipient can result in complications and poor survival after pediatric whole liver transplantation (WLT).

Methods: A retrospective study was designed, which included 114 recipients. Multiple variable predictors of graft loss suggested the graft-to-native-liver weight ratio (GNLWR), and then the GNLWR was calculated and categorized into 2 groups. The demographic, operation, complications, and survival analysis data were collected and compared.

Results: Group 1 with a GNLWR < 0.41 had a higher incidence of hepatic artery thrombosis (HAT) and lower graft survival in the first 3 months (70.4% vs 96.6%, P < .001). Patient survival at 3 months was significantly different between groups (85.2% vs 97.7%, P = .010). As for the graft survival rate, it was 70.4% for group 1 at both 1 and 3 years, whereas it was 94.2% for group 2 at both 1 and 3 years. Additionally, the patient survival rate for group 1 was 85.2% at both 1 and 3 years, whereas for group 2, it was 95.4% at both 1 and 3 years. Further analysis showed the PELD score was the only independent risk factor for graft loss in the group with GNLWR < 0.41. It indicated a worse prognosis when the PELD score was more than 23.5.

Conclusions: A GNLWR of less than 0.41 suggested a poor prognosis for grafts in pediatric WLT recipients with biliary atresia weighing less than 10 kg. Reducing blood transfusions may help improve graft survival.

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Title: Go with the flow: Hepatic hemodynamics impact outcomes in pediatric liver transplant  

Source: Pediatric Transplantation 2026, 30 (3): e70262 

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Date of publication: March 2026 

Publication type: Review article

Abstract: Background: Vascular complications persist as a challenging barrier to pediatric liver transplantation. With an incidence of 5%-10%, portal venous and hepatic arterial thromboses remain a major cause for early graft loss in this population. Real-time evaluation of flow parameters at various time points in the transplant course offers an ability to diagnose and even prevent such complications, and may consequently enhance long-term graft and recipient outcomes.

Methods: This review summarizes clinical studies describing liver hemodynamics in pediatric recipients and the utilization of flow parameters for the hepatic artery, portal vein, and hepatic vein.

Results: Preoperative parameters by doppler ultrasonography (DUS) predict the need for portal vein reconstruction which can assist with perioperative planning. Intraoperatively, real-time assessment of flow parameters predicts vascular complications and assists in evaluating the adequacy of graft inflow modulation (GIM). Postoperative surveillance remains critical to detection of both venous and arterial thrombosis and stenosis, but normal measurement ranges often vary based on patient age, underlying liver disease diagnosis, type of graft, and time from transplantation.

Conclusions: Future studies are needed to evaluate the most effective screening protocols and define intra-operative and post-operative measurements that should prompt surgeons to consider intervention in this vulnerable population.

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Title: Contemporary outcomes of isolated liver and combined liver-lung transplantation for cystic fibrosis in children 

Source: Journal of Pediatric Gastroenterology and Nutrition 2026, Mar 9. [E–publication]

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Date of publication: March 2026

Publication type: Article

Abstract: Objective: To compare isolated liver transplantation (LT) for cystic fibrosis (CF) versus other indications and versus combined liver-lung transplantation (CLLT) for CF in children and identify factors associated with survival.

Methods: We compared clinical and survival data after first isolated LT for CF versus other indications and versus CLLT for CF in children (<18 years) using United Network for Organ Sharing data (02/2002-12/2024).

Results: A total of 157 pediatric CF transplant recipients were included (LT: 145; CLLT: 12). Isolated CF LT recipients had higher total bilirubin (TB) than CLLT (median 1.6 vs. 0.7 mg/dL, p = 0.02). A higher proportion of CF transplant recipients with high TB levels (≥1.5 mg/dL) had ascites, encephalopathy, and required life support compared to those with low TB levels (<1.5 mg/dL). CF LT demonstrated superior patient survival versus CF CLLT (log-rank test, p = 0.02; 5-year: 89.1% vs. 72.2%), but inferior versus non-CF LT (log-rank test, p < 0.001; 5-year: 91.5%). Multivariable Cox regression showed increased risk of patient mortality and liver graft loss in CF CLLT recipients compared to isolated CF LT recipients (hazard ratio [HR] = 2.92, 95% confidence interval [95% CI]: 1.20-7.07, p = 0.02 and HR = 2.56, 95% CI: 1.09-5.98, p = 0.03, respectively) and recipients with higher TB levels (HR = 1.05, 95% CI: 1.01-1.10, p = 0.008 and HR = 1.05, 95% CI: 1.01-1.09, p = 0.008, respectively), when adjusting for recipient age, albumin and international normalized ratio (INR) at time of LT, ICU status, and liver graft type. Multivariable Cox regression of isolated LT recipients showed increased risk of patient mortality (HR = 2.03, 95% CI: 1.41-2.93, p < 0.001) and liver graft loss (HR = 1.54, 95% CI: 1.13-2.11, p = 0.006) for CF compared to non-CF etiologies, when adjusting for recipient age, albumin, INR, and TB at time of LT, ICU status, and liver graft type.

Conclusion: Isolated LT for CF was associated with superior survival compared to CLLT for CF, but inferior survival compared to LT for non-CF indications. Higher TB in CF may be a marker of inferior outcomes post-LT.

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Title: Adenovirus disease following pediatric liver transplantation: 10-year experience from a large pediatric transplant program 

Source: Pediatric Transplantation 2026, 30 (3): e70298

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Date of publication: March 2026  

Publication type: Retrospective cohort study 

Abstract: Background: Human adenovirus in immunocompromised patients can be life-threatening. We describe the prevalence, clinical presentation, and treatment of adenovirus after pediatric liver transplantation at a large transplant center.

Methods: We performed a retrospective cohort study of adenovirus infection in children from 2013 to 2022. We compared incidence, clinical characteristics, and outcomes of post-transplant children by adenovirus treatment status.

Results: Adenovirus disease developed in 26% (84/320) children after liver transplant. Median age at liver transplant was 17.5 months, 48% were female; 50% had biliary atresia. Fever (53%), gastrointestinal symptoms (48%), and hepatitis (41%) were the most common clinical presentations at diagnosis. Median time to adenovirus diagnosis was 80 days (IQR 19-260) with 40% (n = 31/84) identified within 30 days post-transplant. Disseminated adenovirus (≥ 2 organ involvement) occurred in 24% (20/84). Fourteen patients (17%) received cidofovir, and most (13/14, 93%) had DNAemia, compared to 57% untreated patients with DNAemia (p = 0.013). Median peak adenovirus load was 491 805 copies/mL (IQR 24 800-1 900 000) in treated vs. 1000 copies/mL (IQR 595-794 794) in untreated patients (p < 0.001). Overall mortality was 8% (7/84).

Conclusion: The incidence of symptomatic and disseminated adenovirus disease was high in our pediatric liver transplant patients, particularly within 30 days post-transplant. Patients who received cidofovir treatment presented with high viral load and had the highest mortality. There is a critical need for evidence-based guidance for early antiviral management of adenovirus disease after pediatric liver transplant.

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Title: Management of late biliary complications in pediatric liver transplant recipients  

Source: Frontiers in Gastroenterology 2026, Feb 18. [E–publication]

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Date of publication: February 2026  

Publication type: Article 

Abstract: The number of pediatric liver transplant recipients with long-term follow-up exceeding 20 years is steadily increasing. These patients are characterized not only by their extensive medical histories but also by their long future life expectancy. In this context, careful management of post-transplant complications, including biliary issues, is essential. We identified 40 patients from our 193 pediatric transplants performed since the program’s inception in 1995, with more than 20 years of follow-up at our center. Thirteen of these patients developed either early or late biliary complications. Five developed complications within the first post-transplant year, while eight developed late complications, which are the main focus of this study. We detail the management of biliary complications in these patients, providing an in-depth analysis of four case models and an overview of the remaining patients. In addition to the standard interventional options, such as percutaneous bilioplasties and surgical revisions of anastomoses, we identified a subgroup that may benefit from a more conservative approach, provided they are closely monitored through a rigorous follow-up protocol.

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Title: Epstein-Barr virus infection in children with liver transplantation

Source: World Journal of Hepatology 2026, 18 (2): 113686

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Date of publication: February 2026  

Publication type: Review article 

Abstract: Epstein-Barr virus (EBV) infection commonly occurs in children, particularly in developing countries. Most children infected with EBV are asymptomatic, though some develop significant complications, including EBV-associated malignancies, hemophagocytic lymphohistiocytosis, and multiple sclerosis. In immunocompromised children, including those with liver transplantation, EBV infection manifests with a diverse spectrum of presentations, varying from asymptomatic to post-transplant lymphoproliferative disorder, which can evolve into lymphoma. Therefore, close monitoring, early detection, and prompt management are crucial. This review aimed to investigate the pathogenesis and manifestations of EBV in healthy children and those who underwent liver transplantation. The proposed algorithm for early EBV detection and management, along with case studies, is provided to help pediatricians increase their index of suspicion.

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Title: A multivariable model for predicting intraoperative blood loss in pediatric liver transplantation

Source: Livers 2026, 6 (1): 8

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Date of publication: February 2026 

Publication type: Prospective, single-centre observational study

Abstract: Background/Objectives: Intraoperative bleeding remains one of the major challenges in pediatric liver transplantation (PLT), contributing significantly to perioperative morbidity, transfusion-related complications, and prolonged recovery. Although viscoelastic testing has improved intraoperative hemostatic management, there are currently no validated preoperative tools capable of predicting bleeding risk in this vulnerable population.

Methods: We conducted a prospective, single-center observational study including 43 consecutive pediatric patients who underwent orthotopic liver transplantation between May 2008 and August 2009. A comprehensive dataset encompassing demographic, clinical, biochemical, and surgical variables was collected. A multivariable linear regression model was developed to predict intraoperative blood loss (IBL). Variable selection was guided by Mallows’ Cp criterion to ensure optimal model fit and clinical interpretability. Model performance was assessed using adjusted R², diagnostic residual analysis, and internal validation to verify regression assumptions.

Results: Six independent predictors of IBL were identified: presence of ascites, prior abdominal surgery, operative time, baseline fibrinogen concentration, platelet count, and recipient weight. The final model explained 35.2% of IBL variance (adjusted R² = 0.352; F = 7.68; p < 0.001). Model diagnostics confirmed linearity, normal distribution of residuals, and homoscedasticity, supporting its robustness and reliability.

Conclusions: This multivariable model provides an interpretable, clinically applicable framework for individualized preoperative estimation of blood loss in PLT. It may assist in planning perioperative patient blood management strategies and serve as a foundation for future decision-support systems. Limitations include the single-center design and modest sample size; however, internal validation supported the stability and reliability of the model.

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Title: Pediatric liver transplantation for inherited metabolic disease – current challenges

Source: Saudi Journal of Gastroenterology 2026, Mar 6. [E–publication]

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Date of publication: March 2026

Publication type: Review article

Abstract: Liver transplantation (LT) was first introduced in the early 1960s, with early paediatric experience marked by significant technical challenges and high risk. Advances in surgical techniques and immunosuppressive therapy in the late 1970s led to successful paediatric LT outcomes, while continued improvements throughout the 1980s and 1990s have enhanced survival and reduced complications. Current 10-year graft and patient survival rates for elective paediatric indications exceed 90%. Over the past two decades, LT has increasingly been used to treat inherited metabolic diseases (IMDs), which now account for 25-30% of paediatric LT. Initially recommended for tyrosinaemia type 1 in 1978 and later for urea cycle disorders such as ornithine transcarbamylase deficiency, LT can be curative when the metabolic defect is confined to the liver and partially corrective in conditions with extrahepatic involvement. As indications expand and earlier intervention is emphasized, this review examines the role of LT in IMDs, highlighting current concepts, challenges, and controversies.

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Title: Growth in children with biliary atresia before and after liver transplantation: a retrospective analysis  

Source: Frontiers in Pediatrics 2026, Jan 12. [E–publication]

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Date of publication: January 2026

Publication type: Retrospective study 

Abstract: Background: Little is known about the long-term survival and growth outcomes of children following liver transplantation in China. Therefore, we investigated the long-term survival and growth status of children with biliary atresia (BA) before and after liver transplantation and attempted to identify specific influencing factors.

Methods: We included children who underwent liver transplantation for BA at Tianjin First Central Hospital between January 2014 and December 2018. Clinical data, indicators of liver function, growth data, and ascites status were collected for analysis from all patients. Postoperative complications were systematically assessed using a combination of clinical, laboratory, histological, and imaging evaluations. Complications were categorized and graded according to the Clavien-Dindo classification system.

Results: This study included a total of 93 children under 2 years of age who underwent liver transplantation for BA. No significant increase in height was observed six months post-transplantation when compared to pre-transplantation (P = 0.126). A significant increase in the height-for-age Z-score occurred by year 2 (P = 0.001). Preoperative growth was negatively correlated with growth improvement at 2- and 5-years after transplantation (P < 0.001, r = -0.674 and r = -0.774, respectively). The occurrence of biliary complications was significantly associated with impaired catch-up growth post-transplantation (P = 0.008). The weight-for-age Z-score increased significantly over the first two years post-transplantation when compared with that before transplantation (P < 0.001); subsequently, this parameter plateaued and exhibited only minimal changes.

Conclusions: Growth retardation is common in children with BA prior to liver transplantation, with catch-up growth commencing six months post-surgery and peaking after two years. Children with more severe preoperative growth delays exhibited faster postoperative growth. Preoperative growth status exhibited only minimal impact on early liver function recovery post-transplantation.

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Title: Regional anesthesia for pediatric liver transplant patients: a mini review

Source: Pediatric Transplantation 2026, 30 (1): e70258

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Date of publication: January 2026  

Publication type: Review article  

Abstract: Optimizing postoperative analgesia in pediatric liver transplantation remains challenging due to the balance between effective pain control, opioid-related adverse effects, and the risks of neuraxial techniques in coagulopathic patients. Regional anesthesia has gained attention as a potential opioid-sparing adjunct in this setting. This concise review aimed to systematically synthesize evidence on regional anesthesia techniques for pediatric liver transplant recipients. A concise review was conducted in a systematic method following PRISMA principles. Comprehensive searches were performed on February 21, 2025, using PubMed/MEDLINE and Scopus to identify studies evaluating regional anesthesia in pediatric liver transplantation. Inclusion criteria encompassed original studies involving pediatric liver transplant recipients receiving regional analgesia. Two reviewers independently screened titles, abstracts, and full texts, with discrepancies resolved by consensus. Six studies met inclusion criteria, encompassing 55 pediatric liver transplant patients (18 controls). Reported regional techniques included erector spinae plane (ESP) blocks (n = 24), thoracic epidural analgesia (TEA) (n = 4), and quadratus lumborum (QL) blocks (n = 9). Across studies, regional anesthesia was associated with decreased perioperative opioid use, early extubation in the operating room, and faster return of bowel function. ESP and QL blocks demonstrated favorable safety profiles, while TEA-performed only after confirming normal coagulation-was safely implemented without complications. Regional anesthesia may be beneficial as part of multimodal analgesia in carefully selected pediatric liver transplant recipients by reducing opioid exposure and supporting early recovery. However, evidence remains limited by small sample sizes and heterogeneous methodologies. Larger, prospective trials are needed to refine patient selection, establish standardized protocols, and confirm safety and efficacy.

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