Auxiliary Partial Orthotopic Liver Transplantation in Children Under 10 Years Old With Fulminant Hepatic Failure: A Multicenter Experience.

Abstract

Auxiliary partial orthotopic liver transplantation (APOLT) for fulminant hepatic failure (FHF) allows potential withdrawal of lifelong immunosuppression (ISP) following native liver regeneration, which may be advantageous in young children with high regenerative capacity. Despite these potential benefits, APOLT has been rarely used, and long-term outcomes in children under 10 years remain unclear. This study aimed to evaluate perioperative safety, long-term outcomes, and native liver regeneration rates in children under 10 years undergoing APOLT for FHF at major centers in the UK and the USA. We conducted a multicenter international retrospective study using data from King's College Hospital, Columbia University, and the University of Miami. Children under 10 years with FHF who underwent APOLT between 1996 and 2025 were included. Forty-two patients were analyzed. Median age was 3.2 years (interquartile range, 1.69 to 5.89), and 59.5% were males. Etiologies included idiopathic (n = 19), autoimmune hepatitis (n = 8), and adenovirus (n = 7). Left lateral segment grafts were used in 83.3%. No perioperative mortality occurred within 90 days. Perioperative morbidity included hepatic artery thrombosis (7.1%), portal vein thrombosis (4.8%), biliary strictures (7.1%), and bile leaks (2.4%). Median follow-up was 11.1 years (interquartile range, 6.74 to 15.7), with a 25-year overall survival of 97.6%. Native liver regeneration was confirmed in 95.0% (38/40) with successful withdrawal from ISP. Four patients (9.5%) required retransplantation; in 2 of them, APOLT was repeated. Finally, 40 patients underwent APOLT, and 80% are off ISP and 76.2% in the intention-to-treat analysis. APOLT is a safe and effective treatment for patients under 10 years old with FHF, providing excellent long-term survival and a high rate of native liver regeneration.