Pediatric Split Liver Transplantation Using Elderly Donors W. Petz, M. Spada, A. Sonzogni, M. Colledan, A. Segalin, A. Lucianetti, A. Bertani, M. Guizzetti, G. Peloni, and B. Gridelli L IVERS from donors over 50 years of age are often considered inadequate for split liver transplantation (SLTx), although age alone has not been demonstrated to be a contraindication to liver procurement. 1–4 In our cen- ter, we applied a liberal policy of SLTx, to better meet the needs of children under our care. We therefore evaluated for SLTx all the donors referred to our unit, not considering age alone an exclusion criterion. 5 In this study we retro- spectively analyzed our series of pediatric in situ SLTx to compare the results of the use of livers from donors over 50 years of age to those obtained with grafts procured from younger donors. PATIENTS AND METHODS Between October 1997 and July 2000, we performed 105 liver transplantations in 95 children. Of these, 61 were primary in situ SLTx, with 56 left lateral segments, 3 left lobes, and 2 extended right grafts. Recipients comprised 32 males and 29 females, ranging in age from 0.1 to 21 years (median 1.2 years) and in weight from 2.8 to 55 kg (median 8.7 kg). Most frequent indication for liver transplantation was extrahepatic biliary atresia, diagnosed in 38 patients (62%); other indications were cholestatic liver diseases (n = 3), metabolic diseases (n = 2), cancer (n = 6), acute hepatic failure (n = 3), secondary cirrhosis (n = 5), and others (n = 4). Forty-seven patients (77%) were United Network for Organ Shar- ing (UNOS) status 3 at time of transplantation, 9 (15%) were UNOS status 2, and 5 (8%) were UNOS status 1. The liver of every donor assigned to our center was evaluated for elective transplan- tation when at least an ABO-compatible recipient with a donor- to-recipient body weight ratio (DRWR) 12 was wait-listed. The in situ split liver procedure, described by Rogiers et al, 6 was always performed with surgeons from a collaborating center, where the other split liver graft was transplanted. In the evaluation of donors over 50 years of age, only hemodynamically stable donors, with normal liver function tests and metabolic status, and without macroscopically evident steatosis were chosen. Transplantation techniques have been described in detail elsewhere. 5 Immunosuppression was with cyclosporine-based (n = 37) or with tacrolimus-based (n = 24) dual therapy. Cyclosporine (CyA) target plasma level was 250 to 350 ng/mL during the first 2 weeks after LTx, 200 to 300 ng/mL from week 3 to week 12, 150 to 200 ng/mL from month 4 to month 12, and 50 to 150 ng/mL thereafter. Tacrolimus target whole-blood level was 10 to 20 ng/mL in the first 2 weeks, 10 to 15 ng/mL from week 3 to week 4, 5 to 15 ng/mL from month 2 to month 3, and 5 to 10 ng/mL thereafter. Patients who experienced biopsy-confirmed acute cellular rejection were treated with IV steroid boluses. In case of steroid-resistant rejection, patients were switched from CyA to tacrolimus. Patients were compared in terms of patient and graft survival rates, morbidity, graft functional recovery, and incidence of acute rejection. More- over, percutaneous core liver biopsies, performed in case of graft dysfunction, were reevaluated for histopathological significant dif- ferences between recipients of grafts from donors over and below 50 years of age. RESULTS Sixty-nine split liver procurements were commenced: in nine cases (12%) the split liver procurement could not be completed, because of anatomical or dimensional reasons in six cases, donor hemodynamic instability in two cases, and for the presence of an undiagnosed tumor in one case. Three of these donors were over 50 years of age. Except for the donor with unsuspected malignancies, in all the other cases the whole liver was procured and transplanted into an adult recipient. In the remaining 61 donors, in situ SLTx was performed: in 49 (80%) from a donor below 50 years of age (group A) and 12 (20%) from a donor over () 50 years of age (group B). Median donor age was 17 years in group A (range, 2 to 45 years) and 56 years in group B (range, 50 to 62 years). Donor demographics were comparable in the two groups (A vs B) in terms of liver function (median ALT: 33 vs 21 UI/L), metabolic status (median Na + : 145 vs 153 mEq/L), amine requirement (median dopamine: 6 vs 6 /kg/min) and ICU stay (median stay: 2 vs 1 day). Recipient median age and weight were 1.3 years and 8.7 kg, respectively, in group A and 0.8 years and 8.8 kg in group B, respectively. Median cold ischemia time and intraoperative red blood cell (RBC) transfusion were 343 minutes and 15 mL of packed RBC/kg of recipient body weight in group A and 330 minutes and 17 mL of packed RBC/kg in group B, respectively. At the time of transplan- tation, in group A, 38 patients (78%) were UNOS status 3, 6 patients (12%) were UNOS status 2, and 5 patients (10%) were UNOS status 1. In group B, 7 patients (58%) were UNOS status 3 and 5 patients (42%) were UNOS status 2. From the Liver Transplantation Center, ; and the Department of Pathology, Ospedali Riuniti di Bergamo, Bergamo, Italy Address reprint requests to Marco Spada, MD, Chirurgia 3, Ospedali Riuniti, Largo Barozzi 1, 24128 Bergamo, Italy. © 2001 by Elsevier Science Inc. 0041-1345/01/$–see front matter 655 Avenue of the Americas, New York, NY 10010 PII S0041-1345(00)02808-6 Transplantation Proceedings, 33, 1361–1363 (2001) 1361