Liver transplantation in children: Viva

Branch 1: Indications, graft types, and waiting-list priority

The candidate should establish that biliary atresia is the single most common indication for paediatric liver transplantation, accounting for up to half of all cases, and that this infant with a failing Kasai is a classic candidate. A strong candidate lists the accepted indications: synthetic failure, intractable pruritus, growth failure despite nutritional support, recurrent cholangitis, and portal hypertension that is difficult to control. The candidate should also name the other major indication categories: metabolic and genetic disease, acute liver failure, chronic cholestasis and cirrhosis, and liver tumours. ^[1]

If the examiner asks about graft types, the candidate should explain why children rarely receive a whole-organ deceased-donor graft: the small size of the recipient and the scarcity of size-matched paediatric deceased donors mean that most children receive a segmental graft, whether reduced-size, split, or living-donor. The candidate should explain that a left lateral segment from a living donor, typically a parent, fits an infant and shortens waiting time, and that living-donor and split grafts were developed specifically because the smallest infants have the highest waiting-list mortality. The trade-off is donor morbidity and a higher vascular and biliary complication rate. ^[1]

The candidate must then describe the Paediatric End-stage Liver Disease score. It is calculated from five variables: serum bilirubin, the international normalised ratio, serum albumin, growth failure, and age at listing, with additional weight for age under one year. A strong candidate explains the paediatric insight that growth failure is deliberately weighted because malnutrition reflects disease severity in children in a way that no adult variable captures, and that the score prioritises children on the deceased-donor waiting list. The candidate should mention that standardised exception scores exist for conditions whose severity the raw score underestimates, such as metabolic disease and unresectable tumours. ^[3]