Liver transplantation in children: past, present and future.

The tremendous progress accomplished during the last twenty years in liver transplantation has permitted the treatment of infants and children who can now benefit from a new organ before an and stage liver disease. The main indications in paediatrics are congenital biliary obstructions, metabolic disorders leading to cirrhosis and fulminant hepatitis. Nevertheless, in the future, other treatments for metabolic and viral diseases will be possible. The shortage of paediatric donors has been partially alleviated by the method of reduced liver, however the general shortage of organs has led to the use of split livers and living-related donors. Overall survival in children can be expected above 80%. In Geneva, 15 paediatric patients were transplanted, 3 twice, over a 6-year period with a survival rate of 86%. The indications were the same as in other centers. Acute rejection was often noted, but easily treated, mainly by steroid bolus. 13 patients have been followed up for more than 1 year and have had satisfactory growth and normal liver function tests. Whenever a liver transplantation is performed, paediatricians have hopes and fears; hope of an improvement of growth and neuro-psychological developments and fears of side effects of immunosuppressive drugs, such as renal function impairment or lymphoproliferative syndrome. The future in the field of liver transplantation will require new methods, with the aim of decreasing the necessity of whole organ transplantation. This includes alternative treatments for metabolic disorders, transplantation of isolated hepatocytes, possibly after gene therapy, and the use of an artificial liver. Some of this future is already present.