Infant versus paediatric liver transplantation: technical and survival outcomes in a single-centre cohort study

Background: Liver transplantation in infancy presents distinct technical and physiological challenges. Size mismatch, small vascular calibre, immunological immaturity, and altered pharmacokinetics of immunosuppressive agents may influence perioperative morbidity, graft function, and long-term survival. We performed a systems-based comparative analysis examining surgical, vascular, renal, infectious, immunological, and pharmacokinetic outcomes in infant liver transplant recipients compared with older paediatric controls.
Methods: This is a retrospective cohort study of paediatric liver transplant recipients at a single national referral centre over a 10-year period (January 2015 to December 2024). Clinical data were extracted from operative records, laboratory systems, radiology reports, and clinic documentation. Recipients were stratified into Infant and Paediatric cohorts according to age at the point of transplant. Outcome measures included early and late vascular complications, post-operative acute kidney injury, sepsis, delayed abdominal closure, delayed graft function, and patient and graft survival. Tacrolimus exposure was analysed longitudinally across various post-transplant phases for therapeutic range attainment.
Results: Between 2015 and 2024, 229 liver transplants (58 infants; 171 paediatric recipients) were performed in 217 patients. Infants were predominantly transplanted for cholestatic liver disease (70·7%), whereas older children had a broader distribution of underlying aetiologies. Infants experienced higher rates of post-operative AKI and were more likely to require delayed abdominal closure or prosthetic mesh-assisted fascial closure. However, these technical challenges were not associated with increased rates of surgical site infection, sepsis, rejection rates, graft loss, or patient mortality. There were no differences in early vascular complication rates were comparable between cohorts, but infant recipients had a significantly higher incidence of late portal vein stenosis. Tacrolimus variability was greatest in the immediate post-operative period among infants; nevertheless, medium- and long-term therapeutic attainment did not differ significantly between groups.
Conclusion: This comparative cohort study demonstrates that although infants experience distinct early technical and pharmacological challenges, medium-term and long-term survival outcomes are equivalent to older paediatric recipients. These findings support the safety of infant liver transplantation while highlighting the importance of early vascular surveillance and optimised immunosuppression targeting.