Primary Versus Post-Kasai Liver Transplantation for Biliary Atresia in Children: A Comparative Living Donor Transplant Experience

Liver transplant (LT) is life-saving for patients with biliary atresia (BA), either as primary LT or post-Kasai portoenterostomy (KPE), but comparative data are limited. The aim was to compare the clinical profile, peri-transplant course, and 3-month post-transplant survival among children of BA with LT primarily or after KPE. In this single-center retrospective study, electronic medical records of all children with BA who underwent LT between January 2016 and December 2021 were included. Demographic, clinical, laboratory parameters, peri-transplant course, and 3-month survival were compared between the primary and post-KPE groups. One hundred children with BA (53% male), with a median age at LT of 12 (range, 11-17) months, including 29% who underwent post-KPE living donor liver transplant (LDLT) were analyzed. Children in the post-KPE group were older at LT (14 [range, 12-14.5] versus 12 [range, 11-16] months), P = 0.004 and had more frequent cholangitis (17.2% vs 1.4%, P = 0.008) before LT. Those with primary LT were older at their first presentation at the time of diagnosis (60 [15-150] vs 45 [21-60] days of life, P < 0.001), and had ascites (78.9% vs 51.7%, P = 0.008) before LT. The pediatric end-stage liver disease (PELD) score was high (26.9 ± 8.2 vs 27.6 ± 9.9, P = 0.78) in both groups at LT. The duration of surgery and post-transplant complications, including bile leaks, bleeding, hemorrhagic/chylous ascites, vascular complications, and sepsis were comparable in both the groups. The surgical re-exploration rate was higher in the post-KPE group (34.5% vs 18.3%, P = 0.08), but 3-month post-transplant mortality was comparable (6.89% vs 14.1%, P = 0.54). LT for biliary atresia has a comparable peri-transplant course and survival, irrespective of whether performed as primary LT or post-Kasai portoenterostomy.