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Reuters Health Information: Primary liver transplant may best drainage in infants with biliary atresia

Primary liver transplant may best drainage in infants with biliary atresia

Last Updated: 2018-09-20

By David Douglas

NEW YORK (Reuters Health) - Primary liver transplantation is associated with better long-term survival than is biliary-enteric drainage (BED) in infants with biliary atresia, according to a new study.

In the past, the high mortality rate with transplant "relegated it to a salvage procedure reserved for patients whose BED treatment was unsuccessful," Dr. Sophoclis Alexopoulos of Vanderbilt University Medical Center, in Nashville, Tennessee, and colleagues write in JAMA Surgery, online September 12. However, advances in care have meant that a subset of infants have gone directly to transplantation.

To compare the two approaches, the researchers tapped into Californian health data covering 1990 to 2015 on 313 patients who initially underwent BED at a median age of 65 days and a further 313 who underwent primary transplantation.

The primary-transplant group had a higher three-month mortality than the BED group. However, at six months and beyond, their mortality rate was significantly lower (hazard ratio, 0.19).

In addition, the 147 BED patients (46.9%) who subsequently underwent a transplant had a substantially higher mortality rate than the primary-transplant group (HR, 0.43).

Because of considerable changes in liver allocation over the course of the study period, the researchers also compared survival in recipients from 2002. This continued to show the superiority of primary transplantation (HR, 0.16), even when censoring patients who underwent salvage liver transplant (HR 0.23).

As expected, say the researchers, between the earlier and later periods "no substantial improvement was noted in the survival of patients who received BED treatment."

Dr. Alexopoulos told Reuters Health by email, "The current excellent outcomes of pediatric liver transplantation raise the question of whether biliary drainage through hepatic portoenterostomy, with its high associated failure rate requiring salvage liver transplantation, should still be the initial treatment of choice for all infants with biliary atresia."

"A prospective multi-institutional trial needs to be performed to identify which patients would benefit most from a biliary drainage procedure and which should proceed directly to a primary liver transplant," he concluded.


JAMA Surg 2018.

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