Introduction

Liver transplantation has become the standard of care for end-stage liver disease in children and successful outcomes are now achieved in the vast majority of transplant recipients. Progressive improvement has occurred through better preoperative care of patients with liver disease, improved operative techniques that has allowed the donor pool to expand, and improved immunosuppression strategies to prevent rejection while avoiding complications of over-immunosuppression. The success of the past, however, has also bred unique challenges for the future. With the increasing number of liver transplant candidates, improved donor awareness and organ availability must occur. A delicate balance between the risks assumed by living donors and the needs of their children must be struck. The increasing numbers of surviving patients present unique challenges and complications related to lifelong immunosuppression. The future success of pediatric liver transplantation will require appreciation of the increasingly complex care needs of this population and a national focus on donor organ shortages.

The evaluation process

Collective experience suggests that the progression of chronic liver disease is not linear, but rather exponential, suggesting that early warning signs of hepatic compromise, such as deteriorating synthetic function or refractory nutritional failure should lead to prompt evaluation. In children with acute liver failure (ALF) or rapidly progressive decompensation of chronic disease, aggressive critical care intervention is essential to maintain all other physiologic systems until a suitable donor organ becomes available.