Outcomes of pediatric liver transplant recipients who reach adulthood: Current perspectives and unmet needs

Abstract

Pediatric liver transplantation (pLT) has evolved from a purely life-saving intervention into a therapeutic strategy associated with excellent long-term survival, with the majority of recipients now reaching adulthood. As survival outcomes have improved, the focus has progressively shifted from post-transplant survival alone to the pursuit of overall health. This concept encompasses optimal graft function, the absence of significant medical comorbidities, psychological well-being, social integration, and good quality of life, and should be regarded as the ideal long-term outcome after pLT. However, only a minority of patients currently achieve this goal, mainly due to liver-related, often immune-mediated, or extrahepatic medical complications, as well as psychosocial challenges. This minireview summarizes the key factors that limit the attainment of such an endpoint, critically discussing the limitations of currently used diagnostic parameters, and highlights existing challenges and unmet needs. Finally, potential multilevel strategies are proposed, including the implementation of structured and universal transition processes, the incorporation of novel diagnostic and prognostic biomarkers of graft function, and the prevention and early treatment of modifiable risk factors for extrahepatic complications, aimed at enabling the achievement of overall health in the majority of pLT recipients reaching adulthood in the near future.

Keywords: Adherence; Allograft rejection; Chronic kidney disease; Transition; Long-term outcomes

Core Tip: Pediatric liver transplantation has progressed from a life-saving procedure to one offering excellent long-term survival, with most recipients reaching adulthood. The focus has shifted from survival to global health, encompassing medical outcomes, psychological well-being, social integration, quality of life, and long-term functional and developmental success. However, only a minority achieve the ideal outcome, largely due to medical complications. Graft-related issues (such as persistent liver function test abnormalities) and extrahepatic complications, including chronic kidney disease, and metabolic disorders, and de novo cancers, often result from long-term immunosuppression. This minireview highlights determinants of long-term outcomes and proposes refinements to better assess the ideal outcome.