Published online Mar 18, 2024. doi: 10.5500/wjt.v14.i1.87752
Peer-review started: October 7, 2023
First decision: November 17, 2023
Revised: November 29, 2023
Accepted: December 19, 2023
Article in press: December 19, 2023
Published online: March 18, 2024
Processing time: 160 Days and 2.4 Hours
Liver transplantation (LT) is a life-saving procedure for patients with end-stage liver disease and has become the standard and most effective way of treatment for these patients. There are many indications for LT that vary between countries and settings. The outcome of LT depends on the available facilities and surgical expertise, as well as the types of liver graft donors available.
Multiple reports about LT experiences have been published from several countries worldwide. However, there are no reports studying the details of patients from Bahrain who went overseas for LT. This gap of knowledge motivated us to study the experience of an overseas LT in our country.
To assess the clinical characteristics of patients from Bahrain who underwent LT overseas, and analyze factors affecting their survival.
We retrospectively reviewed the medical records and overseas committee registry information of all pediatric and adult patients who were sent overseas to undergo LT by the Pediatric and Medical Departments of Salmaniya Medical Complex and Bahrain Defence Force Hospital via the Overseas Treatment Office, Ministry of Health, Kingdom of Bahrain, between 1997 and 2023. Pediatric and adult patients were compared in terms of demographic data, LT indication, donor-recipient relationship, overseas LT center, graft type, post-LT medications, LT complications, and outcomes. Survival analysis was estimated, and predictors of survival were analyzed.
Up to August 2023, of the 208 listed patients, 170 (81.7%) were sent overseas to undergo LT. Of the latter, 167 (80.3%) underwent LT and were included. The majority were Bahraini (91.0%), and most were males (57.5%). One-hundred-and-twenty (71.8%) were adults and 47 (28.3%) were children. The median age at transplant was 50.0 [interquartile range (IQR): 14.9–58.4] years. The main indication for pediatric LT was biliary atresia (31.9%), while that of adult LT was hepatitis C-related cirrhosis (35.0%). Six (3.6%) patients required re-transplantation. Most patients received a living-related liver graft (82%). Pediatric patients received more living and related grafts than adults (P = 0.038 and P = 0.041, respectively), while adult patients received more cadaveric and unrelated grafts. Most patients required long-term immunosuppressive therapy after LT (94.7%), of which tacrolimus was the most prescribed (84.0%), followed by prednisolone (50.7%), which was prescribed more frequently for pediatric patients (P = 0.001). Most patients developed complications (62.4%) with infectious episodes being the most common (38.9%), followed by biliary stricture (19.5%). Tonsilitis and sepsis (n = 12, 8.1% for each) were the most frequent infections. Pediatric patients experienced higher rates of infection, rejection, and early poor graft function than adult patients (P < 0.001, P = 0.003, and P = 0.025, respectively). The median follow-up time was 6.5 (IQR: 2.6–10.6) years. The overall survival rate was 84.4%, the 5-year survival rate, 86.2%, and the mortality rate, 15.6%. Younger patients had significantly better odds of survival (P = 0.019) and patients who survived had significantly longer follow-up periods (P < 0.001).
Acute and chronic liver failure are conditions that carry a high mortality rate in both pediatric and adult populations. This study found that patients with end-stage liver disease in Bahrain shared comparable clinical characteristics to those published in reports from neighboring countries and worldwide. In a developing country like Bahrain, where LT facilities are not available, an overseas LT can offer great hope to patients with an end-stage liver disease, assuming the presence of a suitable donor.
Greater attention must be made to identify patients at increased risk of developing liver failure and establishing strategies for early overseas LT is crucial. A multicenter prospective study is required to investigate the cost-effectiveness of the overseas LT in countries lacking this important facility.