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Introduction: Biliary atresia (BA) is the main indication for liver transplantation (LT) in the pediatric age. Donor-selection strategy is still matter of debate. Methods: LT performed at our Institution between 1993-beginning of our living donor program-and 2015 were retrospectively analyzed. Patient and graft survivals were studied in BA patients according to age at LT (before and after 2 years-old) and type of donor (living donor vs deceased donor). Among 609 children, recipients of 649 grafts, the indications for LT were as follows: BA (56.1%), cholestatic diseases (19.4%), liver malignancies (7.5%), fulminant hepatitis (4.3%) and others (12.7%). For BA recipients, 150 DD and 216 LD grafts were used: only primary transplantations (342 grafts) were considered for this study. Results: Overall, the median age at LT was significantly lower for BA patients (median: 1.0 year; range: 0.3-15.7) comparing to other indications (3.9 years; 0.1-22.4) (P < 0.0001). Overall 5-year patient and graft survivals were 86.9% and 82.2% respectively for non-BA, vs 95.1%% and 88.8% for BA patients (P = 0.0001 and P = 0.0033). In the BA subgroup (n = 342 pts), the median age was significantly lower when a LD-LT was performed (0.9 years; 0.4-10.8) comparing to DD-LT (1.4 years; 0.3-15.7) (P < 0.0001). 264 patients have been transplanted < 2 years-old (183 LD and 81 DD) and 78 ≥ 2 years-old (31 LD and 47 DD). Overall re-transplantation rate in BA recipients was 9.3%. 5-year PATIENT survival was comparable for patients transplanted ≥ 2 years-old (97.4%) vs those transplanted < 2 years-old (94.1%) (P = 0.9127); conversely, 5-years GRAFT survival was significantly higher when LT was performed < 2 years-old (90.0% vs 84.1%) (P = 0.0316). In the subgroup of children < 2 years-old, 5-year patient and graft survivals were significantly higher after LD-LT (96.6% and 90.6% respectively), than after DD-LT (88.9% and 81.5%) (P = 0.0156 and P < 0.0001). Conclusions: 1) BA constituted the main indication for LT in children, for whom outcome seems to be better comparing to those transplanted for all other indications; 2) The use of LD-LT allowed to transplant children at a younger age, when compared with DD-LT, with a comparable patient survival rate, but with a better graft survival rate; 3) In the subgroup of BA children transplanted earlier (< 2 years-old), LD-LT provides significantly better outcome in both patient and graft survival rate.

Introduction: From 1984 to 2018, 1115 paediatric liver transplantations have been performed, of which 433 with living donors. With patients coming from 13 different countries, our centre has a strong international dimension. The Live Organ Donor Consensus Group has formulated a statement according to which “a psychological evaluation is necessary for each potential donor” [i]. In our centre, we systematically conduct pre-transplant psychological assessments, which consist in a clinical family interview. The complexity of the family situations having increased over the last few years, we aimed to address the relevance and efficiency of our pre-transplant interviews. Methods: Content analysis of 130 pre-transplant reports written between 1/07/2014 and 31/10/2018 were reviewed, as well as personal prospective notes by the psychologist, in the follow-up of the families after transplantation during the same period, with a systemic attention to the transplanted child's family. Results: Our reflective work sheds light on the evolution of our practice of pre-transplant interviews, which has evolved from family interviews focused on the living donor, to interviews that consider all the aspects of the family dynamics, including the cultural dimension. The analysis of our prospective notes revealed that the potential risks are not only related to personal characteristics of the living donor candidate, but can also be connected with his/her environment. Moreover, the psychosocial risk does not concern the donor candidate alone, but may well extend to other significant family members, including those who remained in the country of origin. We are receiving families who have experienced unique life circumstances, such as histories of intra-familial tensions or violence, death of previous children, experiences of war or jail. Family dynamics are affected differently by such circumstances, with psychosocial risks at various level and for different family members as a consequence. As a result of embracing the complexity of such trans-national families, we moved from proceeding to a single family interview focused on the living donor candidate to conducting one or multiple interviews focused on the family situation (including psychiatric or social consultation). Conclusion: In order to prevent short and long-term psychosocial damage for families concerned with living-related donation, we recommend to extend the focus on the donor alone to a focus on the whole family system and history, and to pay attention to the cultural dimension, as this has an impact on important social processes and interactions, which in turn influences the psychological-and sometimes psychiatric-outcomes.

Introduction: From 1984 to 2018, 1115 paediatric liver transplantations (PLTs) have been performed, of which 433 with living donors (LD). In 2000, the Live Organ Donor Consensus Group has formulated a statement according to which “a psychological evaluation is necessary for each potential donor” [i]. Accordingly, we systematically conduct pre-transplant psychological interviews, which consist at least in a clinical family interview. We hypothesize that such approach may predict psychosocial difficulties for families in the course of the transplant. Methods: Content analysis of 130 pre-transplant reports written between 1/07/2014 and 31/10/2018 were reviewed, as well as personal prospective notes by the psychologist, in the follow-up of the families after transplantation during the same period, together with interviews with the co-ordinator of the transplant program, the surgeon, and the chief nurse, to triangulate the data from our own personal notes. Results: The results hereafter are based on the systematic analysis of the first 54 situations of living donor paediatric transplantation. After transplantation, 39/54 (72%) families did not experience particular psychosocial difficulties whereas 15 (28%) needed psychosocial support. Only 9 of these 15 situations had been identified as being at risk, through our clinical interview before transplantation. The red flags identified by the psychologist in relation to these families were in adequacy with the type of difficulties experienced after transplantation, such as tensions within the parental couple, psychosocial fragility of one parent, and previous death of children. Looking at the remaining 6 (11%) whose psychosocial risk had not been identified we analysed whether it would have been possible to predict post-operative psychosocial events or adjustments, based on our pre-transplant psychological assessment. In 3 situations, medical complications and a long hospitalization were the main determinant of the subsequent psychosocial difficulties, which were therefore not predictable. In 3 situations however, the risk might have been predicted if we had investigated more in-depth the larger environment and history of the family, for instance a previous loss of a child in one family, a history of long period of mother-child separation in another, and a complex relationship between a donor candidate and his recent girlfriend. Conclusion: Our results based on the systematic analysis of 54 psychological pre-transplant reports suggests that a systemic approach with at least a clinical family interview predicts in 48/54 (89%) psychosocial risks and points of attention for living donor candidates and their family before paediatric liver transplantation. In the 6/54 (11%) remaining situations, we hypothesize that a more in-depth systemic approach may improve our prediction of psychosocial difficulties.