Outcome of Pediatric Living Donor Liver Transplantation for Cholestatic Liver Disease in Different Body Weight Groups. A Retrospective Cohort Study.

BACKGROUND: Cholestatic liver diseases are the leading indication for pediatric liver transplantation, and low recipient body weight remains a major concern in pediatric living donor liver transplantation (LDLT) because of perceived higher technical complexity and poorer outcomes creating controversy over optimal timing for transplantation. OBJECTIVE: To evaluate the effect of recipient body weight on postoperative complications and survival after LDLT for cholestatic liver diseases in children. METHODS: This retrospective cohort study included 102 pediatric recipients younger than 18 years who underwent LDLT for cholestatic liver diseases between August 2015 and June 2024 at two Cairo transplant centers. Recipients were stratified into three body weight groups: less than 10 kg (n=28), 10-15 kg (n=26), and more than 15 kg (n=48). Demographic, operative, postoperative, and survival outcomes were compared across groups using appropriate statistical tests, and survival was assessed by Kaplan-Meier analysis with log-rank testing. RESULTS: Median age was 6 years and median body weight was 15 kg; 59.8% of recipients were male. Biliary atresia (38.3%) and progressive familial intrahepatic cholestasis (34.3%) were the leading indications for transplantation. Left lateral segment grafts were used in 60.8% of cases, and the median graft-to-recipient weight ratio was 2.11. Recipients weighing less than 10 kg had significantly higher postoperative pneumonia rates (51.7%) and portal vein thrombosis rates (14.3%). Biliary complications occurred across all groups, with bile leak in 9.8 % and biliary stricture in 12.7% bile leak followed by stricture in 5.8 %, without significant between-group differences. Early mortality rates were 25.0%, 19.2%, and 14.6% in the less than 10 kg, 10-15 kg, and more than 15 kg groups, respectively, without significant difference. One-year survival was 71.4%, 76.9%, and 87.5%, and three-year survival was 71.4%, 76.9%, and 81.3%, respectively, also without significant differences. CONCLUSIONS: Children weighing less than 10 kg at the time of LDLT have higher postoperative morbidity, particularly pneumonia and portal vein thrombosis, but achieve survival comparable to that of heavier recipients. Low body weight alone should not be considered a contraindication to pediatric LDLT in experienced centers.