Pediatric liver transplantation has become the optimal treatment for children with acute and chronic liver disease. Developments include reduced and living donor transplantation as well as laparoscopic and split liver techniques. Key challenges include donor scarcity and timing transplantation. The most common indication is biliary atresia. Strategies to expand the donor pool include split liver transplantation and living related donors. Primary liver tumors such as hepatoblastoma may also require transplantation when unresectable. Strict collaboration between medical teams is essential for success.

1. Special issues in paediatric liver transplantation Oscar Imventarza M.D. Chief Liver Transplantation Hospital Garrahan & Hospital Argerich Buenos Aires Argentina

3. Reduced liver 1984 Pediatric Living Related 1989 1963 T.E. Starzl Right living donor 1994 Laparoscopic Left Lateral Segment 1992 H .Bismuth Split liver 1989 OLTX R Pichlmayr S. Raia D. Cherqui Y .Yamaoka K.Tanaka R. Strong Evolution of Liver Transplantation

5. Timing of transplantation

7. Single commonest indication for OLTX in children Biliary Atresia Incidence 1:14.000 - 1:21.000

8. Biliary atresia Congenital absence or closure of the major bile ducts. Porta Hepatis

10. Biliary atresia: Kasai procedure < 1960 No treatment 0 % survival 1960-1990 Kasai 50% survival > 1990 Kasai & OLTX 95% survival

15. Worldwide Activity: Split Liver Transplantation Total numbers of 2009 (% of each national program)

16. In situ Ex situ Imventarza et al. Rev Argen Cirug. 2006

17. Split liver transplantation Transplant International 2011 European Society for Organ Transplantation 24 (2011) Several reports of larger series of classical split liver transplants including matched pair analyses show comparable results of classical split and whole liver transplantation R E V I E W

18. Hospital Garrahan: SPLIT Split liver transplantation in fulminant hepatic failure: results an long term follow up. Imventarza O.et al. HPB Volumen 8 Supplement number 2, September 2006- P.23.53 November 2011 11%

19. Living Related Donors

20. Living Related Donor with monosegment de Santibañes y col. Liver Trasnplantation. 2001 Technique II III

21. Pediatric Living Donors Hospital Garrahan 28%

25. HAV geographical variations Hepatitis A: a main cause of liver transplantataion in fulminant hepatic failure Lendoire J Imventarza O. American Journal of Transplantation, 2001; Suppl 1 (1): 425

27. Tx Evaluation : 1056 pediatric patients Etiologies USA ALF 13% CHILE ALF 30% 1992- 2006

28. VACCINATION CHRONOLOGY of FHF Hep A VIRUS Decline in HAV‑associated fulminant hepatic failure and liver transplant in children in Argentina after the introduction of a universal hepatitis A vaccination program. Hepatic Medicine: Evidence and Research Cervio et al in press 2011

29. CHRONOLOGY of FHF Hep A VIRUS VACCINATION Decline in HAV‑associated fulminant hepatic failure and liver transplant in children in Argentina after the introduction of a universal hepatitis A vaccination program. Hepatic Medicine: Evidence and Research Cervio et al in press 2011

30. FHF Hep A VIRUS Monthly after vaccination Decline in HAV‑associated fulminant hepatic failure and liver transplant in children in Argentina after the introduction of a universal hepatitis A vaccination program. Hepatic Medicine: Evidence and Research Cervio et al in press 2011 No new cases VACCINATION

31. OLTX in primary liver tumors

34. PRETEXT IV Liver Transplantation

35. Hepatoblastoma

36. Is a registry developed by an international collaborationof the Liver Tumors Strategy Group

42. N= 129 patients Primary Hepatic Tumors 90 p. 27 p 12 p 1992-2011