Liver transplant for paediatric acute liver failure: insights from a newly established paediatric liver transplant program in a developing country.

Liver transplantation (LT) is the cure for medically refractory acute liver failure (ALF). In resource-limited settings, establishing a paediatric LT program for paediatric ALF (PALF) encounters unique challenges. This study describes the initial 5-year experience of the paediatric LT (PLT) program at the Colombo North Centre for Liver Diseases (CNCLD), Sri Lanka (March 2020 to March 2025). Data from all PALF cases (n = 35) were retrospectively analyzed. A total of 120 children were referred to LT and 35 (29%) were due to ALF. Median age was 8 years 9 months (range: 2 months - 13 years) and 63% were male. Common etiologies included Wilson disease (23%) and autoimmune liver disease (20%). Spontaneous recovery occurred in 43% (15) while 34% (12/35) underwent LT and 23% (8) died without LT. Of 12 transplant recipients, 8/12 received living donor liver transplants (LDLT) (5/8 related donors, 3/8 altruistic - Buddhist monks), and 4/12 received deceased donor liver transplants (DDLT). The median time from listing to transplant was 72 h. Post-transplant survival in one and three months was 75% and 66% respectively. There were three immediate post-LT deaths due to primary non-function of deceased donor grafts. PALF comprised a substantial proportion of referrals in Sri Lanka's nascent PLT program. The majority of LT for PALF were LDLT with favorable outcomes compared to DDLT. Optimum utilization of a budding LT program with timely referrals and availability of altruistic donors have played key roles in the success of the PLT program in a resource limited setting.