The Duke Pediatric Liver Transplant program has built a track record of exceptional outcomes while maintaining a commitment to offer transplants soon after birth when medically appropriate, providing treatment earlier than other Carolinas centers.

Experienced surgeons offer variant grafts and medical teams collaborate to diagnose and treat complex and life-threatening liver disease as well as tumors in infants. Helping small infants with life-threatening disease receive an early transplant is a priority of the program.

“We have some of the best outcomes in the country and it’s the result of our strong surgical and medical partnership,” says Deborah L. Sudan, MD, chief of the Division of Abdominal Transplant Surgery, and director of the Pediatric Liver Transplant program.

“Duke offers a variety of transplant options that many programs do not perform, including living donor or partial grafts,” she adds. “The fact that we can transplant living donors and are willing to offer innovative methods with segmental transplants means we have very low mortality on our wait list. We transplant patients earlier than most programs.”

The pediatric liver transplant team has completed four times as many transplants as any other North Carolina program, according to data from the Scientific Registry of Transplant Recipients (SRTR).

Based on the SRTR data, outcomes offer a significant metric: one-year patient survival rates are better at Duke than the national average. Among living donors, the one-year conditional survival rate is 100% compared to a national average of 94.64%; using deceased donor livers, the one-year conditional survival rate  for Duke is also at 100 percent, while the national average is 97.87 percent.

Another metric important to the clinical team is access to appointments: urgent hepatology appointments are scheduled within one week; transplant appointments can be scheduled within two to three weeks.

One of the distinctive characteristics of the program, Sudan says, is the emphasis on newborns. The program has not established a minimum weight as acceptable for transplant, preferring to evaluate each patient individually. In the past three years, the smallest liver transplant recipient was two weeks old and weighted under 3 kilograms.

The annual average is 12-15 liver transplants. The team works with patients from birth until age 18 and help with transitional care for young adults.  Although the COVID pandemic reduced the total number of transplants, the number of patients seeking care at Duke has started to increase again.

Deepak Vikraman, MD, surgical director of pediatric abdominal transplant, says addressing liver health as early as possible is the team’s priority. “Obviously, if you can address the liver disease of a child sooner, before the disease process becomes more involved and more complicated, kids tend to do well and have a significantly better recovery process,” Vikraman says.

“Our program is not tied to the idea of offering a transplant only when assessing a ‘right-sized’ patient. If you are only willing to transplant a child based on age and size, they will be on the waiting list for a very long time. When children linger on the wait list longer, they usually get sicker and sicker.”

Gillian O. Noel, MD, MSc, a pediatric gastroenterologist and transplant hepatologist who is medical director for pediatric liver transplant, says the team’s collaborative emphasis on patients and families is a key reason for the track record of good outcomes.

“We want the family to feel like they are the most important part of the team,” Noel says. “The ways in which our medical and surgical teams  interface is designed to benefit the patients and  families.

“We always round together, we review imaging together, and we talk to families at the same time,” she adds. “This ensures they get the medical and surgical perspective simultaneously to help families make the best decisions.”

The team-based approach includes expertise from PhD-level pharmacists, specialty-trained dieticians, ICU teams that are familiar with post-transplant care regimens, and many other members dedicated to transplant, Noel says.

“We work to ensure patients feel that they are well informed and receive comprehensive data about medical options and are supported by a highly coordinated, experienced, and caring clinical team at every step,” Noel adds.

The use of “split livers” allows for segmental transplants in the Duke pediatric liver transplant program, an option that increases the number of organs and reduces wait times, Duke liver specialists says.

“We are the only program in North Carolina that offers split grafts in liver transplant,” Sudan says. An adult cadaveric organ may be used for two separate grafts.

The living donor program, which includes both directed and non-directed donors also increases available organs. “Obviously, living donor grafts are well matched if they are from a relative, so that’s beneficial from an immunological standpoint,” she adds. “Living donors also offer an option for an elective procedure so we do not have to deal with prolonged preservation.”