Long-term Functional Recovery and Quality of Life

Liver transplantation has become a routine life-saving procedure for children with chronic end stage liver disease, with inborn errors of the metabolism in which the defect hampers the quality of life of the patients and/or the function of other organs, or with fulminant hepatic failure. Results of liver transplantation on quality of life will be greatly influenced accordingly to these different situations. The quality of life does not only depend on physical function but also on the psychological welfare and social integration of the child.
Kidney function
Pediatricians are concerned by the progressive nefrotoxicity of Cyclosporine and Tacrolimus, considering that liver transplanted children require lifetime immunosoppression in addition to other nefrotoxic drugs. The Los Angeles group reported an average loss of glomerular filtration rate (GFR) of 50 ml/min per 1,73 m2 after transplantation, with a GFR below 80 ml/min per 1,73 m2 found in more than 50% of the patients &. Normal GFR was correlated with low Cyclosporine blood levels. Kidney transplantation has been reported after liver transplantation, by the Pittsburgh group &.
Growth.
Growth can be impaired by pre-transplant disease, post-transplant complications and steroid treatment. Growth is usually impaired during the initial post-transplant period, while catch-up occurs during the 2nd and 3rd years after liver transplantation, with more than 75% of patients above the 3rd percentile for height, confirming that liver may correct growth retardation.
Those children transplanted earlier in childhood are likely to achieve more normal final height outcomes. It has been clearly demonstrated that growth is better in patients receiving low doses of steroids and/or in patients receiving steroid in alternate day therapy or no steroids at all. On the contrary, high steroid doses, poor liver function and retransplantation are associated with poorer height outcomes. Persisting severe short stature is largely confined to children with severely retarded growth at transplantation. In selected cases, growth hormone administration should be considered, even if it may aggravate glucose intolerance in patients under steroid therapy. Transient delay in puberty and menarche occur early after transplantation, although appropriate puberty progress is resumed after two to three years.
Psychological welfare.
Age at transplantation and pre-transplant disease are the most important determinants for the appreciation of patient’s and parents’ dissatisfaction after liver transplantation. Quality of life will improve for most children with previous long-standing history of chronic liver disease, but may worsen in the case of fulminant hepatitis. In this latter group, teenagers may show transient depression. Behavioral and emotional adjustment is as good as in children with other chronic illnesses. In comparison with physically healthy children, the transplant recipients have subtle signs of emotional difficulties. Familial stress before liver transplantation is exacerbated by the long waiting time and the risk of death before reaching  transplantation. 
Social welfare.
The majority of children achieve normal educational progress, provided they have not accumulated too much delay before transplantation. In the Pittsburgh series, 77% of the children were in age-appropriate grade levels, or 1 year behind. The IQ was not affected by transplantation. The development of children with onset of the disease in the first year of life was more likely to remain delayed after transplantation. The motor skill and overall behavior were greatly improved after transplantation. Transplantation had a positive effect on family life, often socially isolated. Parents tend to remain overprotective. Patients themselves were able to do activities that thay had never done before, in normal  interaction with peers.