Early complications after liver transplantation in children and adults: Are split grafts equal to each other and equal to whole livers?

Split‐liver transplantation (LT) allows transplantation of two recipients from one deceased donor, thereby increasing pool of grafts. However, split LT may be hampered by technical problems, and split grafts are still considered suboptimal organs in some centres. We analysed the outcomes in split‐ and whole‐liver recipients in a combined adult‐to‐paediatric transplantation programme. Records of paediatric and adult patients having undergone LT from 1999 to 2013 were analysed retrospectively. All splits were performed in situ. Adult split‐graft recipients were matched 1:2 with whole‐graft recipients (matching criteria: BMI, MELD, year of transplantation, age), and matched to the paediatric recipient transplanted from the same donor. Post‐LT complications were classified according to the Clavien scale. Among children, 32 split‐ and 31 whole‐graft recipients were analysed. Among adults, 20 split‐ and 40 matched whole‐graft recipients were analysed. In both populations, the post‐operative complications did not differ between split‐ and whole‐graft recipients. There was no difference in 1‐year graft and patient survival between split‐ and whole‐graft recipients in paediatric (90% vs. 97%, 94% vs. 97%, respectively) and in adult recipients (89% in both, 89% vs. 92%, respectively). In the analysis of both recipients issued from the same donor, there was no association in the prevalence and severity of complications. A case‐by‐case analysis showed that split mortality was unrelated to LT in all but one patient (small‐for‐size left split graft). In the setting of careful donor selection, recipient matching and surgical skill, in situ split LT is an effective and safe technique to increase the number of available organs, and split livers should no longer considered marginal grafts.     

A single center experience of donation after cardiac death liver transplantation in pediatric recipients

Bartlett A, Vara R, Muiesan P, Mariott P, Dhawan A, Mieli‐Vergani G, Rela M, Heaton N. A single center experience of donation after cardiac death liver transplantation in pediatric recipients.
Pediatr Transplantation 2010:14: 388–392. © 2009 John Wiley & Sons A/S. Abstract: Many centers are now performing DCD adult LT. There has been a reluctance to transplant pediatric recipients with DCD livers due to concern over the medium to long‐term outcome. We describe the outcome of 14 children (median age seven yr, 8 months–16 yr) that underwent LT with DCD grafts from July 2001 to December 2007. Donors had a median age of 23 yr (10–64), intensive care stay of five d (2–14) and bilirubin of 9 mmol/L (6–60). Median warm and cold ischemic time was 16 min (11–29) and seven h (5.5–8.4). Livers were transplanted as a whole organ (4), reduced graft (8), formal split (1) or auxiliary transplant (1). Compared to DBD recipients AST was significantly higher on the first three post‐operative days and there was no difference in the INR, bilirubin or GGT out to 12 months. There were no biliary or vascular complications and patient and graft survival is 100% at a median follow‐up of 41.8 months (1.7–74 months). LT with DCD grafts in pediatric recipients can be performed with low morbidity and excellent short‐to‐medium term patient and graft outcome.     

Hepatobiliary scintigraphy for the assessment of biliary strictures after pediatric liver transplantation

Abstract: HBS is used in the management of liver transplantation, a significant complication of which is biliary stricture. Strictures may be intraparenchymal within segments and main duct (non‐anastomotic) or at the biliary‐enteric anastomosis (anastomotic). Strictures are definitively diagnosed, and often managed, by PTC. This is invasive, technically challenging, and requires general anesthesia in young children. HBS may allow early detection of these complications and is non‐invasive. The aim of this study was to review the scintigraphic pattern of biliary strictures using ^99mTcDISIDA HBS following pediatric orthotopic liver transplantation, and to assess its role in the diagnostic algorithm of suspected biliary strictures. All available hepatobiliary studies performed post‐transplant in 101 episodes of liver transplantation in 92 pediatric patients were reviewed. Twenty‐three (23%) patients had known biliary strictures. Twenty‐two patients had adequate studies available for review; five had intrahepatic (non‐anastomotic) strictures alone, nine had a stricture of the anastomosis alone, and eight had both intrahepatic and anastomotic strictures. HBS patterns (either segmental or global changes) correlated very highly with clinically significant biliary strictures. All patients with known strictures had abnormal HBS; hence, in patients with abnormal liver function tests post‐liver transplant, a normal HBS makes strictures very unlikely. We propose that HBS can thus be used to determine if further investigation is required.     

Impact of donor preprocurement cardiac arrest on clinical outcomes in pediatric deceased donor liver transplantation

PPCA has historically been considered detrimental to donor quality in LT, but transplantation of grafts from this group of donors is now routine. Our study aims to evaluate the outcomes associated with use of donors with a history of PPCA in the pediatric population. This study is a single‐center retrospective analysis of all pediatric LTs performed over an 18‐year period. Donors and recipients were stratified by the presence and length of donor PPCA time. Preprocurement donor and post‐transplant recipient laboratory values were collected to assess the degree of ischemic liver injury associated with each donor group. Cox regression analysis was used to compare survival. The records for 130 deceased pediatric LT donors and corresponding recipients were reviewed. There were 73 (56%) non‐PPCA donors and 57 (44%) PPCA donors. Donors that experienced a PPCA event demonstrated a higher median, pretransplant peak alanine aminotransferase (ALT) level (P < .001). When comparing post‐transplant recipient median ALT levels, donors with any PPCA had lower median peak ALT (P = .15) and day 3 ALT (P = .43) levels than the non‐PPCA group. Rates of early graft loss did not differ. The PPCA group with >40 minutes of ischemia had markedly lower survival at 10 years, but this finding did not reach statistical significance. Liver grafts from donors with or without PPCA demonstrated no statistically significant differences in function or survival. A history of donor PPCA alone should not be used as an exclusionary criterion in pediatric liver transplantation.     

Risk factors for early and late biliary complications in pediatric liver transplantation

BC are a common source of morbidity after pediatric LT. Knowledge about risk factors may help to reduce their incidence. Retrospective analysis of BC in 116 pediatric patients (123 LT) (single institution, 05/1990–12/2011, medium follow‐up 7.9 yr). One‐, five‐, and 10‐yr survival was 91.1%, no patient died of BC. Prevalence and risk factors for anastomotic and intrahepatic BC were examined. There were 29 BC in 123 LT (23.6%), with three main categories: 10 (8.1%) primary anastomotic strictures, eight (6.5%) anastomotic leaks, and three (2.4%) intrahepatic strictures. Significant risk factors for anastomotic leaks were total operation time (increase 1.26‐fold) and early HAT (<30 days post‐LT; increase 5.87‐fold). Risk factor for primary anastomotic stricture was duct‐to‐duct choledochal anastomosis (increase 5.96‐fold when compared to biliary‐enteric anastomosis). Risk factors for intrahepatic strictures were donor age >48 yr (increase 1.09‐fold) and MELD score >30 (increase 1.2‐fold). To avoid morbidity from anastomotic BC in pediatric LT, the preferred biliary anastomosis appears to be biliary‐enteric. Operation time should be kept to a minimum, and HAT must by all means be prevented. Children with a high MELD score or receiving livers from older donors are at increased risk for intrahepatic strictures.     

Outcomes of children receiving en bloc renal transplants from small pediatric donors

The utilization of en bloc renal allografts from small pediatric donors has been adopted as an effective strategy to expand the organ donor pool in adult recipients. Data in children are limited. The aim of our study is to describe the outcomes of en bloc renal transplants in children from our center. Medical records of children receiving pediatric en bloc renal transplants at our institution from January 2007 were abstracted. Data collected included recipient and donor demographics, operative technique and complications, and post‐operative studies. Eight children received en bloc renal transplants at a median age of 17 yr; median follow‐up was 0.9 yr. Donor body weight ranged from 4 to 22 kg. One kidney was lost to intra‐operative thrombosis, while the other kidney from this en bloc graft remained viable. All grafts showed increased renal size at follow‐up ultrasound. Surveillance biopsies showed glomerulomegaly in two patients. At last follow‐up, the median eGFR was 130 mL/min/1.73 m². The urinary protein to creatinine ratio was normal in four of seven patients. Our data suggest that in experienced centers, en bloc renal transplantation from young donors into pediatric recipients is effective. Long‐term follow‐up to monitor for complications, including hyperfiltration injury, is warranted.     

Liver transplantation in children with hyper‐reduced grafts – A single‐center experience

Thomas N, Thomas G, Verran D, Stormon M, O’Loughlin E, Shun A. Liver transplantation in children with hyper‐reduced grafts – A single‐center experience. Pediatr Transplantation 2010: 14:426–430. © 2010 John Wiley & Sons A/S. Abstract: In small infants and babies who receive split or living‐related adult left lateral segmental liver grafts, further reduction (hyper‐reduction) of the graft may be necessary to optimize the size of the graft for the child. We report our experience with hyper‐reduction of adult left lateral segment grafts in nine children. A retrospective review of the medical records of children who received hyper‐reduced grafts at the Children’s Hospital at Westmead, Australia was performed. Of 215 liver transplants performed on 186 children between 1986 and May 2009, 147 were reduced grafts. Nine grafts were further reduced (hyper‐reduced) after an on‐table assessment of graft size relative to the available abdominal space was made. Mean graft size reduction was by 30%. The pledgetted technique of resection was used in four patients. All required delayed closure of the abdomen, and in three patients, fascial closure was not possible and a Surgisis^® patch (Cook Surgical International, West Lafayette, IN, USA) was placed to augment the abdominal capacity. Two children had hepatic artery thrombosis. One was successfully thrombectomized. In the other, technical problems with the donor liver contributed to death 10 days post‐transplant. Two bile leaks, one from the cut surface and the other at the anastomotic site, were oversewn at the time of abdominal closure. On follow‐up (median 33 months), two developed biliary strictures requiring dilatation. Hyper‐reduction of segmental grafts can be safely performed when needed. In view of its versatility, it may be preferable to hyper‐reduce a graft rather than use a monosegment graft. Comparable long‐term results are possible. The pledgetted technique of resection is easy, quick, and safe. The fact that it can be performed after revascularization with minimal blood loss adds great flexibility to this technically challenging procedure.     

Outcomes after discontinuation of routine use of transanastomotic biliary stents in pediatric liver transplantation at a single site

Routine use of transanastomotic biliary stents (RTBS) for biliary reconstruction in liver transplantation (LT) is controversial, with conflicting outcomes in adult randomized trials. Pediatric literature contains limited data. This study is a retrospective review of 99 patients who underwent first LT (2005–2014). In 2011, RTBS was discontinued at our center. This study describes biliary complications following LT with and without RTBS. 56 (56%) patients had RTBS. Median age at LT was 1.9 yr (IQR 0.7, 8.6); 55% were female. Most common indication for LT was biliary atresia (36%). Most common biliary reconstruction was Roux‐en‐Y choledochojejunostomy (75% with RTBS, 58% without RTBS, p = 0.09). Biliary complications (strictures, bile leaks, surgical revision) occurred in 23% without significant difference between groups (20% with RTBS, 28% without RTBS, p = 0.33). Patients with RTBS had routine cholangiography via the tube at 6–8 wk; thus, significantly more patients with RTBS had cholangiograms (91% vs. 19%, p < 0.0001). There was no difference in the number of patients who required therapeutic intervention via endoscopic or percutaneous transhepatic cholangiography (11% with RTBS, 19% no RTBS, p = 0.26). Routine use of RTBS for biliary reconstruction in pediatric LT may not be necessary, and possibly associated with need for costlier, invasive imaging without improvement in outcomes.     

Very small pediatric donor kidney transplantation in pediatric recipients

Kidneys from very small pediatric donors (age <5 years, weight <21 kg) may be a means to increase the donor pool for pediatric recipients. Transplantation of small pediatric kidneys is more commonly performed in adult recipients due to the increased risks of technical complications, thrombosis, and early graft failure. While these risks are abrogated in adult recipients by limiting the donor weight to ≥10 kg and using the EB technique, it is unknown whether pediatric recipients achieve comparable results. US national data were assessed for all first‐time, deceased‐donor, kidney‐only pediatric recipients, 1/1996‐10/2013, who received very small pediatric donor grafts or grafts from ideal adult donors. We identified 57 pediatric EB, 110 pediatric SK, and 2350 adult transplants. The primary outcome was 3‐year all‐cause graft survival. Kaplan‐Meier curves showed worse outcomes for pediatric grafts compared to adult ideal grafts (P=.042). On multivariate analysis, pediatric recipients of SK grafts had significantly higher HRs (aHR 2.01, 95% CI 1.34‐3.00) and pediatric recipients of EB grafts had somewhat higher non‐significant HRs (1.57; 95% CI 0.88‐2.79) for graft survival. These results suggest cautionary use of very small pediatric donors as a source to expand the donor pool for pediatric candidates.     

Living donor liver transplantation in maple syrup urine disease – Case series and world's youngest domino liver donor and recipient

MSUD occurs due to deficiency of enzyme BCKAD required for metabolism of leucine, isoleucine, and valine leading to the accumulation of these and their ketoacids causing acute metabolic decompensation manifesting as encephalopathy or sudden death. The patient requires special protein‐restricted diet to survive. As this enzyme is expressed in liver, liver transplantation has been successfully performed as a cure. We report two patients of MSUD who underwent LDLT while their livers were used as a domino graft for other biliary cirrhotic patients. A 22‐month‐old male child diagnosed as a case of classic MSUD underwent LDLT from an altruistic aunt as donor following which his serum leucine levels normalized on an unrestricted protein diet. His liver was used as a domino graft. A 38‐month‐old female child with diagnosed MSUD underwent LDLT from a swap donor, and her liver was used as a domino graft. Her DQ improved post‐transplant. LDLT from non‐heterozygous donors is a cure for classical MSUD. Their livers can be used as domino grafts for non‐MSUD cases.     

Preoperative risk factors for intra‐operative bleeding in pediatric liver transplantation

This study analyzes the preoperative risk factors for intra‐operative bleeding in our recent series of pediatric LTs. Between November 2009 and November 2014, 84 consecutive isolated pediatric LTs were performed in 81 children. Potential preoperative predictive factors for bleeding, amount of intra‐operative transfusions, postoperative course, and outcome were recorded. Cutoff point for intra‐operative HBL was defined as intra‐operative RBC transfusions ≥1 TBV. Twenty‐six patients (31%) had intra‐operative HBL. One‐year patient survival after LT was 66.7% (CI 95%=[50.2–88.5]) in HBL patients and 83.8% (CI 95%=[74.6–94.1]) in the others (P=.054). Among 13 potential preoperative risk factors, three of them were identified as independent predictors of high intra‐operative bleeding: abdominal surgical procedure(s) prior to LT, factor V level ≤30% before transplantation, and ex situ parenchymal transsection of the liver graft. Based on these findings, we propose a simple score to predict the individual hemorrhagic risk related to each patient and graft association. This score may help to better anticipate intra‐operative bleeding and improve patient's management.     

A case of pediatric live‐donor liver transplantation with a left lateral segment reduction by a linear stapler after reperfusion

In pediatric LDLT, graft reduction is sometimes required because of the graft size mismatch. Dividing the portal triad and hepatic veins with a linear stapler is a rapid and safe method of reduction. We herein present a case with a left lateral segment reduction achieved using a linear stapler after reperfusion in pediatric LDLT. The patient was a male who had previously undergone Kasai procedure for biliary atresia. We performed the LDLT with his father's lateral segment. According to the pre‐operative volumetry, the GV/SLV ratio was 102.5%. As the patient's PV was narrow, sclerotic and thick, we decided to put an interposition with the IMV graft of the donor between the confluence and the graft PV. The graft PV was anastomosed to the IMV graft. The warm ischemic time was 34 min, and the cold ischemic time was 82 min. The ratio of the graft size to the recipient weight (G/R ratio) was 4.2%. After reperfusion, we found that the graft had poor perfusion and decided to reduce the graft size. We noted good perfusion in the residual area after the lateral edge was clamped with an intestinal clamp. The liver tissue was sufficiently fractured with an intestinal clamp and then was divided with a linear stapler. The final G/R ratio was 3.6%. The total length of the operation was 12 h and 20 min. The amount of blood lost was 430 mL. No surgical complications, including post‐operative hemorrhage and bile leakage, were encountered. We believe that using the linear stapler decreased the duration of the operation and was an acceptable technique for reducing the graft after reperfusion.     

Biliary complications of living related pediatric liver transplant patients

Patients who undergo living related left lateral segment liver transplants have been reported to have a high incidence of biliary complications and some studies suggest that most patients will ultimately need operative revision. We reviewed our experience with living related transplantation in pediatric recipients to examine the occurrence of biliary complications and the utility of percutaneous biliary procedures in their management. Over a 10-yr period, 48 living donor transplants were performed in 47 patients. Sixteen patients (33%) had biliary complications. Complications included 10 leaks (20%) and eight strictures (17%). Although leaks were treated predominantly with operation, other biliary complications were treated almost exclusively non-operatively. Self limited leaks that lead to biloma accumulation were most often treated via percutaneous catheter drainage and all strictures were treated using percutaneous transhepatic biliary cholangioplasty and stenting. Sixty-seven percent of biliary complications underwent non-operative biliary intervention. Most strictures were focal anastomotic strictures and were successfully treated with cholangioplasty although multiple interventions were necessary and patients required stenting for an average of 13 months. Three of eight strictures were diffuse in nature and these included the only patient who required retransplantation. Graft survival with respect to biliary complications was 94%; 1 yr, 5 yr and overall patient survival for those with biliary complications was 88, 88 and 81%, and for the entire living related group was 84, 81 and 77%, respectively. Although biliary complications are frequent in pediatric living related transplantation, they are not associated with decreased patient survival. Excepting significant bile leaks, the majority can be treated non-operatively via biliary cholangioplasty and stenting. Strictures are especially amenable to this technique which, in our experience, has been successful at decreasing or postponing the need for retransplantation.     

Overweight,central obesity,and cardiometabolic risk factors in pediatric liver transplantation

PTMS describes the presence of ≥3 cardiometabolic risk factors that include obesity, hypertension, dyslipidemia, and IR. The prevalence of the clustering of ≥3 cardiometabolic risk factors or central obesity has not been studied in pediatric LT recipients. Single‐center, cross‐sectional study. Inclusion criteria: LT recipients 2–18 yr‐old, at least one yr post‐LT. Exclusion criteria: recipients of liver retransplants or multivisceral transplants. Eighty‐seven patients were identified. Median age was 9.8 yr (range 2–18), median time since LT was 6.9 yr (range 1–17). The most common indication for LT was biliary atresia (56%), and the most frequently used immunosuppressant was tacrolimus (80%). The prevalence of overweight and obesity was 21% and 5%, respectively. Central obesity affected 14%, hypertension 44%, IR 27%, low HDL 20%, and hypertriglyceridemia 39% of patients. The prevalence of ≥3 cardiometabolic risk factors was 19%. Fifty percent of the overweight/obese patients had ≥3 risk factors. Time since transplant, immunosuppression and renal function were not different between those with <3 or ≥3 risk factors. Clustering of cardiometabolic risk factors is prevalent in pediatric LT recipients, suggesting an increased risk of future CV events.     

Current status of liver transplantation

Liver transplantation is accepted therapy for acute or chronic liver failure. Survival after LT has improved significantly in developed countries and this has increased the awareness of this treatment modality in the developing world. Successful LT in both children and adults have now been reported from India. Chronic liver failure secondary to cholestatic liver disease in the most frequent indication for LT, with biliary with atresia as the single commonest cause. Innovative techniques such as reduced size, splint, and living donor liver transplantation are being applied more often to decrease long waiting times and reduce associated morbidity and mortality. Early postoperative complications include primary graft failure, venous thrombosis, rejection, biliary complications and infections. Late complication includes CMV or EBV infections, side effects of immunosuppression, post transplantation lymphoproliferative disease and late biliary strictures. Most children achieve good quality of life. There are still many lessons to learn and there are future challenges such as the ever increasing problems of donor scarcity and the search for potent but less toxic immunosuppressive agents.     

Tacrolimus‐related seizure after pediatric liver transplantation – A single‐center experience

To identify the risk factors for new‐onset seizures after pediatric LT and to assess their clinical implications and long‐term prognosis. The clinical and laboratory data of 27 consecutive children who underwent LT from January 2007 to December 2010 in our center were analyzed retrospectively. Patients were divided into seizures group and a non‐seizures group. Pre‐operative, intra‐operative, and post‐operative data were collected. Seizures occurred in four children, an incidence of 14.8%. All exhibited generalized tonic–clonic seizures within the first two wk after LT. Univariate analysis showed that the risk factors associated with seizures after pediatric LT included gender, pediatric end‐stage liver disease score before surgery, Child–Pugh score before surgery, serum total bilirubin after surgery, and trough TAC level. Multivariate analysis showed that trough TAC level was the only independent risk factor associated with the seizures. All children who experienced seizures survived with good graft function and remained seizure‐free without anti‐epileptic drugs over a mean follow‐up period of 33.7 ± 14.6 months. High trough TAC level was the predominant factor that contributed to seizures in the early post‐operative period after pediatric LT. High PELD and Child‐Pugh scores before LT and high post‐operative serum Tbil may be contributory risk factors for TAC‐related seizures.     

Liver retransplantation in children: The Atlanta experience

Heffron TG, Pillen T, Smallwood G, Henry S, Sekar S, Solis D, Casper K, Fasola C, Romero R. Liver retransplantation in children: The Atlanta experience.
Pediatr Transplantation 2010: 14:417–425. © 2010 John Wiley & Sons A/S. Abstract: Liver retransplantation is routinely offered at our institution. Previous reports document that patient and graft survival is significantly less after pediatric rLT compared to primary LT. This has engendered intense debate regarding optimal allocation of organs. Here, we examine our program’s approach to pediatric hepatic retransplantation related to patient factors affecting outcomes. Between 1997 and 2009, 272 LTs were performed in 234 patients (mean survival 1994 ± 1367 days) at our center. Thirty‐four patients required rLT including 10 who received their primary transplant elsewhere and four who required two retransplantations. Patient survival did not differ significantly between rLT and LT at one and three yr (p = 0.56). Graft survival between rLT and LT was also similar (p = 0.606) at one and three yr. No significant difference in graft or patient survival was noted between: Patients retransplanted <30 days after LT vs. those >30 days (p = 0.152); patients transplanted with technical variants vs. whole grafts (p = 0.966); technical variants utilized for LT vs. rLT (p = 0.713); rLT recipient age (< or >5 yr; p = 0.298); or ABOI for rLT and LT (p = 0.650). Retransplantation should be offered to optimize pediatric recipient survival after LT and offers similar survival as primary transplant.     

Endoscopic retrograde cholangiopancreatography is safe and effective for the diagnosis and treatment of pancreaticobiliary disease following abdominal organ transplant in children

Otto AK, Neal MD, Mazariegos GV, Slivka A, Kane TD. Endoscopic retrograde cholangiopancreatography is safe and effective for the diagnosis and treatment of pancreaticobiliary disease following abdominal organ transplant in children. Abstract: ERCP is a diagnostic and therapeutic imaging modality widely used in adult pancreaticobiliary disease, including the treatment of anastomotic strictures following liver and small bowel transplant. We have previously reported a large series of ERCP in children and demonstrated its safety and utility in pediatric disease. The aim of this study was to evaluate the safety of and indications for ERCP following abdominal organ transplant among pediatric patients by performing a subgroup analysis of our large cohort. Forty‐eight ERCPs were performed on 25 children ages 62 days to 20 yr following isolated liver, isolated small bowel, or composite graft transplant. Mean time from transplantation at the time of ERCP was 18 months. The most common indication for ERCP was the evaluation of non‐specific hepatobiliary complaints, including abdominal pain and elevated liver enzymes. ERCP was also commonly performed for the evaluation or treatment of known or suspected biliary tree strictures. Seventy‐seven percent of cases included therapeutic intervention, including sphincterotomy in 40%, stent placement in 29%, and stone extraction in 19%. The overall complication rate among post‐transplant patients was low (2.9%) and not significantly different than the complication rate reported in our previous study. A history of abdominal organ transplant was not associated with an increased risk of complication following ERCP (OR = 0.41, 95% CI = 0.05–3.33). In our experience, ERCP can be safely performed in children following liver, small bowel, and composite graft transplant with outcomes similar to those seen in a general pediatric population and may be especially useful for the diagnosis and treatment for biliary strictures following transplant. Further investigation of the relationship between the timing of ERCP relative to transplant and the safety of the procedure is needed.     

Transient elastography assessment of liver allograft fibrosis in pediatric transplant recipients

TE measures liver stiffness to assess fibrosis. Its use in post‐transplant patients was reported in few small pediatric studies. We evaluated TE ability to predict liver graft fibrosis in a large cohort while comparing it to the performance of APRI and FIB‐4. We also investigated the effect of graft type on LSMs. Patients at Boston Children's Hospital who underwent LT and LSM ≤ 1 year from biopsy (2007‐2018) were eligible. Ninety‐four patients (45%M) aged 1‐21 years (89% < 18 years; 13% < 2 years) were eligible. Median time between transplant/biopsy and LSM was 5.1 years and 52 days, respectively. Thirty‐nine percent received whole‐liver grafts, 54% TV grafts, and 6% as part of MV. At LSM, median ALT was 25 [IQR 16‐33] IU/L. Twenty‐one percent had METAVIR ≥ F2. LSM was statistically higher among those with significant fibrosis (METAVIR ≥ F2) compared to those with METAVIR F0/F1 (median [IQR] 7.5 [4.6, 13.6] vs 5.1 [4.0, 6.4] kPa, respectively) (P = .005 by Wilcoxon rank‐sum test). APRI and FIB‐4 distributions were not different across METAVIR stages. The AUROC for LSM was 0.71 (95% CI 0.56‐0.85) with an optimal cut‐point of 6.5 kPa. Graft type had no influence on the AUROC for LSM. TE is useful for assessing significant graft fibrosis in children and young adult LT recipients and performs better than APRI and FIB‐4. TV grafts demonstrate similar correlation with histology as whole‐liver grafts.