We read with interest a recent article by Mohan, et al. [1] who have summarized their experience of 200 pediatric living donor liver transplantations in one of the largest series from the country. We would like to highlight some issues with the study.

Authors have mentioned using Pediatric end stage liver disease (PELD) scores (>10 for age <12 years), and Model for end-stage liver disease (MELD) scores (>15 for age >12 years) for listing for liver transplantation in patients with chronic liver disease (CLD) as per Western guidelines [2]. This statement requires careful interpretation as these scores are not at all meant to be used for listing a patient or deciding the need of liver transplantation in an individual patient. The above statement infers that a patient with a PELD score of <10 or a MELD score of <15 would not be listed irrespective of his/her clinical status. Quoting the same guidelines, every CLD patient who develops worsening of hepatic functions (intractable ascites, progressive encephalopathy, uncorrectable coagulopathy and/or, recurrent infections; and not just uncontrolled portal hypertension), mandates evaluation for liver transplantation [2]. These severity scores are meant to be used only in countries having proper organ allocation mechanisms for diseased donor transplantation, and that too, only for deciding the priority and not for listing. In resource-constrained settings, where a vast majority of liver transplantations are living donor related, these scores have limited practical utility, except for prognostication. Thus, using fixed cut-offs for deciding need of liver transplantation in CLD is far from being an ideal strategy.

Despite having a long study period of 13 years, vital information on post transplant follow-up, including attrition/loss to follow-up, drug compliance rates, renal outcomes is missing from the reported study. Reasons for lower incidence of vascular complications, any trend (if seen) in the incidence of complications over the study period, and actual modifications in transplant protocols over the study period (to improve the outcomes) require further clarification [3]. Also, predictors of morbidity and mortality, if studied in the study cohort, would have added much needed information to the national database [4,5].

1. Mohan N, Karkra S, Rastogi A, Dhaliwal MS, Raghunathan V, Goyal D,　et al. Outcome of 200 pediatric living donor liver transplantation in India. Indian Pediatr.　2017;54:913-8.

2. Squires RH, Ng V, Romero R, Ekong U, Hardikar W, Emre S, et al. Evaluation of the Pediatric Patient for Liver Transplantation: 2014 Practice Guideline by the American Association for the Study of Liver Diseases, American Society of Transplantation and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. Hepatology. 2014;60:362-98.

3. Mali VP,　Aw M,　Quak SH,　Loh DL,　Prabhakaran K. Vascular complications in pediatric liver transplantation; single-center experience from Singapore. Transplant Proc.　2012;44:1373-8.

4. Kasahara M,　Umeshita K,　Inomata Y,　Uemoto S;　Japanese Liver Transplantation Society. Long-term outcomes of pediatric living donor liver transplantation in Japan: An analysis of more than 2200 cases listed in the registry of the Japanese Liver Transplantation Society. Am J Transplant.　2013;13:1830-9.

5. Byun J,　Yi NJ,　Lee JM,　Suh SW,　Yoo T,　Choi Y,　et al. Long term outcomes of pediatric liver transplantation according　to　age. J Korean Med Sci.　2014;29:320-7.