Background: Pediatric acute liver failure (PALF) is the second most common cause of liver transplantation (LT), but its outcome is the worst. The purpose of this study is to compare the long-term survival outcomes of PALF to biliary atresia (BA).
Methods: Medical records of 36 PALF and 120 BA patients who underwent LT in our institution for 17 years, were retrospectively reviewed. The most cause of PALF was unknown (66.7%) followed by Wilson’s disease (13.8%). The overall median follow-up period was 133 months.
Results: Patients in PALF group were older (6.2 vs. 2.9 years old) and had higher PELD scores (31.5 vs. 24.4) and shorter waiting time (15.7 vs. 256.1 days) than BA group (p<0.01). PALF group showed higher rates of renal replacement therapy (13.2% vs. 4.2%) and hepatic artery complication (13.9% vs. 0.8%) although portal vein complication rates were lower (0% vs. 10.8%) than BA group (p <0.05). PALF group showed significantly lower 1-year (80.6% vs. 96.7%) and 5-year (77.8% vs. 95.0 %) survival rates compared to the outcome of BA group (p<0.05). However, the 5-year survival rate of PALF group was comparable to BA group beyond the first year of LT (96.4% vs. 98.3%, p=0.548). In multivariate analysis, hepatic artery complications and postoperative renal replacement therapy were associated with poor survival outcomes (p<0.05). 
Conclusion: The survival outcome of PALF group was comparable to BA group beyond the first year of LT. More attention to the recipients with PALF should be given to immediate postoperative care including hepatic artery complications.