From graft survival to life: redefining success after pediatric liver transplantation.

Over four decades, pediatric liver transplantation represents a major medical achievement. Graft function and biochemical stability alone no longer define success. Recent data show that only a minority of long-term survivors meet composite criteria for "meaningful" survival, which includes psychological wellbeing, social integration, and treatment adherence. Growing up with a transplant shapes identity, autonomy, and life trajectory. Although many recipients achieve education, employment, and parenthood, patient-reported outcomes reveal persistent psychological distress, reduced health-related quality of life, and ongoing vulnerability. Mental health symptoms, limited health literacy, and gaps in disease understanding may compromise adherence and long-term outcomes. Substance use, while not necessarily more prevalent than in the general population, carries disproportionate risks in this fragile group and underscores the need for early, structured prevention. Transition from pediatric to adult care represents a critical pivotal and formative period, marked by increased risk of nonadherence and graft complications or graft loss, but also a unique opportunity to strengthen autonomy, psychoeducation, and self-management skills. We argue for a paradigm shift toward lifelong, multidisciplinary follow-up integrating psychological screening, structured transition pathways, and sustained health education. Pediatric transplantation has created long-term survivors. The next challenge is to ensure they become informed, autonomous, and psychologically supported adults.