One of the key problems facing children awaiting liver transplantation is the shortage of donor organs. Surgical procedures that address this problem include: reduced-size liver transplantation (RLT), split liver transplantation (SLT), and living related liver transplantation (LRLT). RLT makes more of the current donor pool accessible to the pediatric recipient. SLT furnishes 2 liver grafts from 1 cadaveric donor, and LRLT provides an innovative supply of donor organs. This report compares the results achieved with RLT, SLT, and LRLT to those seen with full-size orthotopic liver transplantation (OLT). Between November 1984 and February 1991, 457 liver transplants were performed at the University of Chicago. Two hundred fourteen of these transplants were placed into recipients less than 13 years of age. Of these 214 pediatric orthotopic liver transplants (OLT), 103 were full-size livers and 111 were some type of reduced graft (RLT, SLT, or LRLT). There were 57 RLT, 34 SLT, and 20 LRLT. The recipients of the reduced grafts (RLT, SLT, or LRLT) averaged 1.9 +/- 1.8 years of age and 9.6 +/- 6.4 kg compared to the recipients of the full-size livers who averaged 3.5 +/- 3.4 years of age and 14.1 +/- 8.8 kg (p = 0.0001). The most common indication for transplantation was biliary atresia (105 patients). Overall patient survival after primary full-size OLT was 71.8%. Reduced-size OLT (RLT, SLT, and LRLT) resulted in an overall patient survival of 72.6% after primary transplantation. Patient survivals for primary transplants with specific types of reduced-size grafts were: RLT 76.5% (after RLT was used routinely), SLT 66.7%, and LRLT 89.5%.(ABSTRACT TRUNCATED AT 250 WORDS)