Society of pediatric liver transplantation: Current registry status 2011-2018

BACKGROUND

SPLIT was founded in 1995 in order to collect comprehensive prospective data on pediatric liver transplantation, including waiting list data, transplant, and early and late outcomes. Since 2011, data collection of the current registry has been refined to focus on prospective data and outcomes only after transplant to serve as a foundation for the future development of targeted clinical studies.

OBJECTIVE

To report the outcomes of the SPLIT registry from 2011 to 2018.

METHODS

This is a multicenter, cross-sectional analysis characterizing patients transplanted and enrolled in the SPLIT registry between 2011 and 2018. All patients, <18 years of age, received a first liver-only, a combined liver-kidney, or a combined liver-pancreas transplant during this study period.

RESULTS

A total of 1911 recipients from 39 participating centers in North America were registered. Indications included biliary atresia (38.5%), metabolic disease (19.1%), tumors (11.7%), and fulminant liver failure (11.5%). Greater than 50% of recipients were transplanted as either Status 1A/1B or with a MELD/PELD exception score. Incompatible transplants were performed in 4.1%. Kaplan-Meier estimates of 1-year patient and graft survival were 97.3% and 96.6%. First 30 days of surgical complications included reoperation (31.7%), hepatic artery thrombosis (6.3%), and portal vein thrombosis (3.2%). In the first 90 days, biliary tract complications were reported in 13.6%. Acute cellular rejection during first year was 34.7%. At 1 and 2 years of follow-up, 39.2% and 50.6% had normal liver tests on monotherapy (tacrolimus or sirolimus). Further surgical, survival, allograft function, and complications are detailed.

P942 Outcome prediction by exercise stress echocardiography and cardiopulmonary exercise testing assessment in patients with heart failure

Background

Cardiopulmonary exercise testing (CPX) is essential to the assessment of functional impairment and prognosis in patients with heart failure (HF). Peak oxygen consumption (peak VO2) continues to be considered the gold standard for assessing prognosis in HF. The minute ventilation-carbon dioxide production (VE-VCO2) slope has recently demonstrated prognostic significance in patients with HF. Ergometer stress echocardiography (Erg-Echo) is useful to evaluate the exercise-induced pulmonary hypertension and the potential cardiac dysfunction that are difficult to evaluate in the resting state.

Objective

The aim of this study is to evaluate the relationship between CPX and Erg-echo indices, and the usefulness of Erg-echo to determine the severity of cardiac dysfunction and the prognosis in patients with HF.

Methods

We studied 58 patients with HF (age 65.2 ± 11.9 years) and performed CPX and Erg-Echo. The peak VO2 and the VE-VCO2 slope were measured by CPX. Cardiac output (CO) and estimated mean pulmonary artery pressure (mPAP) were measured by Erg-Echo at rest and peak exercise load, and the change ratio (ΔmPAP / ΔCO) were calculated. We evaluated the clinical outcome during a1 year period.

Results

The ΔmPAP / ΔCO was significantly correlated with the peak VO2 (R = -0.6767, P &lt;0.0001) and the VE-VCO2 slope (R = 0.6809, P &lt;0.0001). Cardiovascular events (1 patient of cardiovascular death, 8 patients of re-hospitalization due to HF, 4 patients of myocardial ischemia, 2 patients of Cardiac Resynchronization Therapy (CRT) devices implantation, 1 patient of ventricular tachycardia) developed in 16 of the 58 patients (27.5%: Group CE) during the 1 year. The peak VO2 was significantly lower (12.1 ± 2.5 vs. 16.1 ± 3.1ml/min/kg, P &lt;0.0001) and the VE-VCO2 slope was significantly higher (41.1 ±. 12.3 vs. 31.8 ± 6.1ml/ml, P &lt;0.0001) in Group CE compared to the other 42 patients (Group N). The ΔmPAP was significantly higher (19.1 ± 4.4 vs. 14.9 ± 6.4, P = 0.0408) and the ΔCO was significantly lower (2.4 ± 1.2 vs. 4.1 ± 2.0, P = 0.0078), and the ΔmPAP / ΔCO was significantly higher (9.7 ± 4.6 vs. 4.4 ± 2.4, P &lt;0.0001) in Group CE compared to Group N.

Conclusions

The ΔmPAP/ ΔCO by Erg-Echo is useful to evaluate the severity of cardiac dysfunction and the prognosis of HF patients.

P1802 Prevalence and prognostic significance of pulmonary artery aneurysms in patients with pulmonary artery hypertension

Background

Pulmonary artery aneurysm (PAA) occurs in some patients with pulmonary arterial hypertension (PAH) and can be accompanied by various complications.

Objective

The aim of the this study is to evaluate the characteristics of cardiac dysfunction and the prognostic impact of PAA by analysing the outcome of patients with PAH complicated by PAA.

Methods

We performed echocardiography and right-heart catheterization in 130 PAH patients. We measured the maximum dimensions of the main pulmonary artery (MPA) trunk. We evaluated the right ventricular (RV) function and the five-year prognosis of patients with PAA.

Results

The maximum MPA trunk diameter of &gt;40 mm by echocardiography was defined as PAA. PAA appeared in 32 of the 130 PAH patients (24.6%: Group PAA), other 98 patients were defined as Group non-PAA. Systolic pulmonary artery pressure (76 ±18 vs. 61 ± 21 mmHg, P = 0.0008) and mean right atrial pressure (10.0 ± 8.1 vs. 5.4 ± 3.8 mmHg, P &lt; 0.0001) were significantly higher in Group PAA than in Group non-PAA. RV end-diastolic area index was significantly larger (37.3 ± 8.8 vs. 32.3 ± 7.8 mmHg, P = 0.0048), and RV fractional area change (32 ± 8 vs. 36 ± 9 %, P = 0.0176) and RV longitudinal strain amplitude (-16 ±5 vs. -20 ± 6, P = 0.0017) were significantly lower in Group PAA than those in Group non-PAA. During the five-year follow-up period, 20 patients (15%) died. The five-year mortality rate was significantly higher in Group PAA compared to Group non-PAA (30% vs. 10%, P = 0.007).

Conclusion

In PAH patients with PAA, RV dysfunction was more severe and the prognosis was poor. Assessment of PAA can be a useful index for the extraction of high-risk PAH patients.

[How to Implant a Prosthetic Valve in the Aortic and Mitral Valve Positions]

We surgeons have to achieve a good result for surgical valve replacement which is not inferior to trans-catheter heart valve treatments. This column aimed to learn fundamental skills for surgical valve implantation and to learn types of suturing techniques. For updated information, we mentioned about choice of valve and suturing technique for valve-in-valve procedure into surgical valve. We should take into consideration valve type, size, and how-to implantation of surgical valve which would affect the future valve-in-valve procedure.

Anti-C1 domain antibodies that accelerate factor VIII clearance contribute to antibody pathogenicity in a murine hemophilia A model

Essentials Inhibitor formation remains a challenging complication of hemophilia A care. The Bethesda assay is the primary method used for determining bleeding risk and management. Antibodies that block factor VIII binding to von Willebrand factor can increase FVIII clearance. Antibodies that increase clearance contribute to antibody pathogenicity.

SUMMARY

Background The development of neutralizing anti-factor VIII (FVIII) antibodies remains a challenging complication of modern hemophilia A care. In vitro assays are the primary method used for quantifying inhibitor titers, predicting bleeding risk, and determining bleeding management. However, other mechanisms of inhibition are not accounted for in these assays, which may result in discrepancies between the inhibitor titer and clinical bleeding symptoms. Objectives To evaluate FVIII clearance in vivo as a potential mechanism for antibody pathogenicity and to determine whether increased FVIII dosing regimens correct the associated bleeding phenotype. Methods FVIII-/- or FVIII-/- /von Willebrand factor (VWF)-/- mice were infused with anti-FVIII mAbs directed against the FVIII C1, C2 or A2 domains, followed by infusion of FVIII. Blood loss via the tail snip bleeding model, FVIII activity and FVIII antigen levels were subsequently measured. Results Pathogenic anti-C1 mAbs that compete with VWF for FVIII binding increased the clearance of FVIII-mAb complexes in FVIII-/- mice but not in FVIII-/- /VWF-/- mice. Additionally, pathogenic anti-C2 mAbs that inhibit FVIII binding to VWF increased FVIII clearance in FVIII-/- mice. Anti-C1, anti-C2 and anti-A2 mAbs that do not inhibit VWF binding did not accelerate FVIII clearance. Infusion of increased doses of FVIII in the presence of anti-C1 mAbs partially corrected blood loss in FVIII-/- mice. Conclusions A subset of antibodies that inhibit VWF binding to FVIII increase the clearance of FVIII-mAb complexes, which contributes to antibody pathogenicity. This may explain differences in the bleeding phenotype observed despite factor replacement in some patients with hemophilia A and low-titer inhibitors.

Multiple Re-entry Closures After TEVAR for Ruptured Chronic Post-dissection Thoraco-abdominal Aortic Aneurysm

Introduction

Although thoracic endovascular aortic repair (TEVAR) has become a promising treatment for complicated acute type B dissection, its role in treating chronic post-dissection thoraco-abdominal aortic aneurysm (TAA) is still limited owing to persistent retrograde flow into the false lumen (FL) through abdominal or iliac re-entry tears.

Report

A case of chronic post-dissection TAA treatment, in which a dilated descending FL ruptured into the left thorax, is described. The primary entry tear was closed by emergency TEVAR and multiple abdominal re-entries were closed by EVAR. In addition, major re-entries at the detached right renal artery and iliac bifurcation were closed using covered stents. To close re-entries as far as possible, EVAR was carried out using the chimney technique, and additional aortic extenders were placed above the coeliac artery. A few re-entries remained, but complete FL thrombosis of the rupture site was achieved. Follow-up computed tomography showed significant shrinkage of the FL.

Discussion

In treating post-dissection TAA, entry closure by TEVAR is sometimes insufficient, owing to persistent retrograde flow into the FL from abdominal or iliac re-entries. Adjunctive techniques are needed to close these distal re-entries to obtain complete FL exclusion, especially in rupture cases. Recently, encouraging results of complete coverage of the thoraco-abdominal aorta with fenestrated or branched endografts have been reported; however, the widespread employment of such techniques appears to be limited owing to technical difficulties. The present method with multiple re-entry closures using off the shelf and immediately available devices is an alternative for the endovascular treatment of post-dissection TAA, especially in the emergency setting.

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A case of ruptured post-dissection thoraco-abdominal aneurysm was treated.

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Following entry closure by TEVAR, EVAR was performed to close multiple re-entries.

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Re-entries at the renal artery ostium and iliac artery were closed by covered stents.

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Complementary re-entry closure techniques are essential to treat false lumen rupture.

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This report demonstrates successful re-entry closure techniques following TEVAR.

Comparing the risk of hepatitis B virus reactivation between direct-acting antiviral therapies and interferon-based therapies for hepatitis C

Hepatitis B virus (HBV) reactivation has been reported during antihepatitis C treatment in patients with hepatitis C virus (HCV) and HBV co-infection. We aimed to evaluate the frequency and risk factors of HBV reactivation during anti-HCV therapy and compared those between interferon (IFN)-free direct-acting antiviral (DAA) therapies and IFN-based therapies. Three hundred and twenty-two patients with HCV infection receiving anti-HCV therapy were retrospectively screened. The baseline HBV infection statuses of all eligible patients and the HBV-DNA level of all patients with current or previous HBV infection were examined at the end of treatment. In patients with baseline anti-HBs positivity, changes in anti-HBs titre were evaluated. Of 287 patients who met the inclusion criteria, 157 had current (n=4) or previous (n=153) HBV infection; 85 were treated with IFN-free DAA therapies and 72 were treated with IFN-based therapies. Six patients experienced HBV reactivation (n=2) or HBV reappearance (n=4) after IFN-free DAA therapies, while no patient developed HBV reactivation after IFN-based therapies. The risk factors of HBV reactivation or reappearance were DAA therapies and a reduction in anti-HBs titre to <12 mIU mL^-1 by the end of treatment. The decline changes of anti-HBs titre were significantly higher in patients treated with DAA therapies. Although HBV reactivation hepatitis was not observed, three of four patients with HBV reactivation or reappearance after achieving HCV eradication had viremia 8 weeks after completion of therapy. A significant proportion of patients develop HBV reactivation or reappearance without hepatitis after IFN-free DAA therapies. Low levels of anti-HBs and their decrease to <12 mIU mL^-1 after treatment are significant risk factors for HBV reactivation or reappearance.

Cost-effectiveness of cognitive remediation and supported employment for people with mental illness: a randomized controlled trial

BACKGROUND

Little is known about the economic benefits of cognitive remediation and supported employment (CR + SE). The present study aimed to investigate the cost-effectiveness of CR + SE compared with traditional vocational services (TVS).

METHOD

Individuals with mental illness and low cognitive function were recruited at six sites in Japan. A total of 111 participants were randomly allocated to the CR + SE group or the TVS group. Clinical and vocational outcomes were assessed at baseline and 12-month follow-up. Service utilization data were collected monthly. The data on outcomes and costs were combined to examine cost-effectiveness.

RESULTS

The data were obtained from a total of 92 participants. The CR + SE group resulted in better vocational and clinical outcomes (employment rate, 62.2%; work tenures, 78.6 days; cognitive improvement, 0.5) than the TVS group (19.1%, 24.9 days and 0.2). There was no significant difference in mean total costs between the groups (CR + SE group: $9823, s.d. = $6372, TVS group: $11 063, s.d. = $11 263) with and without adjustment for covariates. However, mean cost for medical services in the CR + SE group was significantly lower than that in the TVS group after adjusting covariates (Β = -$3979, 95% confidence interval -$7816 to -$143, p = 0.042). Cost-effectiveness acceptability curves for vocational outcomes illustrated the high probabilities (approximately 70%) of the CR + SE group being more cost-effective than TVS when society is not willing to pay additional costs.

CONCLUSIONS

CR + SE appears to be a cost-effective option for people with mental illness who have low cognitive functioning when compared with TVS.

Hair cell stereociliary bundle regeneration by espin gene transduction after aminoglycoside damage and hair cell induction by Notch inhibition

Once inner ear hair cells (HCs) are damaged by drugs, noise or aging, their apical structures including the stereociliary arrays are frequently the first cellular feature to be lost. Although this can be followed by progressive loss of HC somata, a significant number of HC bodies often remain even after stereociliary loss. However, in the absence of stereocilia they are nonfunctional. HCs can sometimes be regenerated by Atoh1 transduction or Notch inhibition, but they also may lack stereociliary bundles. It is therefore important to develop methods for the regeneration of stereocilia, in order to achieve HC functional recovery. Espin is an actin-bundling protein known to participate in sterociliary elongation during development. We evaluated stereociliary array regeneration in damaged vestibular sensory epithelia in tissue culture, using viral vector transduction of two espin isoforms. Utricular HCs were damaged with aminoglycosides. The utricles were then treated with a γ-secretase inhibitor, followed by espin or control transduction and histochemistry. Although γ-secretase inhibition increased the number of HCs, few had stereociliary arrays. In contrast, 46 h after espin1 transduction, a significant increase in hair-bundle-like structures was observed. These were confirmed to be immature stereociliary arrays by scanning electron microscopy. Increased uptake of FM1-43 uptake provided evidence of stereociliary function. Espin4 transduction had no effect. The results demonstrate that espin1 gene therapy can restore stereocilia on damaged or regenerated HCs.

29 THE NOVEL CRYOPROTECTIVE AGENT CARBOXYLATED ε-POLY-L-LYSINE IS EFFECTIVE FOR VITRIFICATION OF PRE-IMPLANTATION MOUSE EMBRYOS AT THE DIFFERENT STAGES

Embryo cryopreservation is one of the important technologies in various research and clinical areas. Very recently, carboxylated ε-poly-L-lysine (COOH-PLL) has been developed as a new cryoprotective regent, and we previously demonstrated that combined treatment of COOH-PLL with ethylene glycol (EG), which is a commonly used cryoprotective regent, is effective for vitrification of unfertilized mouse oocytes and pronuclear embryos. In this study, we examined different concentration of COOH-PLL and tried to vitrify the embryos at the different stages beyond the 2-cell stage using the same protocol. Embryos at the pronuclear, 2-cell, 4-cell, 8-cell, morulae, and blastocyst stages were treated with 7.5% (vol/vol) EG and 7.5% (vol/vol) COOH-PLL for 3 min and then vitrified with 15% EG (vol/vol) and 15% (vol/vol) COOH-PLL (E15P15) for 1 min by the Cryotop. The embryos except for pronuclear embryos showed low rates of survival, blastocyst, and hatched blastocysts. To improve the survival and developmental ability of the vitrified embryos, blastocysts were vitrified with different concentrations of COOH-PLL. At the results, the survival and developmental rates of vitrified blastocyst in E20P10 group were higher (98.0 ± 2.5% and 93.3 ± 4.0%) than those of the E30, E25P5, and E15P15 groups (P < 0.05). When 2-cell, 4-cell, and 8-cell embryos or morulae were vitrified with E20P10, survival, blastocyst, and hatched blastocyst rates were dramatically improved (more than 86.0%). Taken together, vitrification with 20% COOH-PLL and 10% EG is available for vitrification of mouse pre-implantation embryos at the different stages.