Improvements in Disease-Specific Health-Related Quality of Life of Pediatric Liver Transplant Recipients During Immunosuppression Withdrawal

Long-term immunosuppression (IS) leads to systemic complications affecting health-related quality of life (HRQOL) in pediatric liver transplantation (LT) recipients. We serially assessed HRQOL using the PedsQL Generic and Multidimensional Fatigue Scales and Family Impact and Transplant Modules as part of a multicenter prospective immunosuppression withdrawal (ISW) trial between 2012 and 2018. Participants received a primary LT ≥4 years before the study and were on stable IS with normal liver tests and without rejection in the prior 2 years. IS was withdrawn in 7 steps over 36 to 48 weeks. HRQOL was assessed at regular intervals. The primary endpoint was change in disease-specific HRQOL measured by the PedsQL Transplant Module. Generic HRQOL was measured by the PedsQL Generic Scale and was compared with an age-matched and sex-matched multicenter cohort. Of the 88 participants, 39 were boys, median age was 11 years (range, 8-13), and time since transplant was 9 years (range, 6-11). For 36 months, disease-specific HRQOL improved for all participants, whereas generic HRQOL was unchanged. Neither generic nor disease-specific HRQOL changed for the 35 participants who developed acute rejection during ISW. In the first use of patient-reported outcome measures during an ISW trial, we found improvements in disease-specific HRQOL in all participants and no lasting detrimental effects in those who experienced rejection.

The Sclerosing Cholangitis Outcomes in Pediatrics (SCOPE) Index: A Prognostic Tool for Children

BACKGROUND AND AIMS

Disease progression in children with primary sclerosing cholangitis (PSC) is variable. Prognostic and risk-stratification tools exist for adult-onset PSC, but not for children. We aimed to create a tool that accounts for the biochemical and phenotypic features and early disease stage of pediatric PSC.

APPROACH AND RESULTS

We used retrospective data from the Pediatric PSC Consortium. The training cohort contained 1,012 patients from 40 centers. We generated a multivariate risk index (Sclerosing Cholangitis Outcomes in Pediatrics [SCOPE] index) that contained total bilirubin, albumin, platelet count, gamma glutamyltransferase, and cholangiography to predict a primary outcome of liver transplantation or death (TD) and a broader secondary outcome that included portal hypertensive, biliary, and cancer complications termed hepatobiliary complications (HBCs). The model stratified patients as low, medium, or high risk based on progression to TD at rates of <1%, 3%, and 9% annually and to HBCs at rates of 2%, 6%, and 13% annually, respectively (P < 0.001). C-statistics to discriminate outcomes at 1 and 5 years were 0.95 and 0.82 for TD and 0.80 and 0.76 for HBCs, respectively. Baseline hepatic fibrosis stage was worse with increasing risk score, with extensive fibrosis in 8% of the lowest versus 100% with the highest risk index (P < 0.001). The model was validated in 240 children from 11 additional centers and performed well.

CONCLUSIONS

The SCOPE index is a pediatric-specific prognostic tool for PSC. It uses routinely obtained, objective data to predict a complicated clinical course. It correlates strongly with biopsy-proven liver fibrosis. SCOPE can be used with families for shared decision making on clinical care based on a patient's individual risk, and to account for variable disease progression when designing future clinical trials.

Oral Vancomycin, Ursodeoxycholic Acid, or No Therapy for Pediatric Primary Sclerosing Cholangitis: A Matched Analysis

BACKGROUND AND AIMS

Many children with primary sclerosing cholangitis (PSC) receive oral vancomycin therapy (OVT) or ursodeoxycholic acid (UDCA). There is a paucity of data on whether these medications improve outcomes.

APPROACH AND RESULTS

We analyzed retrospective data from the Pediatric PSC Consortium. Children treated with OVT were matched 1:1:1 to those treated with UDCA or managed with observation (no treatment) based on the closest propensity score, ensuring similar baseline characteristics. Two hundred sixty-four patients (88 each with OVT, UDCA, or observation) had matching propensity scores and were similar in demographics, phenotype, immunosuppression, baseline biochemistry, and hepatic fibrosis. After 1 year in an intention-to-treat analysis, all outcome metrics were similar regardless of treatment group. In OVT, UDCA, and untreated groups, respectively: Gamma-glutamyltransferase normalized in 53%, 49%, and 52% (P = not significant [NS]), liver fibrosis stage was improved in 20%, 13%, and 18% and worsened in 11%, 29%, and 18% (P = NS), and the 5-year probability of liver transplant listing was 21%, 10%, and 12% (P = NS). Favorable outcome was associated with having a mild phenotype of PSC and minimal hepatic fibrosis.

CONCLUSIONS

We presented the largest-ever description of outcomes on OVT in PSC and compared them to carefully matched patients on UDCA or no therapy. Neither OVT nor UDCA showed improvement in outcomes compared to a strategy of observation. Patients progressed to end-stage liver disease at similar rates. Spontaneous normalization of biochemistry is common in children receiving no therapy, particularly in the majority of children with a mild phenotype and an early stage of disease. Placebo-controlled treatment trials are needed to identify effective treatments for pediatric PSC.

A Learning Health System for Pediatric Liver Transplant: The Starzl Network for Excellence in Pediatric Transplantation

OBJECTIVE

Learning health systems (LHS) integrate research, improvement, management, and patient care, such that every child receives "the right care at the right time...every time," that is, evidence-based, personalized medicine. Here, we report our efforts to establish a sustainable, productive, multicenter LHS focused on pediatric liver transplantation.

METHODS

The Starzl Network for Excellence in Pediatric Transplantation (SNEPT) is the first multicenter effort by pediatric liver transplant families and providers to develop shared priorities and a shared agenda for innovation in clinical care. This report outlines SNEPT's structure, accomplishments, and challenges as an LHS.

RESULTS

We prioritized 4 initial projects: immunosuppression, perioperative anticoagulation, quality of life, and transition of care. We shared center protocols/management to identify areas of practice variability between centers. We prioritized actionable items that address barriers to providing "the right care at the right time" to every pediatric liver transplant recipient: facilitating transparency of practice variation and the connection of practices to patient outcomes, harnessing existing datasets to reduce the burden of tracking outcomes, incorporating patient-reported outcomes into outcome metrics, and accelerating the implementation of knowledge into clinical practice. This has allowed us to strengthen collaborative relationships, design quality improvement projects, and collect pilot data for each of our priority projects.

CONCLUSIONS

The field of pediatric liver transplantation can be advanced through application of LHS principles. Going forward, SNEPT will continue to unite patient advocacy, big data, technology, and transplant thought leaders to deliver the best care, while developing new, scalable solutions to pediatric transplantation's most challenging problems.

Outcomes following liver transplantation in young infants: Data from the SPLIT registry

Liver transplantation (LT) in young patients is being performed with greater frequency. We hypothesized that objective analysis of pre-, intra-, and postoperative events would help understand contributors to successful outcomes and guide transplant decision processes. We queried SPLIT registry for pediatric transplants between 2011 and 2018. Outcomes were compared for age groups: 0-<3, 3-<6, 6-<12 months, and 1-<3 years (Groups A, B, C, D respectively) and by weight categories: <5, 5-10, >10 kg; 1033 patients were available for analysis. Cholestatic disease and fulminant failure were highest in group A and those <5 kg; and biliary atresia in group C (72.8%). Group A had significantly higher life support dependence (34.6%; P < .001), listing as United Network for Organ Sharing status 1a/1b (70.4%; P < .001), and shortest wait times (P < .001). The median (interquartile range) for international normalized ratio and bilirubin were highest in group A (3.0 [2.1-3.9] and 16.7 [6.8-29.7] mg/dL) and those <5 kg (2.6 [1.8-3.4] and 13.5 [3.0-28.4] mg/dL). A pediatric end -stage liver disease score ≥40, postoperative hospital stays, rejection, and nonanastomotic biliary strictures were highest in group A with lowest survival at 93.1%. Infants 0 to <3 months and those <5 kg need more intensive care with lower survival and higher complications. Importantly, potential LT before reaching status 1a/1b and aggressive postoperative management may positively influence their outcomes.

1396. Live Virus Vaccination Following Pediatric Liver Transplantation: Results from Two Academic Children’s Hospitals

Background

Guidelines for immunization following solid organ transplantation discourage live virus vaccination (LVV) in most recipients. Single-center studies support LVV as safe and effective in orthotopic liver transplant (OLT) recipients on steroid-free immunosuppression (IS). We retrospectively evaluated LVV after OLT at 2 pediatric hospitals.

Methods

Records from OLT recipients between Jan 2007 and Dec 2017 at Lurie Children’s (Chicago) and Children’s Hospital of Philadelphia were reviewed. Patients who underwent OLT at either institution, had ≥ 2 years of follow up, and had documentation of vaccination prior to OLT were included. Adverse events (AEs) within two weeks of receipt of LVV were captured. Factors that might influence the selection of patients for LVV were reviewed, including choice, dose, frequency, and levels of IS medications. IS in non-vaccinated patients was compared to vaccinated patients at two year post-transplant follow-up in both groups using Chi-Square and T-test.

Results

Data from 249 patients met inclusion criteria. Varicella zoster (VZV) vaccine was given at least once to 92 patients post-transplant, and MMR to 91 (Table 1). Compared to patients who were re-vaccinated after transplant, those who received their first LVV after OLT were transplanted at a younger age (0.8 v 2.2 years) and received LVV sooner post-OLT (649 v 907 days). AEs were rare for either LVV: 2 experienced injection site reaction, 2 localized rash, and 1 had fever. One recipient experienced worsening rejection one month after MMR and received IV steroids and increased IS, but had no clinical findings concerning for viral infection from vaccination. Most LVV recipients were on a single IS agent both at time of LVV and 2 year post-OLT (Table 2), with tacrolimus the most frequent agent. Compared to those that did not received LVV post-OLT, those that did were on one IS agent more often. Tacrolimus levels were similar among patients receiving LVV post-OLT compared with those who did not.

Table 1

Table 2

Conclusion

In a series of pediatric OLT recipients, post-OLT LVV was generally safe and well tolerated. Patients who received LVV post-OLT were more often on one IS agent at 2 year follow up compared to those who did not. Our study supports prospective efforts to define guidelines for patients who may safely receive LVV after OLT.

Disclosures

Kevin J. Downes, MD, Merck, Inc. (Grant/Research Support)

Concomitant back and leg pain as predictors for trajectories of poor outcome after single level lumbar micro-decompression alone and with micro-discectomy: a study of 3,308 patients

BACKGROUND

Lumbar decompression is the commonest spinal intervention. One in four patients have suboptimal outcome postoperatively, however no large studies identified clear poor outcome predictors. The aim of this study was to study low back pain (LBP) as a predictor of poor outcome following lumbar micro-decompression.

METHODS

Prospectively collected spinal registry data was analysed for patients who underwent primary, single-level, decompression with or without discectomy at single spinal centre (2011-2017). Based on the response to the Likert global outcome question, we had two outcome groups (good & poor). Percentage of achievement of minimum clinically relevant change (MCRC) for Core Outcome Measures Index (COMI) score, LBP and leg pain (LP) was examined. A two-step approach was adopted. First, COMI score, LBP and LP visual analogue scales (VAS) trajectories were modelled using a discrete mixture model. Second, multinomial logistic regression was used to determine the association between variables and trajectories.

RESULTS

We included 3,308 patients with mean follow up (1.4 y). MCRC was achieved in COMI score in 63% of cases, 42% in LBP and 62% in LP. A three-group trajectory model was identified: large-improvement (LI) (n=980), moderate-improvement (MI) (n=1,364) and no-improvement (NI) (n=966) with 99.5%, 84.5% and 31.5% of patients presenting good outcome, respectively. Higher pre-operative LBP and COMI score and smoking were strongly associated with MI and NI. In addition, higher LP, post-operative surgical complications, previous surgery at same level, conservative treatment >6 months and anxiety/depression were associated with NI.

CONCLUSIONS

This is the first large-scale study reporting preoperative LBP severity, spinal stenosis and smoking as predictors for poor functional outcomes post lumbar decompression with or without discectomy. This is very useful while counselling patients for surgery to meet realistic expectations.

A community divided: Post-transplant live vaccine practices among Society of Pediatric Liver Transplantation (SPLIT) centers

BACKGROUND

Historically, the IDSA and the AST have recommended that live vaccines not be administered post-transplant due to concern for induction of vaccine-strain disease in immunocompromised hosts. However, recent prospective studies and revised AST guidelines published in April 2019 suggest that in the current era of immunosuppression minimization, live vaccines may be safely administered to select transplant recipients with resulting immunoprotection. The goal of this study was to assess current post-transplant live vaccine practices at individual pediatric liver transplant centers following the updated AST guidelines.

METHODS

A six-item email survey detailing center-specific post-transplant live vaccine practices followed by up to three response-specific questions were distributed between July 2019 and May 2020 to a representative from each center participating in the SPLIT consortium.

RESULTS

The overall survey response rate was 93% (41/44 centers). Only 29% (12/41) of centers offer live vaccines post-transplant; each of these 12 centers uses different eligibility criteria for live vaccines. There was no difference between large (ten or more transplants per year) and small (less than ten transplants per year) centers in likelihood to offer live vaccines post-transplant. The main reasons for a center not offering post-transplant live vaccines were safety concerns and inability to reach group consensus.

CONCLUSIONS

The majority of pediatric liver transplant centers are reluctant to offer live vaccines post-transplant despite the updated AST guidelines. Prospective multicenter studies are needed to confirm safety and immunogenicity of live vaccines post-transplant.

Vertebral body cemented stents combined with posterior stabilization in the surgical treatment of metastatic spinal cord compression of the thoracolumbar spine

Background

Extensile interventions to provide anterior spinal column support in metastatic spinal cord compression (MSCC) surgery incur added morbidity in this surgically frail group of patients. We present our preliminary results of posterior spinal decompression and stabilization coupled with vertebral body cemented stents for anterior column support in MSCC.

Methods

Fourteen patients underwent posterior spinal decompression and pedicle screw construct along with vertebral body stenting (VBS) technique for reconstruction and augmentation of the vertebral body. The primary in all except one was solid organ malignancy and 10 patients (71%) were treatment naïve. The mean revised Tokuhashi score was 10.7 ± 2.7 and the mean spinal instability neoplastic score was 9.6 ± 1.9. All vertebral body lesions were purely lytic and were associated with a cortical defect in the posterior wall.

Results

A mean 5.3 ± 2.7 ml low-viscosity polymethyl methacrylate bone cement was injected within the stent at each compression level. No cement extrusion posteriorly was noted in any case from intraoperative fluoroscopy or postoperative radiographs. Five patients died at a mean 6.8 months (range 1-15 months), while the remaining patients have a mean survival of 18 months. Neither further revision surgical intervention nor any neurological deterioration was noted in any patient, who all continued to be ambulatory. The mean postoperative Core Outcome Measures Index score for 11 patients was 4.03 (standard deviation 3.11, 95% confidence interval (1.93-6.12).

Conclusion

In lytic vertebral body lesions with posterior wall erosions, cemented VBS technique adds to the surgical armamentarium in MSCC surgery showing promising early results without added complications.

Impact of Acuity Circles on Outcomes for Pediatric Liver Transplant Candidates

BACKGROUND

In December 2018, United Network for Organ Sharing approved an allocation scheme based on recipients' geographic distance from a deceased donor (acuity circles [ACs]). Previous analyses suggested that ACs would reduce waitlist mortality overall, but their impact on pediatric subgroups was not considered.

METHODS

We applied Scientific Registry of Transplant Recipients data from 2011 to 2016 toward the Liver Simulated Allocation Model to compare outcomes by age and illness severity for the United Network for Organ Sharing-approved AC and the existing donor service area-/region-based allocation schemes. Means from each allocation scheme were compared using matched-pairs t tests.

RESULTS

During a 3-year period, AC allocation is projected to decrease waitlist deaths in infants (39 versus 55; P < 0.001), children (32 versus 50; P < 0.001), and teenagers (15 versus 25; P < 0.001). AC allocation would increase the number of transplants in infants (707 versus 560; P < 0.001), children (677 versus 547; P < 0.001), and teenagers (404 versus 248; P < 0.001). AC allocation led to decreased median pediatric end-stage liver disease/model for end-stage liver disease at transplant for infants (29 versus 30; P = 0.01), children (26 versus 29; P < 0.001), and teenagers (26 versus 31; P < 0.001). Additionally, AC allocation would lead to fewer transplants in status 1B in children (97 versus 103; P = 0.006) but not infants or teenagers. With AC allocation, 77% of pediatric donor organs would be allocated to pediatric candidates, compared to only 46% in donor service area-/region-based allocation (P < 0.001).

CONCLUSIONS

AC allocation will likely address disparities for pediatric liver transplant candidates and recipients by increasing transplants and decreasing waitlist mortality. It is more consistent with federally mandated requirements for organ allocation.

Health utility and quality of life in pediatric liver transplant recipients

To measure HU and HRQOL in pediatric liver transplant (LT) recipients, a cross-sectional study of patient-parent dyads was conducted. Direct HU were assessed in 48 adolescents ≥12 years using SG and TTO techniques. Indirect HU were measured by Health Utility Index 2 and HUI3 for subjects ≥12 years and CHU9D for ≥7 years. Patients reported HRQOL using PedsQL™ GC and PedsQL™ TM. A total of 108 dyads participated (55.6% female; 73.2% Caucasian; 42.6% biliary atresia; 35.2% living donor; 37.0% Medicaid). Mean age at survey was 13.6 ± 3.5 years, and time from LT was 8.9 ± 4.9 years. 61.2% were on monotherapy, 25 (23.2%) had acute rejection within 3 years, and 15 (13.9%) had a biliary obstruction within 5 years. Mean indirect HU and HRQOL scores by child report were lower than norms (P < .001). LRD recipients had higher PedsQL™ GC, PedsQL™ TM, and HUI3 scores (P < .01). HU in pediatric LT recipients are lower than norms. Availability of HU scores for post-transplant health states will enable measurement of quality-adjusted life years for future comparative effectiveness studies.

Pediatric liver transplantation from a living donor in mitochondrial disease: Good outcomes in DGUOK deficiency?

DGUOK deficiency is an autosomal recessive mitochondrial disorder characterized by hepatic and neurological manifestations. In patients with liver failure, the decision to perform LT can be difficult due to the likelihood of progressive neurological disease. We present a case of a 9-month-old boy who had DGUOK deficiency (E227K/R118H genotype) intact neurological status and liver failure. His MRI indicated extensive white matter changes, which created hesitation to perform LT. After a multidisciplinary evaluation, he underwent LT from a living donor at 11 months of age. Six years post-transplant, he has had no significant complications and no progression of neurological symptoms. Our case supports that even in the presence of neurological MRI findings, but in the absence of significant neurological symptoms, LT represents a viable option in DGUOK-deficient patients who have the E227K/R118H mutation combination along with liver failure.

The evolution of early liver biopsy findings in babies with jaundice may delay the diagnosis and treatment of biliary atresia

BACKGROUND

The early diagnosis of biliary atresia (BA) is associated with a better outcome after portoenterostomy. However, very early liver biopsy findings may appear atypical for BA and delay diagnosis. Repeat biopsy histology may change rapidly to show more typical features.

METHODS

Between 1997 and 2018, 6 babies with jaundice had more than one biopsy to establish diagnosis. Clinical and histologic data were collected. chi-Square was used for analysis (p < 0.05 significant).

RESULTS

Five patients had two biopsies, and one had three. Median age at first, second, and third biopsy was 40 (13-57), 68.5 (35-78), and 133 days, respectively. Biopsy readings showed no portal edema initially (0/6), but in all 6 on repeat biopsy (p = 0.001). Bile duct proliferation was seen in 6/6 final biopsies, but in only 1/6 initially (p = 0.003). All patients underwent a portoenterostomy (median age 75 days (43-113)). Median delay between initial biopsy and Kasai was 29 days (14-67). Transplant free survival (n = 5 patients) ranged from 184 to 716 days (median 309 days). One patient died before being transplanted.

CONCLUSION

Early biopsies may not display characteristic findings of BA, but these can appear quickly on subsequent evaluation. The interval needed to repeat a biopsy may have an adverse effect on bile drainage.

LEVEL OF EVIDENCE

IV.

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.

The clinical and radiological outcomes of multilevel posterior lumbar interbody fusion in the treatment of degenerative scoliosis: a consecutive case series with minimum 2 years follow up

Background

Surgical treatment for adult degenerative scoliosis (ADS) is a complex undertaking and is associated with a high complication rate. Our aim was to evaluate the clinical and radiological outcomes, mortality and morbidity of multilevel posterior lumbar interbody fusion (MPLIF) in the treatment in ADS based on the experience of a single tertiary referral center for spinal surgery.

Methods

We performed a retrospective analysis of prospectively collected data of consecutive patients who had undergone multi-level posterior interbody fusion for degenerative scoliosis. We prospectively recorded patients' demographics, co-morbidities; coronal and sagittal plane deformity assessment and surgical details: number of instrumented levels, and intra-operative and postoperative complications. Functional outcomes and patient-reported complications were entered in our local spine surgery database (part of the Eurospine Spine Tango Registry) and used to collect data on functional scores and patient-reported complications preoperatively and at 6, 12 and 24 months' follow-up.

Results

Our study involved 13 males and 51 females with a mean age of 70.26 (range 49-90, SD 8.9). MPLIF was performed at five levels in one patient, four levels in 29 patients, three levels in 20 patients, and two levels in 14 patients. There were a total of 14 (21.87%) major, minor and mechanical complications. There were no procedure-related mortalities. The average COMI and Eq5d scores improved significantly post-surgery, and this improvement was maintained at a mean follow-up of up to two years.

Conclusions

Multilevel posterior interbody fusion is a safe procedure, and in selected cases can result in good clinical and radiological outcomes with improvement in patient quality of life.

Concomitant back pain as a predictor of outcome after single level lumbar micro-decompressive surgery - A study of 995 patients

Objective

To determine if preoperative leg pain and low back pain severity affected postoperative outcome.

Method

Prospectively collected Spine-Tango data was analysed for 995 consecutive patients who underwent a primary, single level, lumbar micro-decompression/microdiscectomy at a single tertiary spinal centre.

Result

At 3 months, 72% of patients were satisfied with the outcome of surgery. Pre-operative low back pain was a significant predictor of poor outcome (P < 0.01).

Conclusion

Our study has shown that patients with a low back pain VAS of 6 or more have a significantly greater chance of a poor outcome following primary lumbar microdecompressive/microdiscectomy surgery.

Magnetic Resonance Imaging: A Personalized Approach to Understanding Fatty Liver Disease

OBJECTIVES

To assess information retention by parents/caretakers regarding nonalcoholic fatty liver disease (NAFLD) utilizing the actual image of their child's affected liver.

METHODS

In this pilot study, parents/caretakers of children with newly diagnosed NAFLD were presented with an magnetic resonance (MR) image of their child's fatty liver. An adjacent image of a normal-appearing liver was used to highlight the degree of fat accumulation present in their child's liver. The appearance of the fatty liver was used as an adjunct to patient education as provided by a nurse clinician. The efficacy of this approach was determined by a set of image- and disease-specific queries. Health literacy was assessed concurrently by the Newest Vital Sign (NVS) instrument. The image- and disease-specific queries were then repeated by telephone follow-up 2 to 4 weeks after initial clinic visit.

RESULTS

Parents/caretakers initially gave 100% correct responses regarding the variation of appearance of normal liver (pink) and their child's fatty liver (yellow). They also all correctly stated the fat content initially. At follow-up, their recall was 95% for the appearance of normal liver and 81% for fatty liver; recall was only 52% for fat content at follow-up. Nonvisualized elements of nonalcoholic steatohepatitis (NASH) and cirrhosis were not identified or recalled as well. Results may have been influenced by parent/caretaker health literacy competence.

CONCLUSIONS

Personalized images of fatty liver were effective visualization tools for parents/caretakers to comprehend NAFLD and comprehension was not compromised by health literacy. Clear visual instruments may improve parent/caretaker comprehension of these conditions and may help to address deficiencies in health literacy.

Corticosteroid Therapy for Indeterminate Pediatric Acute Liver Failure and Aplastic Anemia with Acute Hepatitis

OBJECTIVE

To examine the characteristics and outcomes of a multicenter patient cohort with indeterminate pediatric acute liver failure (IND-PALF) and with aplastic anemia with acute hepatitis treated with corticosteroids.

STUDY DESIGN

Retrospective study of patients age 1-17 years with IND-PALF and aplastic anemia with acute hepatitis who presented between 2009 and 2018 to 1 of 4 institutions and were treated with corticosteroids for presumed immune dysregulation.

RESULTS

Of 28 patients with IND-PALF (median of 4.0 years of age [range 1-16] and 71% male) 71% (n = 20) were treated with 0.5-4 mg/kg/day of intravenous methylprednisolone, and 8 patients received 10 mg/kg/day followed by a taper. By 21 days postcorticosteroid initiation, 14 patients (50%) underwent liver transplantation, 13 patients (46%) recovered with their native liver, and 1 patient (4%) died. Patients who recovered with their native liver received a median of 139 days (range 19-749) of corticosteroid therapy, with a median of 12 days (range 1-240) to international normalized ratio ≤1.2. Patients with aplastic anemia with acute hepatitis (n = 6; median of 9.5 years of age [range 1-12], 83% male), received 1-2 mg/kg/day of methylprednisolone for a median of 100 days (range 63-183), and all recovered with their native liver. One patient with IND-PALF and 2 patients with aplastic anemia with acute hepatitis developed a serious infection within 90 days postcorticosteroid initiation.

CONCLUSIONS

Many patients with IND-PALF or aplastic anemia with acute hepatitis that were treated with corticosteroids improved, but survival with native liver may not be different from historical reports. A randomized controlled trial exploring the benefits and risks of steroid therapy is needed before it is adopted broadly.

Comparative study of multilevel posterior interbody fusion plus anterior longitudinal ligament release versus classic multilevel posterior interbody fusion in the treatment of adult spinal deformities

OBJECTIVE

Sagittal imbalance and loss of lumbar lordosis are the main drivers of functional disability in adult degenerative scoliosis. The main limitations of the classic posterior lumbar interbody fusion technique are increased risk of neurological injury and suboptimal correction of the segmental lordosis. Here, the authors describe the radiological results of a modified posterior lumbar interbody fusion and compare the results with a historical cohort of patients.

METHODS

Eighty-two consecutive patients underwent surgical treatment for degenerative scoliosis/kyphosis in a single tertiary referral center for complex spinal surgery. Fifty-five patients were treated using the classic multilevel posterior lumbar interbody fusion (MPLIF) technique and 27 were treated using the modified MPLIF technique to include a release of the anterior longitudinal ligament (ALL) and the annulus. A radiographic review of both series of patients was performed by two independent observers. Functional outcomes were obtained, and patients were registered in the European Spine Tango registry.

RESULTS

The mean L4-5 disc angle increased by 3.14° in the classic MPLIF group and by 12.83° in MPLIF plus ALL and annulus release group. The mean lumbar lordosis increased by 15.23° in the first group and by 25.17° in the second group. The L4-S1 lordosis increased on average by 4.92° in the classic MPLIF group and increased by a mean of 23.7° in the MPLIF plus ALL release group when both L4-5 and L5-S1 segments were addressed. There were significant improvements in the Core Outcome Measures Index and EQ-5D score in both groups (p < 0.001). There were no vascular or neurological injuries observed in either group.

CONCLUSIONS

The authors' preliminary results suggest that more correction can be achieved at the disc level using posterior-based ALL and annulus release in conjunction with posterior lumbar interbody fusion. They demonstrate that ALL and annulus release can be performed safely using a posterior-only approach with minimal risk of vascular injury. However, the authors recommend that this approach should only be used by surgeons with considerable experience in anterior and posterior spinal surgery.

The implementation of enhanced recovery after surgery (ERAS) in complex spinal surgery

Background

This paper aims to review the introduction of an enhanced recovery after surgery (ERAS) service within complex spinal surgery, with an aim to assess if this is a cost effective way to improve the overall experience of such complex surgery.

Methods

The ERAS model was defined and followed within a regional centre for complex spinal surgery in the UK. Outcomes such as length of stay (LOS) and satisfaction were measured before and after implementation of the service.

Results

LOS was reduced and both patient and staff satisfaction improved following the implementation of the ERAS service.

Conclusions

The ERAS model can successfully be implemented within complex spinal surgery, to help improve satisfaction and reduce cost.

Liver histopathology in patients with hepatic masses and the Abernethy malformation

BACKGROUND/PURPOSE

The Abernethy malformation (AM) is a congenital venous malformation in which the splanchnic venous return bypasses the liver and drains directly into the systemic circulation. This deprives the liver of hepatotrophic growth factors and allows metabolic products of digestion to enter the systemic veins without the benefit of passing through the liver. The histologic features of liver biopsies in children with an AM were reviewed.

METHODS

A retrospective review of liver biopsies in patients with AM between 1997 and 2017 was performed. Patients were divided into two groups for comparison of histologic features: presence (M+) or absence (M-) of a coexistent liver mass on imaging. Biopsies were reviewed by a pediatric pathologist. Chi-square test was used for statistical analysis between groups. Significance was assigned to p values <0.05.

RESULTS

Eighteen liver biopsies were reviewed. Masses were present in only 6 patients who had a liver biopsy. Masses were observed with similar frequencies in either type of the Abernethy malformation (I or II). Nine of 12 M- patients and 3/6 M+ patients had the type I AM. Histologically, all patients were noted to have small or absent portal veins. Isolated capillaries were seen more frequently in patients with a known liver mass (p = 0.045), while crowding of portal tracts was more commonly seen in patients without a liver mass (p = 0.019).

CONCLUSION

Liver biopsies in patients with AM demonstrate abnormal vascular and parenchymal histologic features. Livers with coexistent masses were more commonly found to have features suggesting an increased dependence on arterial blood supply.

LEVEL OF EVIDENCE

III.

Liver Biopsy Can Be Safely Performed in Pediatric Acute Liver Failure to Aid in Diagnosis and Management

OBJECTIVES

Liver biopsy can be a valuable tool to help determine the etiology of pediatric acute liver failure (PALF), but is often not performed due to safety concerns. The primary aim was to describe the incidence of major complications after liver biopsy performed in the setting of PALF.

METHODS

Medical records from 2006 to 2016 were reviewed. Patients age 0 to 17 years, who met criteria for PALF, and had a liver biopsy performed while their international normalized ratio (INR) was ≥1.5 were included.

RESULTS

A total of 26 cases of liver biopsy in the setting of PALF were identified. The majority (n = 22, 85%) of patients had primary liver disease. Most biopsies (n = 17, 65%) were performed by the transjugular route, with 5 (19%) performed percutaneously under ultrasound guidance and 4 (15%) during a surgical procedure. Median INR before biopsy was 2.1 (IQR = 1.73-2.9). Blood products were given before or during the procedure in 23 (88%) cases. One patient (3.8%) had a major complication of biopsy-associated bleeding requiring a blood transfusion. An additional 3 patients had a hemoglobin decrease of 2.1 to 2.9 g/dL post-biopsy that was attributed to the procedure but no interventions were necessary. Biopsy results contributed to establishing a diagnosis in 62% (n = 16) of cases, and influenced treatment decisions in 9 of those cases.

CONCLUSIONS

Liver biopsy is safe in the majority of patients with PALF and associated with infrequent major complications. Clinicians should consider performing liver biopsy in this setting, especially when the transjugular approach is feasible, since findings may guide diagnosis and therapy.