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López Santamaría M, Gámez M, Murcia J, Frauca E, Hierro L, Camarena C, de la Vega A, Díaz M, Jara P, Prieto C, Berrocal T, Garzón G, Tovar J. [Pre-hepatic portal hypertension as a late complication of liver transplantation in children]. CIRUGIA PEDIATRICA : ORGANO OFICIAL DE LA SOCIEDAD ESPANOLA DE CIRUGIA PEDIATRICA 2001; 14:135-8. [PMID: 12601959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
UNLABELLED In the long-term after liver transplantation (LT), some children develop prehepatic portal hypertension (PPH) and raise problems not very well known yet; many of the lessons learned with the management of these patients may be useful outside the LT. AIM 1. To analyze the incidence and risk factors of PPH after LT. 2. To evaluate the results with the different treatments used. METHODS Retrospective study over 164 children surviving more than 1 year after LT. Univariant analysis of possible risk factors associated and multivariant (logistic regression), for those that had significance in the univariant analysis. Other factors associated are analyzed as well as the indications and results of two types of treatment: percutaneous pneumatic dilatation and surgical shunt (splenorenal and Rex shunt). RESULTS 9 children developed symptomatic PPH (hemorrhage in 8, ascites in 1), associated to lymphoproliferative post-LT disease in 2, and to anastomotic biliary stricture in 1. The age at first LT (children under 1 year old), weight (below 10 kg), and need of retransplantation (reLT) were in the univariant analysis the associated variables with increased risk of PPH. The diagnosis (biliary atresia) and the emergency status of the LT were almost significative. In the multivariant analysis, the need of reLT is the only independent variable that increases the risk (relative risk: 4.5, confidence interval 95%: 1.29-18.87). At diagnosis 3 cases showed portal estenosis, and 5 showed absence of permeability with cavernomatous transformation. The PPH was caused in one case because of the esplenic vein disconnection (treatment not required at the moment); the three cases of portal estenosis were dilated percutaneously with success, and 2 of the 5 cases with portal thrombosis have been surgically shunted: one by an splenorenal shunt and the other by a Rex shunt (first case done in Spain); the other 3 cases are stable waiting for a surgical solution. The hepatic function is normal in the 9 cases. CONCLUSIONS The PPH can complicate the prognostic of the pediatric LT in the long term. The treatment depends on the permeability of the portal trunk. Whenever possible, percutaneous dilatation should be attempted; should surgery be required, the Rex shunt is the best option.
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Murcia J, López Santamaría M, Gámez M, Hierro L, Frauca E, Camarena C, de la Vega A, Díaz M, Jara P, Tovar J. [Liver transplantation in infants younger than one year of age]. CIRUGIA PEDIATRICA : ORGANO OFICIAL DE LA SOCIEDAD ESPANOLA DE CIRUGIA PEDIATRICA 2001; 14:121-3. [PMID: 11547633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
BACKGROUND The development of the surgical techniques of hepatic division has maken that the young age (less than one year old) is no longer considered a risk factor in the pediatric liver transplant (TH). AIM To show our experience with the TH in children younger than one year, comparing these results with the rest of the series and in second place to analyze if a bigger experience improves the results of the TH in this group of patients. METHODS 44 patients that received a TH with less than a year of age are reviewed. Among them, 27 were in the last five years. The survival indexes of the graft and the patient are determined at 1, 5 and 10 years comparing them with three rest of the series. RESULTS The grafts and patients survival was slightly inferior in the less than one year old, although in the last five years it improved 71.4% vs 82.1% at one year follow-up, and 61.9 in front of 74.5% at five years. The clinical situation of the patients that were transplanted before the year of life was worse: 43% (UNOS III, IV) in front of 13.1% in the same stadiums in the rest of the serie. In the younger patients, 54% of the grafts were reduced, versus 21% in the older. There were not a higher rate of complications in the young group. CONCLUSIONS In spite of the difficulties of the TH in children younger than one year of age, the results are not very different from those obtained in the rest of the patients. In these results the experience of the transplant center have a great influence.
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De Diego JI, Prim MP, Hardisson D, Verdaguer JM, Jara P. Post-transplant lymphoproliferative disease in tonsils of children with liver transplantation. Int J Pediatr Otorhinolaryngol 2001; 58:113-8. [PMID: 11278019 DOI: 10.1016/s0165-5876(01)00415-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To assess the incidence and characteristics of post-transplant lymphoproliferative disease (PTLD) in tonsils of the liver transplanted children. METHODS All patients under 14 years of age recipients of a liver transplant at the institution and operated on for tonsillectomy under suspicion of malignancy were included in this study. RESULTS Seven patients underwent surgery on their tonsils under suspicion of PTLD. One case of B-cell lymphoma, and three cases of polymorphic diffuse B-cell hyperplasia were found. This represents an incidence of 1.4% of PTLD in the tonsils of the 283 pediatric liver transplants performed at the hospital. CONCLUSION The incidence of PTLD in tonsils after liver transplantation is very low at the institution. However, it is very important to follow-up allograft recipients for early diagnosis of this entity.
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Murcia J, López Santamaría M, Gámez M, Hierro L, Frauca E, Camarena C, de la Vega A, Díaz M, Jara P, Tovar J. [Prognosis in children with biliary atresia successfully treated with Kasai's operation]. CIRUGIA PEDIATRICA : ORGANO OFICIAL DE LA SOCIEDAD ESPANOLA DE CIRUGIA PEDIATRICA 2001; 14:66-8. [PMID: 11480194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
BACKGROUND The Kasai procedure, portoenteroanastomosis (PEA) didn't reach international spreading until the seventy's decade, making difficult to find long-term results from children with ABE successfully treated with this technique. At our institution in the last fifteen years all the therapeutics procedures for these patients can be offered, including the liver transplant. AIM To show the evolution of our patients with ABE treated with the PEA and that survive long-term without being transplanted. METHODS The clinical course of 22 patients that survive more than 10 years after the PEA with their own liver is reviewed. The hepatic survival indexes of (success, death or transplant) are beyond the tenth year. The problems raised during the follow-up are analysed. RESULTS From 99 patients with ABE treated primarily in our center, 22 reached the 10 year-old age after the PEA without a liver transplant. In the follow-up, seven if the these finally needed the transplant. Their median age was 12.2 year-old (range: 10.5-13.8) for a progressive hepatocellular damage in 5 cases associated to syndrome hepatopulmonar in two cases. The other fifteen patients have a compensated hepatopathy. Five of them do not have hyperesplenisme and the serum bilirrubine levels are lower than 1.3 mg/dL. The medium age of these patients at the end of the follow-up was 14.8 years. CONCLUSIONS In spite of the reestablishment of the biliary flow with the PEA, few are the patients with ABE that preserve their hepatic function lapsed long periods of time. Nevertheless the prognosis of these patients is excellent.
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López Santamaría M, de Vicente E, Gámez M, Murcia J, Migliazza L, Quijano Y, Nuño J, Larrauri J, Frauca E, Molina M, Sarriá J, Prieto G, Jara P, Polanco I, Tovar J. [Intestinal transplantation. First experience in Spain]. CIRUGIA PEDIATRICA : ORGANO OFICIAL DE LA SOCIEDAD ESPANOLA DE CIRUGIA PEDIATRICA 2001; 14:25-7. [PMID: 11339115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
UNLABELLED We present the first case of intestinal transplant (IT) performed in Spacin. CASE REPORT 28 months old boy with secretory diarrhea since the first month of life, diagnosed of microvillous inclusion disease (MID). He is on total parenteral nutrition (TPN) and had suffered of multiple episodes of catheter related sepsis with lost of standard venous access. An isolated small bowel transplant from a cadaveric donor was performed at the age of 3 years. The native ileocaecal valve and colon were not removed. RESULTS Enteral feeding was started in the 2nd. week after the IT. On the 25th day he was off TPN. Since the 77th day, he eats regular foods by mouth. At the 6th month post IT the ileostomy was closed. Among the complications, he suffered a rotavirus infection on the 38th post IT day and an episode of mild rejection responsive to methil-prednisolone bolus. CONCLUSIONS The IT is a therapeutic option that can be already offered with possibilities of success in our country. Although the colonic enterocytes express MVD, the recipient ileocaecal valve and colon can be preserved.
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Abstract
OBJECTIVE The main aim of this research is to study the quantitative evolution of the incidence of AIDS in the 19 Spanish Communities. The hypothesis is that incidence follows a multilevel autoregressive model, where each Community shows random variability around a general process. METHOD On the basis of official data on the number of existing AIDS cases, an autorregressive multilevel time-series model was developed. RESULTS AND CONCLUSIONS Analysis shows that the hypothesis is supported, indicating that overall AIDS incidence in Spain has already reached a maximum and has a tendency to remain stable or to decline in future. Long term expected values have become stable in most Communities; a slight increase is expected only in Extremadura. However, this Community has a relatively sparse population, and its contribution on the overall Spanish incidence is small. Long term expected values are estimated to be around 152.99 new cases per million inhabitants per year. This value is slightly smaller than the maximum incidence, observed in 1994 (179.4 cases).
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López Santamaría M, Gámez M, Murcia J, Díez-Pardo J, Vázquez J, Migliazza L, Clavijo J, Tovar J, Hierro L, Frauca E, Camarena C, de la Vega A, Díaz MC, Jara P. [Kasai operation in the age of liver transplantation. Healing or merely palliative technique?]. CIRUGIA PEDIATRICA : ORGANO OFICIAL DE LA SOCIEDAD ESPANOLA DE CIRUGIA PEDIATRICA 2000; 13:102-5. [PMID: 12601938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
AIM To assess the results of portoenteroanastomosis (PEA) and liver transplantation (OLT) in extrahepatic biliary atresia (EHBA). METHODS Out of a series of 148 EHBA, 92 cases primarily treated by us were selected. Survival with the native liver (end point = death or OLT) and its relationship with the age at PEA, type of EHBA, ductal size and bile flow restablishment were assessed. Patient survival was compared in those patients who had access to OLT when needed (Group I, n = 69) and those in whom only PEA was available (Group II, n = 23). (OLT program started in january 1986). RESULTS At the end of follow-up, 32 children are alive with their native livers, 22 died and 38 had OLT. 40/85 patients who underwent PEA had complete restablishment of bile flow (47%). The no failure rate (survival of the native liver) at 1, 5, 10 and 20 years, was 91%, 49%, 38% and 21%, respectively. Bile flow restablishment was the only predictor significantly associated with good prognosis (survival of native liver at 5, 10 and 20 years of 89%, 86% and 51%, respectively). Differences in survival were significant (p < 0.001) between patients in groups I and II at 1 year (92% vs 74%), 5 years (78% vs 35%), 10 years (76% vs 30%) and 20 years (76% vs 30%). CONCLUSIONS Bile flow restablishment after PEA can be obtained in experienced centers in about 50% of cases of EHBA. The combined and sequential use of PEA and OLT allows excellent long-term survival in EHBA.
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Bortolotti F, Jara P, Barbera C, Gregorio GV, Vegnente A, Zancan L, Hierro L, Crivellaro C, Vergani GM, Iorio R, Pace M, Con P, Gatta A. Long term effect of alpha interferon in children with chronic hepatitis B. Gut 2000; 46:715-8. [PMID: 10764718 PMCID: PMC1727912 DOI: 10.1136/gut.46.5.715] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND/AIMS The purpose of this study was to better define the long term prognosis of infection and disease in children with chronic hepatitis B treated with interferon (IFN) alpha. PATIENTS A total of 107 children with chronic hepatitis B who received IFN alpha for three or six months in two clinical trials were followed for a mean period of 69 (17) months. Response to treatment was defined as loss of hepatitis B e antigen (HBeAg) within 12 months after stopping treatment. A control group of 59 patients was also followed for a shorter mean time (46 (19) months). RESULTS Sixteen (15%) treated children responded during therapy and 18 (17%) during post-treatment follow up; 31 (29%) non-responders lost HBeAg during subsequent years. High pretreatment levels of transaminases and a greater histological activity index were predictors of response. Kaplan-Meier estimates of cumulative HBeAg clearance rates at five years were similar between treated patients (60%) and controls (65%). After HBeAg clearance, all cases lost hepatitis B virus DNA and 94% had normal transaminase levels. Loss of hepatitis B surface antigen (HBsAg) occurred in four (25%) patients who responded during treatment but in none of the other treated or untreated patients. CONCLUSIONS After five years' observation, the proportion of treated children with sustained HBeAg clearance comprised an equal number of responders and non-responders and did not differ from that observed in untreated controls, suggesting that IFN simply accelerated a spontaneous event. However, IFN significantly improved the rate of HBsAg loss in cases with more prominent disease activity who were early responders, and may be particularly useful in this type of patient.
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López-Santamaria M, Migliazza L, Gamez M, Murcia J, Diaz-Gonzalez M, Camarena C, Hierro L, De la Vega A, Frauca E, Diaz M, Jara P, Tovar J. Liver transplantation in patients with homozygotic familial hypercholesterolemia previously treated by end-to-side portocaval shunt and ileal bypass. J Pediatr Surg 2000; 35:630-3. [PMID: 10770402 DOI: 10.1053/jpsu.2000.0350630] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Familial hypercholesterolemia is the result of mutations in the gene that encodes the synthesis of the cellular receptor for low density lipoprotein (LDL). In the homozygous form of the disease (HFHC), cellular LDL receptors either do not form, or, when present, cannot bond LDL and mediate its cellular uptake LDL, and the cholesterol that it transports accumulate in plasma, producing severe premature atherosclerosis and death from coronary artery disease usually before the age of 20. Currently, the only effective treatment is liver transplantation, which, alone or in association with medications, normalizes plasma cholesterol levels. The authors report the cases of 2 siblings with HFHC who underwent portocaval shunt at the ages of 2.5 and 1.5 years, respectively. Portocaval shunt produced an immediate, but insufficient decrease in cholesterol (by 40% and 35%, respectively), leaving them with cholesterol concentrations of about 500 mg/dL. One year later they each underwent ileal bypass without obtaining any significant response. Liver transplantation at the ages of 18 and 16 years, respectively, reduced plasma cholesterol concentrations to 129 and 225 mg/dL, respectively. The earlier operations seriously increased the technical difficulty of liver transplantation and did not produce a favorable effect on the natural course of the disease, so portocaval shunt and ileal bypass are not indicated in HFHC, not even for the purpose of delaying liver transplantation.
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Migliazza L, López Santamaría M, Murcia J, Gamez M, Clavijo J, Camarena C, Hierro L, Frauca E, de la Vega A, Diaz M, Jara P, Tovar JA. Long-term survival expectancy after liver transplantation in children. J Pediatr Surg 2000. [PMID: 10646764 DOI: 10.1016/s0022-3468(00)80003-2] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE The aim of this study was to assess the long-term survival rate in children who have undergone orthotopic liver transplantation (OLT) in the last 13 years. METHODS The records of 198 consecutive patients under 18 years of age who underwent 249 OLTs between 1986 and 1998 were reviewed. Actuarial patient survival rates were assessed at 1, 3, 5, and 10 years in the whole series, in the last 5 years, and in patients surviving more than 1 year. Age, weight, and indications were analyzed, as well as type and incidence of posttransplant complications. The median follow-up period was 41 months (0 to 154 months). RESULTS Biliary atresia was the most common indication (41.9%) followed by alpha-1 antitrypsin deficiency (8.1%), Alagille syndrome (7.6%), and fulminant hepatic failure (6.6%). One hundred forty-six patients (58.6%) were below 5 years, and 46 patients were (18.5%) younger than 1 year at operation. Sixty-eight patients (27.3%) weighed less than 10 kg. One hundred seventy whole organs and 70 reduced, 5 living-related donor, and 4 split-liver allografts were used. Hepatic artery thrombosis (n = 18), primary nonfunction (n = 15), and chronic rejection (n = 14) were the most common causes for allograft failure. Fourteen patients (7%) had posttransplant lymphoproliferative disorders (PTLD) at a median time of 28 months (4 to 124 months) postoperation (3 died). The 1-, 3-, 5-, and 10-year actuarial patient survival rates are 80%, 76%, 74%, and 74%, respectively; over the last 5 years it is 88% at 1 year and 82% at 3 and 5 years. For patients surviving more than 1 year, 3-, 5-, and 10-year actuarial survival rates are 95%, 93%, and 93%, respectively. CONCLUSIONS (1) Overall results of OLT improve with increasing experience. (2) Children who survive more than 1 year after OLT have an excellent prognosis, although long-term complications of immunosuppression can be expected.
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Migliazza L, López Santamaría M, Murcia J, Gamez M, Clavijo J, Camarena C, Hierro L, Frauca E, de la Vega A, Diaz M, Jara P, Tovar JA. Long-term survival expectancy after liver transplantation in children. J Pediatr Surg 2000; 35:5-7; discussion 7-8. [PMID: 10646764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
PURPOSE The aim of this study was to assess the long-term survival rate in children who have undergone orthotopic liver transplantation (OLT) in the last 13 years. METHODS The records of 198 consecutive patients under 18 years of age who underwent 249 OLTs between 1986 and 1998 were reviewed. Actuarial patient survival rates were assessed at 1, 3, 5, and 10 years in the whole series, in the last 5 years, and in patients surviving more than 1 year. Age, weight, and indications were analyzed, as well as type and incidence of posttransplant complications. The median follow-up period was 41 months (0 to 154 months). RESULTS Biliary atresia was the most common indication (41.9%) followed by alpha-1 antitrypsin deficiency (8.1%), Alagille syndrome (7.6%), and fulminant hepatic failure (6.6%). One hundred forty-six patients (58.6%) were below 5 years, and 46 patients were (18.5%) younger than 1 year at operation. Sixty-eight patients (27.3%) weighed less than 10 kg. One hundred seventy whole organs and 70 reduced, 5 living-related donor, and 4 split-liver allografts were used. Hepatic artery thrombosis (n = 18), primary nonfunction (n = 15), and chronic rejection (n = 14) were the most common causes for allograft failure. Fourteen patients (7%) had posttransplant lymphoproliferative disorders (PTLD) at a median time of 28 months (4 to 124 months) postoperation (3 died). The 1-, 3-, 5-, and 10-year actuarial patient survival rates are 80%, 76%, 74%, and 74%, respectively; over the last 5 years it is 88% at 1 year and 82% at 3 and 5 years. For patients surviving more than 1 year, 3-, 5-, and 10-year actuarial survival rates are 95%, 93%, and 93%, respectively. CONCLUSIONS (1) Overall results of OLT improve with increasing experience. (2) Children who survive more than 1 year after OLT have an excellent prognosis, although long-term complications of immunosuppression can be expected.
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Herzog D, Yamamoto AM, Jara P, Maggiore G, Sarles J, Alvarez F. Sera of children with hepatitis C infection and anti-liver-kidney microsome-1 antibodies recognize different CYP2D6 epitopes than adults with LKM+/HCV+ sera. J Pediatr Gastroenterol Nutr 1999; 29:551-5. [PMID: 10554122 DOI: 10.1097/00005176-199911000-00015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Liver-kidney microsome type 1 (LKM1) antibodies are specific markers of autoimmune hepatitis (AIH) type 2. Antibodies to LKM1 have been found in 2% to 3% of adults infected with hepatitis C virus (HCV) without AIH. Thirty percent of these antibodies are directed against linear sequences of CYP2D6 protein. LKM1 antibodies in HCV+/LKM1+ sera and in sera of AIH patients do not recognize the same CYP2D6 epitopes. The current study was conducted to determine whether LKM1 antibodies in HCV+/LKM1+ children's sera are the result of the same immune response as the antibodies described in AIH type 2 and in HCV+/LKM1+ adult patients. METHODS Sera from 10 HCV+/LKM1+ children were tested against human liver microsomal and cytosolic proteins by Western blot analysis and against synthetic peptides of the CYP2D6 sequence between amino acids 200 and 429 by dot blot. The same sera were tested against radiolabeled CYP2D6 by immunoprecipitation. RESULTS Four of 10 sera tested by Western blot analysis showed immunoglobulin (Ig) G-type antibodies against CYP2D6, and 2 had antibodies against proteins of 58, 66, and 84 kDa. One of the sera also contained IgM-type anti-66-kDa and 84-kDa proteins. The radioligand test detected anti-CYP2D6 antibodies in 9 of 10 patients. Five of the anti-CYP2D6-positive sera recognized a peptide between amino acids 200 and 429 including amino acids 254-271. CONCLUSIONS Most HCV+/LKM1+ sera from children recognize conformational epitopes of the CYP2D6 antigen, and half recognize linear epitopes. Some HCV+/LKM1+ sera demonstrated antibodies against the AIH type 2 main antigenic site of the CYP2D6. Screening of HCV RNA should be performed before starting treatment of presumed autoimmune hepatitis associated with LKM1.
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Jara P, Bortolotti F. Interferon-alpha treatment of chronic hepatitis B in childhood: a consensus advice based on experience in European children. J Pediatr Gastroenterol Nutr 1999; 29:163-70. [PMID: 10435653 DOI: 10.1097/00005176-199908000-00012] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The efficacy of interferon (IFN) in children with chronic hepatitis B has been evaluated in randomized controlled trials over the past decade, but recommendations for treatment based on this experience have not been published yet. The purpose of this workshop, held in Madrid in October 1997, was to provide pediatricians with guidelines for practical use of IFN in hepatitis B. METHODS Eighteen European pediatricians and hepatologists agreed to report and discuss their experience on 1,122 treated children, 40% of whom were considered responders. RESULTS Agreement was obtained on the following main items: 1) rationale for treatment is to accelerate hepatitis B early antigen (HBeAg) clearance in a subgroup of patients; 2) candidates for treatment are children with HBeAg and HBV DNA positivity, with low-intermediate HBV DNA levels and abnormal alanine aminotransferase values, aged 2 years or more; 3) IFN is contraindicated in children with decompensated liver disease, cytopenia, severe renal or cardiac disorders, and autoimmune disease; 4) the standard treatment regimen is 5 mU/m2 thrice weekly for 6 months. Retreatment in nonresponders is not indicated. CONCLUSIONS A consensus was obtained on the use of IFN in children with hepatitis B, based on its short-term efficacy. The long-term clinical and virological effects of the drug, however, remain to be evaluated.
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López Santamaría M, Gámez M, Murcia J, Hierro L, Camarena C, de la Vega A, Frauca E, Jara P, Berrocal T, Prieto C, Garzón G, Tovar J. [Pediatric liver transplantation: now the patients are different and the problems are different as well]. CIRUGIA PEDIATRICA : ORGANO OFICIAL DE LA SOCIEDAD ESPANOLA DE CIRUGIA PEDIATRICA 1999; 12:75-9. [PMID: 10570860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
AIM 1. To show how in a program of pediatric liver transplantation (PLT) with 12 years of experience, the continuous use of technical innovations has allowed to improve the results and to treat the most complex cases. 2. To point out that when the immediate results of the transplant improve and the evolution time get longer, the late complications become the main source of concern. MATERIAL AND METHODS The graft survival and the incidence of early surgical complications was compared between the first 100 PLT and the last 100 PLT (Total 235 PLT). The patients survival was also compared between the first and the last 5 years. In every case it was analyzed the age and weight of the children at the time of the transplant and the type of graft (full or reduced liver). The incidence of late complications in the global series was also analyzed, especially the posttransplant lymphoproliferative disease (PTLD) and the late biliary and vascular complications. RESULTS There are significant differences between the first 100 PLT and the last 100 PLT in relation with the age of the patients (6.8 +/- 0.6 vs 4.2 +/- 0.5 years), the number of children younger than 1 year (4 vs 28), weight (22.4 +/- 1.2 vs 16.9 +/- 1.7 kg), number of PLT in children under 10 kg (7 vs 43), use of reduction techniques (7 vs 49), rate of hepatic artery thrombosis (12% vs 3%), and rate of early biliary complications (13% vs 4%). The 5 years survival of the graft was 51% in the first 100 PLT vs 65% in the last 100 PLT, and the 5 years patients survival was 70.1% in the first 5 years of the program vs 79.6% in the last 5 years. Among the late complications in the global series, 13 cases of PTLD (2 deaths) have special relevance, 6 cases of late anastomotic biliary stricture, 4 cases of portal stenosis, 1 arterial thrombosis, 1 death due to a fulminant sepsis and another death because of a colitis with multiple hepatic abscess. CONCLUSIONS 1. The result of PLT improve, despite of the fact that in the last years the difficulty of the surgical procedures have increased (the patients are younger, with less weight and the reduction techniques are used more frequently). 2. The late complications have a significant influence in the prognosis, being that influence not completely established yet.
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López-Santamaria M, Martinez L, Hierro L, Gamez M, Murcia J, Camarena C, De la Vega A, Frauca E, Jara P, Diaz M, Berrocal T, Prieto C, Garzón G, Tovar JA. Late biliary complications in pediatric liver transplantation. J Pediatr Surg 1999; 34:316-20. [PMID: 10052813 DOI: 10.1016/s0022-3468(99)90199-9] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE The aim of this study was to review the biliary complications occurring in late follow-up after liver transplantation in children. METHODS The medical records of 135 children who received orthotopic liver transplantations (OLT) and had graft survival of more than 1 year were reviewed. Technical variants using a reduced-size graft were applied in 32 (23.7%). For biliary reconstruction, 15 patients had choledochocholedochostomy and 120 a Roux-en-Y loop. Biliary reoperation in the early post-OLT period was needed in 24 patients (17.7%). Routine checking of liver function and duplex Doppler ultrasonography (DDS) were performed during the follow-up period, which averaged 58 months. Late biliary complication was defined as that occurring after the first hospital discharge. RESULTS Late biliary complications occurred in 18 children (13.3%); 16 showed symptoms or analytical disturbances in liver function tests. The Diagnoses included uncomplicated cholangitis (n = 6), anastomotic biliary stricture (n = 7), ischaemic damage of the biliary tree (n = 3) including one late (28 months) hepatic artery thrombosis leading to an intrahepatic biloma. and bile leak after T-tube removal (n = 2). The six children with uncomplicated cholangitis had no repeat episodes in follow-up despite persistent aerobilia. Six patients affected by anastomotic strictures were treated successfully with percutaneous dilatation and, if present, stone removal. Persisting dysfunction and cholangitis occurred in one case affected by ischaemic biliary disease. Biliary leaks after T tube removal settled spontaneously. Risk factors for late biliary complications were determined. There was no relation to the cold ischaemia time, type of graft or biliary reconstruction, or previous early post-OLT biliary reoperation. Aerobilia (affecting 21.5% of OLT patients) was related to cholangitis (P = .001). CONCLUSIONS Anastomotic strictures, reflux of intestinal contents via the Roux-en-Y loop, and residual ischaemic damage led to late biliary complications in 12% of paediatric OLT patients. Evidence of biliary dilatation on DDS may be delayed in anastomotic strictures; in these cases the results of percutaneous treatment were excellent. Children with aerobilia have and increased risk of cholangitis.
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Sánchez-Albisua I, Garde T, Hierro L, Camarena C, Frauca E, de la Vega A, Díaz MC, Larrauri J, Jara P. A high index of suspicion: the key to an early diagnosis of Wilson's disease in childhood. J Pediatr Gastroenterol Nutr 1999; 28:186-90. [PMID: 9932853 DOI: 10.1097/00005176-199902000-00018] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND To study the clinical features of Wilson's disease in childhood. METHODS Retrospective review of the clinical, laboratory, and histologic features and prognosis of Wilson's disease in 26 Spanish children. RESULTS The first medical visit, at age 9.8+/-3.4 years (range, 4-16 years), was prompted by liver dysfunction detected accidentally (61%), symptoms of liver disease (27%), family screening (8%), and extrapyramidal symptoms and personality changes (4%). There were laboratory data of hepatic failure in 27%. All copper metabolism test results (total serum copper, 24-hour urine excretion, serum ceruloplasmin) were abnormal in 62%, two in 27%, and one in 11%. All patients in whom extrahepatic involvement was found at diagnosis had severe liver disease. Histologic findings were portal fibrosis with steatosis (29%), cirrhosis (21%), portal fibrosis (17%), chronic active hepatitis (17%), and minimal changes or normality (17%). Penicillamine was administered to all but one patient. Four children underwent liver transplantation, three of them having received penicillamine for 12, 45, and 70 days. Three other patients recovered from liver failure after 1 year of treatment with penicillamine. After a follow-up of 4.5+/-3.3 years, all the children survived. Penicillamine caused severe toxicity in one patient. CONCLUSIONS Wilson's disease in childhood is generally detected by maintaining a high suspicion of liver disease in patients who have no or nonspecific hepatic symptoms. Kayser-Fleischer ring is rare in childhood. Drug therapy is effective and well tolerated, even in some cases of hepatic insufficiency.
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Jara P. [Metabolic hepatopathies in infancy. Alpha 1-antitrypsin deficiency]. GASTROENTEROLOGIA Y HEPATOLOGIA 1999; 22 Suppl 1:8-12. [PMID: 10085595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
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68
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Clemente G, Durán F, Loinaz C, Casanovas T, Rímola A, Jara P, Cuervas Mons V, Pons JA, Margarit C, Prieto M, de la Mata M, Bárcena R, Casafont F, Suarez F, Quiroga JA, Varo E, González A, Maldonado J, Suarez MJ. Late orthotopic liver retransplant: indications and survival. Liver Transplant Spanish Group. Transplant Proc 1999; 31:511-4. [PMID: 10083214 DOI: 10.1016/s0041-1345(98)01732-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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69
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Esquinas A, González G, Del Baño M, Jara P, Rodríguez M, Garciá F, Carrillo A. Effects of mask-ventilator interface elements in a home noninvasive portable ventilator. Study in cold hypercapnic patients. Crit Care 1999. [PMCID: PMC3301725 DOI: 10.1186/cc397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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70
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Esquinas A, González D, Carrillo A, Del Baño M, Rodríguez M, García F, Jara P. Noninvasive mechanical ventilation in asthma crisis: an alternative ventilatory therapy to endotracheal intubation. Crit Care 1999. [PMCID: PMC3301728 DOI: 10.1186/cc400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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71
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García-Monzón C, Jara P, Fernández-Bermejo M, Hierro L, Frauca E, Camarena C, Díaz C, De la Vega A, Larrauri J, García-Iglesias C, Borque MJ, Sanz P, García-Buey L, Moreno-Monteagudo JA, Moreno-Otero R. Chronic hepatitis C in children: a clinical and immunohistochemical comparative study with adult patients. Hepatology 1998; 28:1696-701. [PMID: 9828237 DOI: 10.1002/hep.510280633] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
Limited information is available regarding the characteristics of the hepatitis C virus (HCV) infection in children. We compared the epidemiological background along with the virological and histological features as well as the intrahepatic immunologic phenotype of both children and adults with chronic hepatitis C (CHC). Serum samples of 24 pediatric and 32 adult patients were drawn for alanine transaminase (ALT) levels, HCV-typing, and viral load. The histological diagnosis and a semiquantitative immunohistochemical assessment were performed in all patients. The majority of children (62%) had been transfused and the mean duration of viral infection in these cases was 11 +/- 4 years, being similar in adults (11 +/- 9 years, not significant). Although genotype distribution was similar, viral load was lower in children than in adults. The mildest histological forms of chronic hepatitis along with a weak intrahepatic immunological phenotype were significantly more frequent among children than adult patients. In conclusion, in children with CHC, perinatal blood transfusion was the most frequent source of viral infection and the liver disease was characterized by both low ALT level and viral load, as well as the mildest histological and immunohistochemical forms of chronic hepatitis.
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Guido M, Rugge M, Jara P, Hierro L, Giacchino R, Larrauri J, Zancan L, Leandro G, Marino CE, Balli F, Bagni A, Timitilli A, Bortolotti F. Chronic hepatitis C in children: the pathological and clinical spectrum. Gastroenterology 1998; 115:1525-9. [PMID: 9834281 DOI: 10.1016/s0016-5085(98)70032-0] [Citation(s) in RCA: 114] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND & AIMS Apart from the high-risk groups, the pathology of chronic hepatitis C in children is not well known. The aim of this study was to investigate the morphology of chronic hepatitis C in children without any underlying systemic disease and to evaluate its relationship to clinicovirological factors. METHODS Liver biopsy specimens from 80 children positive for antibody to hepatitis C virus were evaluated using a semiquantitative scoring system. RESULTS Chronic hepatitis was mild in most cases but had high-grade activity in 17 children (21.2%). A significant association was found between the grade of focal necrosis and alanine transaminase levels (P < 0.003). Fibrosis was absent in 22 cases (27.5%), mild in 44 (55%), and moderate in 13 (16.2%). Only 1 patient had cirrhosis. A significant relationship was detected between fibrosis scores and (1) duration of disease (P < 0.03); (2) portal inflammation (P < 0. 002); and (3) interface hepatitis (P < 0.003). CONCLUSIONS In otherwise healthy children, chronic hepatitis C is a morphologically mild disease in most cases. Fibrosis increases with the duration of disease, suggesting that end-stage disease may develop in young adulthood. Alanine transaminase levels correlate with intralobular focal necrosis but not with other lesions. In this respect, liver biopsy retains its importance in the management of chronic hepatitis C in children.
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Bruguera M, Buti M, Diago M, García Bengoechea M, Jara P, Pedreira JD, Ruiz Estremera A. [Indications and prescription of hepatitis A vaccine in Spain. Report of the Spanish Association for the Study of the Liver]. Med Clin (Barc) 1998; 111:341-6. [PMID: 9810537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
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74
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Moreno M, Manzanares C, Castellano F, Medina E, Urruzuno P, Camarena C, Manzanares J, Jara P. Monitoring of tacrolimus as rescue therapy in pediatric liver transplantation. Ther Drug Monit 1998; 20:376-9. [PMID: 9712459 DOI: 10.1097/00007691-199808000-00003] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The introduction of tacrolimus as rescue therapy represents a significant advance in the prevention of late graft failure and second liver transplantation. The authors report the blood level monitoring of tacrolimus as a rescue therapy in 21 children who underwent liver transplantation, and they report the dose-concentration relationship in the presence or absence of hepatitis C virus (HCV) in these patients. This was a retrospective study conducted from May 1993 to January 1997. Indication for the conversion from cyclosporine (CsA) to tacrolimus were acute rejection (62%), chronic rejection (33%), and CsA toxicity (5%). Mean daily dose in the first month was 0.32 mg/kg, whereas at the end of the follow-up period it was 0.14 mg/kg. Tacrolimus mean whole blood concentration levels were between 7.1 ng/ml and 9.4 ng/ml, without significant differences over time. Mean daily doses in HCV+ and HCV- patients were 0.08 and 0.24 mg/kg, respectively (p < 0.01), and mean concentrations were 8.3 and 8.4 ng/ml (NS). HCV+ children required a mean dose three times lower than the dose used in HCV- children to obtain the same tacrolimus trough blood level. Therefore, doses in HCV+ children must be decreased to achieve levels within the therapeutic range.
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Bortolotti F, Jara P, Crivellaro C, Hierro L, Cadrobbi P, Frauca E, Camarena C, De La Vega A, Diaz C, De Moliner L, Noventa F. Outcome of chronic hepatitis B in Caucasian children during a 20-year observation period. J Hepatol 1998; 29:184-90. [PMID: 9722198 DOI: 10.1016/s0168-8278(98)80002-0] [Citation(s) in RCA: 92] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND/AIMS Chronic hepatitis B virus infection can lead to cirrhosis and hepatocellular carcinoma, particularly in men over 40 years of age and in areas where childhood-onset infection is common. The sequence of events from paediatric infection to severe disease in adults is only partially known. The aim of this study was to evaluate the evolution of chronic hepatitis B acquired in childhood during 20 years of follow-up. PATIENTS One hundred and eighty-five consecutive, otherwise healthy, Caucasian children were enrolled in Padua (Italy) and in Madrid (Spain) between 1975 and 1985, and followed for an average period of 13 years; 168 were hepatitis B e antigen (HBeAg) positive and five had cirrhosis. RESULTS Thirty patients received steroids or levamisole and 21 interferon, but treatment did not significantly influence HBeAg clearance. Overall, two (1.1%) children, with initial cirrhosis, developed hepatocellular carcinoma and the other three (1.6%) cirrhotic patients became asymptomatic carriers of infection after anti-HBe seroconversion and biochemical remission; 14 (7.5%) children maintained HBeAg positive hepatitis; 155 (83.8%) became asymptomatic carriers of infection after anti-HBe seroconversion and biochemical remission; six (3.2%) experienced reactivation of liver disease and viral replication after remission and five (2.7%) maintained biochemical features of liver damage after HBeAg clearance. Only 6% cleared hepatitis B surface antigen. CONCLUSIONS Even considering the bias of treatment, the large majority of Caucasian children with chronic hepatitis B became asymptomatic carriers of infection with normal alanine amino-transferase during the first 20 years of observation. Cirrhosis is an early, rare complication, and a risk factor for hepatocellular carcinoma. A subgroup of patients who experienced reactivation or maintained liver damage after HBeAg clearance seems to be at greater risk for disease progression during adult life.
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