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Banc-Husu AM, Shiau H, Dike P, Shneider BL. Beyond Varices: Complications of Cirrhotic Portal Hypertension in Pediatrics. Semin Liver Dis 2023; 43:100-116. [PMID: 36572031 DOI: 10.1055/s-0042-1759613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Complications of cirrhotic portal hypertension (PHTN) in children are broad and include clinical manifestations ranging from variceal hemorrhage, hepatic encephalopathy (HE), ascites, spontaneous bacterial peritonitis (SBP), and hepatorenal syndrome (HRS) to less common conditions such as hepatopulmonary syndrome, portopulmonary hypertension, and cirrhotic cardiomyopathy. The approaches to the diagnosis and management of these complications have become standard of practice in adults with cirrhosis with many guidance statements available. However, there is limited literature on the diagnosis and management of these complications of PHTN in children with much of the current guidance available focused on variceal hemorrhage. The aim of this review is to summarize the current literature in adults who experience these complications of cirrhotic PHTN beyond variceal hemorrhage and present the available literature in children, with a focus on diagnosis, management, and liver transplant decision making in children with cirrhosis who develop ascites, SBP, HRS, HE, and cardiopulmonary complications.
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Affiliation(s)
- Anna M Banc-Husu
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Henry Shiau
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Peace Dike
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Benjamin L Shneider
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
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Neto JS, Chapchap P, Feier FH, Pugliese R, Vincenzi R, Benavides MR, Roda K, Kondo M, Fonseca EA. The impact of low recipient weight [≤ 7kg] on long-term outcomes in 1078 pediatric living donor liver transplantations. J Pediatr Surg 2022; 57:955-961. [PMID: 35697543 DOI: 10.1016/j.jpedsurg.2022.05.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 05/11/2022] [Accepted: 05/18/2022] [Indexed: 12/19/2022]
Abstract
BACKGROUND infants who require liver transplantation represent a treatment challenge because chronic liver disease at this early age affects the child's growth and development during a critical phase. The aim is to compare demographics, operative data, and long-term outcomes according to recipient weight at the time of LDLT. METHODS This retrospective study included primary LDLT analyzed in 2 groups: BW ≤ 7 kg (n = 322) and BW > 7 kg (n = 756). A historical comparison between periods was also investigated. RESULTS BW ≤ 7 kg had significantly lower height/age and weight/age z-scores, with median PELD score of 19. Transfusion rates were higher in the BW ≤ 7 kg group (30.9 ml/kg versus 15.5 ml/kg, P < 0.001). Higher frequencies of PV complications were seen in the BW ≤ 7 kg cohort. HAT and retransplantation rates were similar. Those with BW ≤ 7 kg required longer ICU and hospital stays. Patient and graft survival were similar. Patient survival in BW≤ 7 kg was significantly better in the most recent period. CONCLUSION Malnutrition and advanced liver disease were more frequent in BW ≤ 7 kg. Despite increased rates of PVT and longer hospital stay, patient and graft long-term survival were similar between groups.
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Affiliation(s)
- João Seda Neto
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, Rua Barata Ribeiro, 414, cj 65, Bela Vista, SP, Brazil; Hepatology and Liver Transplantation, A. C. Camargo Cancer Center, São Paulo, SP, Brazil; Hospital Municipal Infantil Menino Jesus, São Paulo, SP, Brazil.
| | - Paulo Chapchap
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, Rua Barata Ribeiro, 414, cj 65, Bela Vista, SP, Brazil
| | - Flavia H Feier
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, Rua Barata Ribeiro, 414, cj 65, Bela Vista, SP, Brazil; Hepatology and Liver Transplantation, A. C. Camargo Cancer Center, São Paulo, SP, Brazil
| | - Renata Pugliese
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, Rua Barata Ribeiro, 414, cj 65, Bela Vista, SP, Brazil; Hepatology and Liver Transplantation, A. C. Camargo Cancer Center, São Paulo, SP, Brazil; Hospital Municipal Infantil Menino Jesus, São Paulo, SP, Brazil
| | - Rodrigo Vincenzi
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, Rua Barata Ribeiro, 414, cj 65, Bela Vista, SP, Brazil; Hepatology and Liver Transplantation, A. C. Camargo Cancer Center, São Paulo, SP, Brazil; Hospital Municipal Infantil Menino Jesus, São Paulo, SP, Brazil
| | - Marcel R Benavides
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, Rua Barata Ribeiro, 414, cj 65, Bela Vista, SP, Brazil; Hepatology and Liver Transplantation, A. C. Camargo Cancer Center, São Paulo, SP, Brazil; Hospital Municipal Infantil Menino Jesus, São Paulo, SP, Brazil
| | - Karina Roda
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, Rua Barata Ribeiro, 414, cj 65, Bela Vista, SP, Brazil; Hepatology and Liver Transplantation, A. C. Camargo Cancer Center, São Paulo, SP, Brazil; Hospital Municipal Infantil Menino Jesus, São Paulo, SP, Brazil
| | - Mário Kondo
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, Rua Barata Ribeiro, 414, cj 65, Bela Vista, SP, Brazil
| | - Eduardo A Fonseca
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, Rua Barata Ribeiro, 414, cj 65, Bela Vista, SP, Brazil; Hepatology and Liver Transplantation, A. C. Camargo Cancer Center, São Paulo, SP, Brazil; Hospital Municipal Infantil Menino Jesus, São Paulo, SP, Brazil
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Flores-Calderón J, Cisneros-Garza LE, Chávez-Barrera JA, Vázquez-Frias R, Reynoso-Zarzosa FA, Martínez-Bejarano DL, Consuelo-Sánchez A, Reyes-Apodaca M, Zárate-Mondragón FE, Sánchez-Soto MP, Alcántara-García RI, González-Ortiz B, Ledesma-Ramírez S, Espinosa-Saavedra D, Cura-Esquivel IA, Macías-Flores J, Hinojosa-Lezama JM, Hernández-Chávez E, Zárate-Guerrero JR, Gómez-Navarro G, Bilbao-Chávez LP, Sosa-Arce M, Flores-Fong LE, Lona-Reyes JC, Estrada-Arce EV, Aguila-Cano R. Consensus on the management of complications of cirrhosis of the liver in pediatrics. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2022; 87:462-485. [PMID: 35810090 DOI: 10.1016/j.rgmxen.2022.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 03/08/2022] [Indexed: 12/07/2022]
Abstract
The Asociación Mexicana de Hepatología A.C. carried out the Consensus on the Management of Complications of Cirrhosis of the Liver in Pediatrics to provide physicians with useful information for treating said complications. A group of pediatric gastroenterologists and experts in nutrition, nephrology, and infectious diseases participated and reviewed the medical literature. The Delphi method was applied to obtain the level of agreement on the statements that were formulated. The statements were sent to the participants to be analyzed and voted upon, after which they were discussed in virtual sessions, and the final versions were produced. The aim of the consensus results was to issue indications for the management of pediatric patients with liver cirrhosis, to prevent or control complications.
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Affiliation(s)
- J Flores-Calderón
- UMAE Hospital de Pediatría, CMN XXI Dr. Silvestre Frenk Freund IMSS, Cd, México, Mexico.
| | | | - J A Chávez-Barrera
- UMAE Hospital General CMN La Raza, Dr. Gaudencio González Garza IMSS, Cd, México, Mexico
| | | | | | | | | | | | | | - M P Sánchez-Soto
- Hospital de Especialidades del Niño y la mujer de Querétaro Dr. Felipe Núñez Lara, Querétaro, Mexico
| | | | - B González-Ortiz
- UMAE Hospital de Pediatría, CMN XXI Dr. Silvestre Frenk Freund IMSS, Cd, México, Mexico
| | - S Ledesma-Ramírez
- UMAE Hospital de Pediatría, CMN XXI Dr. Silvestre Frenk Freund IMSS, Cd, México, Mexico
| | - D Espinosa-Saavedra
- UMAE Hospital de Pediatría, CMN XXI Dr. Silvestre Frenk Freund IMSS, Cd, México, Mexico
| | | | - J Macías-Flores
- Hospital Infantil de Especialidades de Chihuahua, Chihuahua, Mexico
| | | | - E Hernández-Chávez
- UMAE Hospital de Pediatría Centro Médico de Occidente, IMSS, Guadalajara, Mexico
| | - J R Zárate-Guerrero
- UMAE Hospital de Pediatría Centro Médico de Occidente, IMSS, Guadalajara, Mexico
| | - G Gómez-Navarro
- UMAE Hospital de Pediatría Centro Médico de Occidente, IMSS, Guadalajara, Mexico
| | - L P Bilbao-Chávez
- UMAE Hospital General CMN La Raza, Dr. Gaudencio González Garza IMSS, Cd, México, Mexico
| | - M Sosa-Arce
- UMAE Hospital General CMN La Raza, Dr. Gaudencio González Garza IMSS, Cd, México, Mexico
| | - L E Flores-Fong
- Nuevo Hospital Civil de Guadalajara "Dr. Juan I. Menchaca", Guadalajara, Mexico
| | - J C Lona-Reyes
- Nuevo Hospital Civil de Guadalajara "Dr. Juan I. Menchaca", Guadalajara, Mexico
| | - E V Estrada-Arce
- Nuevo Hospital Civil de Guadalajara "Dr. Juan I. Menchaca", Guadalajara, Mexico
| | - R Aguila-Cano
- Nuevo Hospital Civil de Guadalajara "Dr. Juan I. Menchaca", Guadalajara, Mexico
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Bass LM, Ye W, Hawthorne K, Leung DH, Murray KF, Molleston JP, Romero R, Karpen S, Rosenthal P, Loomes KM, Wang KS, Squires RH, Miethke A, Ng VL, Horslen S, Kyle Jensen M, Sokol RJ, Magee JC, Shneider BL, Bass L, Kelly S, Riordan M, Melin‐Aldana H, Bezerra J, Bove K, Heubi J, Miethke A, Tiao G, Denlinger J, Chapman E, Sokol R, Feldman A, Mack C, Narkewicz M, Suchy F, Sundaram S, Van Hove J, Garcia B, Kauma M, Kocher K, Steinbeiss M, Lovell M, Loomes K, Piccoli D, Rand E, Russo P, Spinner N, Erlichman J, Stalford S, Pakstis D, King S, Squires R, Sindhi R, Venkat V, Bukauskas K, McKiernan P, Haberstroh L, Squires J, Rosenthal P, Bull L, Curry J, Langlois C, Kim G, Teckman J, Kociela V, Nagy R, Patel S, Cerkoski J, Molleston JP, Bozic M, Subbarao G, Klipsch A, Sawyers C, Cummings O, Horslen S, Murray K, Hsu E, Cooper K, Young M, Finn L, Kamath B, Ng V, Quammie C, Putra J, Sharma D, Parmar A, Guthery S, Jensen K, Rutherford A, Lowichik A, Book L, Meyers R, Hall T, Wang K, Michail S, Thomas D, Goodhue C, Kohli R, Wang L, Soufi N, Thomas D, Karpen S, Gupta N, Romero R, Vos MB, Tory R, Berauer J, Abramowsky C, McFall J, Shneider B, Harpavat S, Hertel P, Leung D, Tessier M, Schady D, Cavallo L, Olvera D, Banks C, Tsai C, Thompson R, Doo E, Hoofnagle J, Sherker A, Torrance R, Hall S, Magee J, Merion R, Spino C, Ye W. Risk of variceal hemorrhage and pretransplant mortality in children with biliary atresia. Hepatology 2022; 76:712-726. [PMID: 35271743 PMCID: PMC9378352 DOI: 10.1002/hep.32451] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 02/24/2022] [Accepted: 02/25/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS The natural history of gastroesophageal variceal hemorrhage (VH) in biliary atresia (BA) is not well characterized. We analyzed risk factors, incidence, and outcomes of VH in a longitudinal multicenter study. APPROACH AND RESULTS Participants enrolled in either an incident (Prospective Database of Infants with Cholestasis [PROBE]) or prevalent (Biliary Atresia Study of Infants and Children [BASIC]) cohort of BA were included. Variceal hemorrhage (VH) was defined based on gastrointestinal bleeding in the presence of varices accompanied by endoscopic or nontransplant surgical intervention. Cumulative incidence of VH and transplant-free survival was compared based on features of portal hypertension (e.g., splenomegaly, thrombocytopenia) and clinical parameters at baseline in each cohort (PROBE: 1.5 to 4.5 months after hepatoportoenterostomy [HPE]; BASIC: at enrollment > 3 years of age). Analyses were conducted on 869 children with BA enrolled between June 2004 and December 2020 (521 in PROBE [262 (51%) with a functioning HPE] and 348 in BASIC). The overall incidence of first observed VH at 5 years was 9.4% (95% CI: 7.0-12.4) in PROBE and 8.0% (5.2-11.5) in BASIC. Features of portal hypertension, platelet count, total bilirubin, aspartate aminotransferase (AST), albumin, and AST-to-platelet ratio index at baseline were associated with an increased risk of subsequent VH in both cohorts. Transplant-free survival at 5 years was 45.1% (40.5-49.6) in PROBE and 79.2% (74.1-83.4) in BASIC. Two (2.5%) of 80 participants who had VH died, whereas 10 (12.5%) underwent transplant within 6 weeks of VH. CONCLUSIONS The low risk of VH and associated mortality in children with BA needs to be considered in decisions related to screening for varices and primary prophylaxis of VH.
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Affiliation(s)
- Lee M Bass
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Wen Ye
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | - Kieran Hawthorne
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - Daniel H Leung
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Karen F Murray
- Division of Gastroenterology, Department of Pediatrics, Hepatology, Seattle Children's Hospital and the University of Washington School of Medicine, Seattle, Washington State, USA
| | - Jean P Molleston
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Riley Hospital for Children, Indiana University, Indianapolis, Indiana, USA
| | - Rene Romero
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, Georgia, USA
| | - Saul Karpen
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, Georgia, USA
| | - Philip Rosenthal
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
| | - Kathleen M Loomes
- Division of Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kasper S Wang
- Department of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Robert H Squires
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Pittsburgh, School of Medicine and Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Alexander Miethke
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Vicky L Ng
- Division of GI, Hepatology and Nutrition, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Simon Horslen
- Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington State, USA
| | - M Kyle Jensen
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Ronald J Sokol
- Department of Pediatrics-Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA
| | - John C Magee
- Department of Surgery, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Benjamin L Shneider
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
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Alexander E, Weatherhead J, Creo A, Hanna C, Steien DB. Fluid management in hospitalized pediatric patients. Nutr Clin Pract 2022; 37:1033-1049. [PMID: 35748381 DOI: 10.1002/ncp.10876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 04/28/2022] [Accepted: 05/21/2022] [Indexed: 11/09/2022] Open
Abstract
The proper use of intravenous fluids has likely been responsible for saving more lives than any other group of substances. Proper use includes prescribing an appropriate electrolyte and carbohydrate solution, at a calculated rate or volume, for the right child, at the right time. Forming intravenous fluid plans for hospitalized children requires an understanding of water and electrolyte physiology in healthy children and how different pathology deviates from the norm. This review highlights fluid management in several disease types, including liver disease, diabetic ketoacidosis, syndrome of inappropriate antidiuretic hormone, diabetes insipidus, kidney disease, and intestinal failure as well as in those with nonphysiologic fluid losses. For each disease, the review discusses specific considerations, evaluations, and management strategies to consider when customizing intravenous fluid plans. Ultimately, all hospitalized children should receive an individualized fluid plan with recurrent evaluations and fluid modifications to provide optimal care.
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Affiliation(s)
- Erin Alexander
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatric and Adolescent Medicine, Mayo Clinic Children's Center, Rochester, Minnesota, USA.,Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jeffrey Weatherhead
- Division of Pediatric Critical Care, Department of Pediatric and Adolescent Medicine, Mayo Clinic Children's Center, Rochester, Minnesota, USA
| | - Ana Creo
- Division of Pediatric Endocrinology, Department of Pediatric and Adolescent Medicine, Mayo Clinic Children's Center, Rochester, Minnesota, USA
| | - Christian Hanna
- Division of Pediatric Nephrology and Hypertension, Department of Pediatric and Adolescent Medicine, Mayo Clinic Children's Center, Rochester, Minnesota, USA.,Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic Children's Center, Rochester, Minnesota, USA
| | - Dana B Steien
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatric and Adolescent Medicine, Mayo Clinic Children's Center, Rochester, Minnesota, USA
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Impact of COVID-19 Infection on Children and Adolescents after Liver Transplantation in a Latin American Reference Center. Microorganisms 2022; 10:microorganisms10051030. [PMID: 35630472 PMCID: PMC9143523 DOI: 10.3390/microorganisms10051030] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 05/12/2022] [Accepted: 05/13/2022] [Indexed: 02/01/2023] Open
Abstract
Background: The COVID-19 infection has received the attention of the scientific community due to its respiratory manifestations and association with evolution to severe acute respiratory syndrome (SARS-CoV-2). There are few studies characterizing SARS-CoV-2 in pediatric immunocompromised patients, such as liver transplanted patients. The aim of this study was to analyze the outcomes of the largest cohort of pediatric liver transplant recipients (PLTR) from a single center in Brazil who were infected with COVID-19 during the pandemic. Methods: Cross-sectional study. Primary outcomes: COVID-19 severity. The Cox regression method was used to determine independent predictors associated with the outcomes. Patients were divided into two groups according to the severity of COVID-19 disease: moderate−severe COVID and asymptomatic−mild COVID. Results: Patients categorized as having moderate−severe COVID-19 were younger (12.6 months vs. 82.1 months, p = 0.03), had a higher prevalence of transplantation from a deceased donor (50% vs. 4.3%, p = 0.02), and had a higher prevalence of COVID infection within 6 months after liver transplantation (LT) (75% vs. 5.7%, p = 0.002). The independent predictor of COVID-19 severity identified in the multivariate analysis was COVID-19 infection <6 months after LT (HR = 0.001, 95% CI = 0.001−0.67, p = 0.03). Conclusion: The time interval of less than 6 months between COVID-19 infection and LT was the only predictor of disease severity in pediatric patients who underwent liver transplantation.
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Variability of Care and Access to Transplantation for Children with Biliary Atresia Who Need a Liver Replacement. J Clin Med 2022; 11:jcm11082142. [PMID: 35456234 PMCID: PMC9032543 DOI: 10.3390/jcm11082142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 02/24/2022] [Accepted: 03/09/2022] [Indexed: 02/04/2023] Open
Abstract
Background & Aims: Biliary atresia (BA) is the commonest single etiology indication for liver replacement in children. As timely access to liver transplantation (LT) remains challenging for small BA children (with prolonged waiting time being associated with clinical deterioration leading to both preventable pre- and post-transplant morbidity and mortality), the care pathway of BA children in need of LT was analyzed—from diagnosis to LT—with particular attention to referral patterns, timing of referral, waiting list dynamics and need for medical assistance before LT. Methods: International multicentric retrospective study. Intent-to-transplant study analyzing BA children who had indication for LT early in life (aged < 3 years at the time of assessment), over the last 5 years (2016−2020). Clinical and laboratory data of 219 BA children were collected from 8 transplant centers (6 in Europe and 2 in USA). Results: 39 patients underwent primary transplants. Children who underwent Kasai in a specialist -but not transplant- center were older at time of referral and at transplant. At assessment for LT, the vast majority of children already were experiencing complication of cirrhosis, and the majority of children needed medical assistance (nutritional support, hospitalization, transfusion of albumin or blood) while waiting for transplantation. Severe worsening of the clinical condition led to the need for requesting a priority status (i.e., Peld Score exception or similar) for timely graft allocation for 76 children, overall (35%). Conclusions: As LT currently results in BA patient survival exceeding 95% in many expert LT centers, the paradigm for BA management optimization and survival have currently shifted to the pre-LT management. The creation of networks dedicated to the timely referral to a pediatric transplant center and possibly centralization of care should be considered, in combination with implementing all different graft type surgeries in specialist centers (including split and living donor LTs) to achieve timely LT in this vulnerable population.
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Relative Adrenal Insufficiency in Decompensated Cirrhotic Children: Does It Affect Outcome? Am J Gastroenterol 2022; 117:120-128. [PMID: 34506335 DOI: 10.14309/ajg.0000000000001486] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 08/03/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Relative adrenal insufficiency (RAI) is associated with poor outcome in adult cirrhotics. So far, pediatric studies are not available on the same. We aimed to prospectively study the presence and outcome of RAI in children with decompensated cirrhosis over 180 days. METHODS Hemodynamically stable children with decompensated cirrhosis were sampled for serum basal cortisol and peak cortisol (after 30 minutes of 1-μg intravenous Synacthen) at day 1 and day 21. RAI was diagnosed as peak cortisol <500 nmol/L. Serum cytokines (interleukin-6 and tumor necrosis factor-α) and lipid profile were correlated with RAI. Cohort was followed up for outcomes over 180 days for complications and survival. With the identified risk factors, prognostic models were derived and compared with pediatric end-stage liver disease (PELD) and Child-Turcotte-Pugh scores. RESULTS Prevalence of RAI was 54% at baseline and 61% at day 21 in the enrolled patients (n = 63, aged 128 ± 48 months, male 78%). No significant differences in cytokines and serum lipid levels were seen between RAI and normal adrenal function groups. Patients with RAI at baseline (D1-RAI) developed higher complications at follow-up as compared to the normal adrenal function group (53% vs 24%, P = 0.02). The PELD score (odds ratio 1.08, confidence interval 1.05-1.12, P < 0.01) and D1-RAI (odds ratio 3.19, confidence interval 1.32-7.73, P = 0.01) were independent predictors of follow-up complications. The PELD-delta cortisol model (area under the receiver operating curve 0.84, P < 0.001, 92% sensitivity; 60% specificity) predicted morbidity better than isolated PELD or Child-Turcotte-Pugh scores. DISCUSSION RAI is a risk factor for development of complications in pediatric cirrhosis over short-term follow-up. The PELD-delta cortisol score is a promising prognostic model for predicting follow-up complications.
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Fonseca EA, Feier F, Pugliese R, Freitas AF, Porta G, Miura I, Baggio V, Kondo M, Benavides M, Vincenzi R, Roda K, Oliveira CV, Chapchap P, Seda‐Neto J. Pediatric liver transplantation activity in a high-volume program during the COVID-19 pandemic in Brazil. Pediatr Transplant 2021; 25:e14112. [PMID: 34396644 PMCID: PMC8420104 DOI: 10.1111/petr.14112] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 07/15/2021] [Accepted: 07/28/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND The impact of the COVID pandemic on liver transplant (LT) programs varied among countries. Few data are available about that impact in pediatric liver transplant (PLT) programs. This study aimed at comparing the data of our program in Brazil (2019 vs. 2020). METHODS Retrospective cohort study. RESULTS One hundred and seventy-four PLT were performed in the period (93% living donors). Patients were divided into two groups according to the LT date: pre-COVID-19 period (march/2019-February/2020) and COVID-19 period (March/2020-February 2021). In the pre-COVID-19 period, 97 LTs were performed, and 77 LTs were performed in the COVID-19 period. Patients in the COVID-19 period were younger (10.9 months vs. 16 months, p 0.009), had higher PELD scores (15 vs. 14, p 0.04), more ascites (66.2 vs. 51.5%, p 0.03), and more frequently hospitalized before LT (27.3 vs. 17.5%). However, there was no difference in post-LT complications, retransplantation nor survival rates. Six (6.2%) patients from pre-COVID-19 period were COVID positive at a median of 15.5 months (14-17.5), and 6 (7.8%) patients from COVID-19 period were COVID positive at a median of 3 months (20 days-6 months) from LT. There was neither mortality nor complications in those patients. Four (33%) were hospitalized, and one had prolonged intubation. Four (33%) were asymptomatic, 4 (33%) had upper airways symptoms, and the remaining had gastrointestinal symptoms. CONCLUSION Overall, PLT was not affected during COVID-19 period. Even though patients from COVID-19 period were sicker, there was no significant impact in LT outcomes. All the recipients who tested positive for COVID had a favorable outcome.
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Affiliation(s)
- Eduardo A. Fonseca
- Hepatology and Liver TransplantationHospital Sírio‐LibanêsSão PauloBrazil,Hepatology and Liver Transplantation A. C. Camargo Cancer CenterSão PauloBrazil
| | - Flavia Feier
- Hepatology and Liver TransplantationSanta Casa de Porto AlegrePorto AlegreBrazil
| | - Renata Pugliese
- Hepatology and Liver TransplantationHospital Sírio‐LibanêsSão PauloBrazil,Hepatology and Liver Transplantation A. C. Camargo Cancer CenterSão PauloBrazil
| | - Aline F. Freitas
- Hepatology and Liver TransplantationHospital Sírio‐LibanêsSão PauloBrazil,Hepatology and Liver Transplantation A. C. Camargo Cancer CenterSão PauloBrazil
| | - Gilda Porta
- Hepatology and Liver TransplantationHospital Sírio‐LibanêsSão PauloBrazil,Hepatology and Liver Transplantation A. C. Camargo Cancer CenterSão PauloBrazil
| | - Irene Miura
- Hepatology and Liver TransplantationHospital Sírio‐LibanêsSão PauloBrazil,Hepatology and Liver Transplantation A. C. Camargo Cancer CenterSão PauloBrazil
| | - Vera Baggio
- Hepatology and Liver TransplantationHospital Sírio‐LibanêsSão PauloBrazil,Hepatology and Liver Transplantation A. C. Camargo Cancer CenterSão PauloBrazil
| | - Mario Kondo
- Hepatology and Liver TransplantationHospital Sírio‐LibanêsSão PauloBrazil,Hepatology and Liver Transplantation A. C. Camargo Cancer CenterSão PauloBrazil
| | - Marcel Benavides
- Hepatology and Liver TransplantationHospital Sírio‐LibanêsSão PauloBrazil,Hepatology and Liver Transplantation A. C. Camargo Cancer CenterSão PauloBrazil
| | - Rodrigo Vincenzi
- Hepatology and Liver TransplantationHospital Sírio‐LibanêsSão PauloBrazil,Hepatology and Liver Transplantation A. C. Camargo Cancer CenterSão PauloBrazil
| | - Karina Roda
- Hepatology and Liver TransplantationHospital Sírio‐LibanêsSão PauloBrazil,Hepatology and Liver Transplantation A. C. Camargo Cancer CenterSão PauloBrazil
| | - Caio V. Oliveira
- Hepatology and Liver TransplantationHospital Sírio‐LibanêsSão PauloBrazil,Hepatology and Liver Transplantation A. C. Camargo Cancer CenterSão PauloBrazil
| | - Paulo Chapchap
- Hepatology and Liver TransplantationHospital Sírio‐LibanêsSão PauloBrazil,Hepatology and Liver Transplantation A. C. Camargo Cancer CenterSão PauloBrazil
| | - João Seda‐Neto
- Hepatology and Liver TransplantationHospital Sírio‐LibanêsSão PauloBrazil,Hepatology and Liver Transplantation A. C. Camargo Cancer CenterSão PauloBrazil
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10
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Kulkarni S, Chi L, Goss C, Lian Q, Nadler M, Stoll J, Doyle M, Turmelle Y, Khan A. Random forest analysis identifies change in serum creatinine and listing status as the most predictive variables of an outcome for young children on liver transplant waitlist. Pediatr Transplant 2021; 25:e13932. [PMID: 33232568 PMCID: PMC8058171 DOI: 10.1111/petr.13932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 10/09/2020] [Accepted: 11/09/2020] [Indexed: 11/27/2022]
Abstract
Young children listed for liver transplant have high waitlist mortality (WL), which is not fully predicted by the PELD score. SRTR database was queried for children < 2 years listed for initial LT during 2002-17 (n = 4973). Subjects were divided into three outcome groups: bad (death or removal for too sick to transplant), good (spontaneous improvement), and transplant. Demographic, clinical, listing history, and laboratory variables at the time of listing (baseline variables), and changes in variables between listing and prior to outcome (trajectory variables) were analyzed using random forest (RF) analysis. 81.5% candidates underwent LT, and 12.3% had bad outcome. RF model including both baseline and trajectory variables improved prediction compared to model using baseline variables alone. RF analyses identified change in serum creatinine and listing status as the most predictive variables. 80% of subjects listed with a PELD score at time of listing and outcome underwent LT, while ~70% of subjects in both bad and good outcome groups were listed with either Status 1 (A or B) prior to an outcome, regardless of initial listing status. Increase in creatinine on LT waitlist was predictive of bad outcome. Longer time spent on WL was predictive of good outcome. Subjects with biliary atresia, liver tumors, and metabolic disease had LT rate >85%, while >20% of subjects with acute liver failure had a bad outcome. Change in creatinine, listing status, need for RRT, time spent on LT waitlist, and diagnoses were the most predictive variables.
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Affiliation(s)
- Sakil Kulkarni
- Department of Pediatrics, Washington University in St. Louis, St. Louis Children’s Hospital, St. Louis, MO, U.S.A
| | - Lisa Chi
- Department of Pediatrics, Washington University in St. Louis, St. Louis Children’s Hospital, St. Louis, MO, U.S.A
| | - Charles Goss
- Division of Biostatistics, Washington University in St. Louis, St. Louis, MO, U.S.A
| | - Qinghua Lian
- Division of Biostatistics, Washington University in St. Louis, St. Louis, MO, U.S.A
| | - Michelle Nadler
- Department of Surgery, Washington University in St. Louis, Barnes Jewish Hospital, St. Louis, MO, U.S.A
| | - Janis Stoll
- Department of Pediatrics, Washington University in St. Louis, St. Louis Children’s Hospital, St. Louis, MO, U.S.A
| | - Maria Doyle
- Department of Surgery, Washington University in St. Louis, Barnes Jewish Hospital, St. Louis, MO, U.S.A
| | - Yumirle Turmelle
- Department of Pediatrics, Washington University in St. Louis, St. Louis Children’s Hospital, St. Louis, MO, U.S.A
| | - Adeel Khan
- Department of Surgery, Washington University in St. Louis, Barnes Jewish Hospital, St. Louis, MO, U.S.A
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11
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Aneja A, Scott E, Kohli R. Advances in management of end stage liver disease in children. Med J Armed Forces India 2021; 77:129-137. [PMID: 33867627 DOI: 10.1016/j.mjafi.2021.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 03/05/2021] [Indexed: 02/07/2023] Open
Abstract
End stage liver disease (ESLD) is an irreversible condition that is a management challenge to the paediatrician. The aetiology and natural history of ESLD in children is not only distinct from adults but also variable depending upon the age of presentation. Children are especially vulnerable to developmental delay, frailty and malnutrition. Nutritional support is the cornerstone of management of these children as it has a significant impact on the clinical course and survival, both before and after transplantation. Further, the complications of ESLD in children including but not limited to, ascites, portal hypertension, spontaneous bacterial peritonitis and encephalopathy raise unique management challenges. In this review we provide a concise review of and highlight recent advances in the management of paediatric ESLD.
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Affiliation(s)
- Aradhana Aneja
- Classified Specialist (Pediatrics) & Pediatric Gastroenterologist, Army Hospital (R&R), New Delhi, India
| | - Elizabeth Scott
- Transplant Dietitian, Division of Gastroenterology, Hepatology & Nutrition, Children's Hospital Los Angeles, 4650 Sunset Boulevard, Los Angeles, CA, USA
| | - Rohit Kohli
- Head of Division, Division of Gastroenterology, Hepatology & Nutrition, Children's Hospital Los Angeles, 4650 Sunset Boulevard, Los Angeles, CA, USA
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12
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Thalji L, Thalji NM, Heimbach JK, Ibrahim SH, Kamath PS, Hanson A, Schulte PJ, Haile DT, Kor DJ. Renal Function Parameters and Serum Sodium Enhance Prediction of Wait-List Outcomes in Pediatric Liver Transplantation. Hepatology 2021; 73:1117-1131. [PMID: 32485002 DOI: 10.1002/hep.31397] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 04/03/2020] [Accepted: 05/03/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Reliance on exception points to prioritize children for liver transplantation (LT) stems from concerns that the Pediatric End-Stage Liver Disease (PELD) score underestimates mortality. Renal dysfunction and serum sodium disturbances are negative prognosticators in adult LT candidates and various pediatric populations, but are not accounted for in PELD. We retrospectively evaluated the effect of these parameters in predicting 90-day wait-list death/deterioration among pediatric patients (<12 years) listed for isolated LT in the United States between February 2002 and June 2018. APPROACH AND RESULTS Among 4,765 patients, 2,303 (49.3%) were transplanted, and 231 (4.8%) died or deteriorated beyond transplantability within 90 days of listing. Estimated glomerular filtration rate (eGFR) (hazard ratio [HR] 1.09 per 5-unit decrease, 95% confidence interval [CI] 1.06-1.10) and dialysis (HR 7.24, 95% CI 3.57-14.66) were univariate predictors of 90-day death/deterioration (P < 0.001). The long-term benefit of LT persisted in patients with renal dysfunction, with LT as a time-dependent covariate conferring a 2.4-fold and 17-fold improvement in late survival among those with mild and moderate-to-severe dysfunction, respectively. Adjusting for PELD, sodium was a significant nonlinear predictor of outcome, with 90-day death/deterioration risk increased at both extremes of sodium (HR 1.20 per 1-unit decrease below 137 mmol/L, 95% CI 1.16-1.23; HR per 1-unit increase above 137 mmol/L 1.13, 95% CI 1.10-1.17, P < 0.001). A multivariable model incorporating PELD, eGFR, dialysis, and sodium demonstrated improved performance and superior calibration in predicting wait-list outcomes relative to the PELD score. CONCLUSIONS Listing eGFR, dialysis, and serum sodium are potent, independent predictors of 90-day death/deterioration in pediatric LT candidates, capturing risk not accounted for by PELD. Incorporation of these variables into organ allocation systems may highlight patient subsets with previously underappreciated risk, augment ability of PELD to prioritize patients for transplantation, and ultimately mitigate reliance on nonstandard exceptions.
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Affiliation(s)
- Leanne Thalji
- Department of Anesthesiology and Perioperative MedicineMayo ClinicRochesterMN
| | | | | | - Samar H Ibrahim
- Department of PediatricsDivision of Gastroenterology and HepatologyMayo ClinicRochesterMN
| | - Patrick S Kamath
- Department of MedicineDivision of Gastroenterology and HepatologyMayo ClinicRochesterMN
| | - Andrew Hanson
- Division of Biomedical StatisticsMayo ClinicRochesterMN
| | | | - Dawit T Haile
- Department of Anesthesiology and Perioperative MedicineMayo ClinicRochesterMN
| | - Daryl J Kor
- Department of Anesthesiology and Perioperative MedicineMayo ClinicRochesterMN
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13
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Mortality Determinants in Children with Biliary Atresia Awaiting Liver Transplantation. J Pediatr 2021; 228:177-182. [PMID: 32950533 DOI: 10.1016/j.jpeds.2020.09.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 08/11/2020] [Accepted: 09/02/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To determine risk factors for waitlist mortality in children with biliary atresia listed for liver transplantation. STUDY DESIGN There were 2704 children with biliary atresia (<12 years of age) listed for a first liver transplant (2002-2018) in the United Network for Organ Sharing database. Fine-Gray regression models for competing risks analysis (main risk = waitlist mortality/delisting owing to too sick; competing risk = liver transplantation) were implemented to identify risk factors for waitlist mortality. RESULTS The median waitlist time was 83 days (IQR, 34-191). The cumulative incidence of waitlist mortality was 5.2%. In multivariable analysis (n = 2253), increasing bilirubin level (P < .001), portal vein thrombosis (P = .03), and ventilator dependence (P < .001) at listing were associated with a higher risk, whereas weight ≥10 kg at listing (P = .009) was associated with a lower risk of waitlist mortality. When ascites at listing was included in multivariable analysis (n = 1376), it was associated with a higher risk for the composite outcome (P = .03). Encephalopathy at listing was not associated with waitlist mortality (n = 1376; P = .15). CONCLUSIONS These parameters can be used to more objectively prioritize children with biliary atresia awaiting liver transplantation and identify children with biliary atresia-related end-stage liver disease at high-risk of mortality.
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14
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Hyponatremia Is Associated With Increased Mortality in Children on the Waiting List for Liver Transplantation. Transplant Direct 2020; 6:e604. [PMID: 33134484 PMCID: PMC7591120 DOI: 10.1097/txd.0000000000001050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 07/13/2020] [Accepted: 07/14/2020] [Indexed: 12/21/2022] Open
Abstract
Our aim was to determine whether hyponatremia is associated with waiting list or posttransplantation mortality in children having liver transplantation (LT).
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15
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Guedes RR, Kieling CO, Dos Santos JL, da Rocha C, Schwengber F, Adami MR, Chedid MF, Vieira SMG. Severity of Ascites Is Associated with Increased Mortality in Patients with Cirrhosis Secondary to Biliary Atresia. Dig Dis Sci 2020; 65:3369-3377. [PMID: 31907773 DOI: 10.1007/s10620-019-06029-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 12/22/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Very few prior studies have investigated the presence of ascites as a prognostic factor in children with cirrhosis. To the best of our knowledge, there are no prior studies evaluating the relationship between severity of ascites and patient survival in children with biliary atresia and cirrhosis. AIMS To evaluate the association between severity of ascites and survival of children with cirrhosis and biliary atresia. METHODS All children with cirrhosis secondary to biliary atresia evaluated at our institution from 2000 to 2014 were included in this study. Patients were classified into four groups: NA = no ascites; A1 = grade 1 ascites; A2 = grade 2 ascites; and A3 = grade 3 ascites. The primary endpoint of the study was mortality within the first year after patient inclusion. Ninety-day mortality was also evaluated. Prognostic factors related to both endpoints also were studied. RESULTS One-year patient survival for NA was 97.1%, versus 80.8% for A1, versus 52% for A2, versus 13.6 for A3 (p < 0.001). The presence of ascites increased mortality by 17 times. In the multivariate analysis, clinically detectable ascites (HR 3.14, 95% CI 1.14-8.60, p = 0.026), lower sodium (HR 1.15, 95% CI 1.04-1.27, p = 0.006), higher bilirubin (HR 1.06, 95% CI 1.00-1.12, p = 0.023), and higher PELD score (HR 1.05, 95% CI 1.02-1.08, p = 0.001) were all associated with decreased survival. Lower serum sodium (HR 1.20, 95% CI 1.09-1.32, p < 0.001) and higher PELD score (HR 1.03, 95% CI 1.001-1.063, p = 0.043) were associated with increased 90-day mortality. CONCLUSIONS Clinically detectable ascites is associated with decreased 1-year survival of children with biliary atresia. These patients should be treated with caution and prioritized for liver transplantation.
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Affiliation(s)
- Renata R Guedes
- Pediatric Liver Transplantation Unit, Pediatric Service, Hospital de Clínicas de Porto Alegre, Postgraduation Program in Gastroenterology and Hepatology Sciences, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2350, Sala 1143, Porto Alegre, RS, 90035-903, Brazil.
| | - Carlos O Kieling
- Pediatric Liver Transplantation Unit, Pediatric Service, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos, 2350, Sala 1143, Porto Alegre, RS, 90035-903, Brazil
| | - Jorge L Dos Santos
- Health Science Research Centre, University of Beira Interior (CICS, UBI), Universidade da Beira Interior, R. Marquês de Ávila e Bolama, 6201-001, Covilhã, Portugal
| | - Carolina da Rocha
- Pediatric Service, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos, 2350, Sala 1045, Porto Alegre, RS, 90035-903, Brazil
| | - Fernando Schwengber
- Internal Medicine Service, Hospital de Clínicas de Porto Alegre, Rua Corte Real 82, Porto Alegre, RS, 90630-080, Brazil
| | - Marina R Adami
- Pediatric Liver Transplantation Unit, Pediatric Service, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos, 2350, Sala 1143, Porto Alegre, RS, 90035-903, Brazil
| | - Marcio F Chedid
- Postgraduation Program in Surgical Sciences, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2350, Sala 743, Porto Alegre, RS, 90035-903, Brazil
| | - Sandra M G Vieira
- Pediatric Liver Transplantation Unit, Pediatric Service, Hospital de Clínicas de Porto Alegre, Postgraduation Program in Gastroenterology and Hepatology Sciences, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2350, Sala 1143, Porto Alegre, RS, 90035-903, Brazil
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16
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Silva Duarte Dos Santos R, Kieling CO, Adami MR, Guedes RR, Vieira SMG. Hypervolemic hyponatremia and transplant-free survival in children with cirrhosis due to biliary atresia. Pediatr Transplant 2020; 24:e13687. [PMID: 32134176 DOI: 10.1111/petr.13687] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 11/10/2019] [Accepted: 02/03/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Biliary atresia is the number one cause of cirrhosis and liver transplantation in children. Hyponatremia is the most important electrolytic disturbance observed in decompensated cirrhosis. Studies of hyponatremia in cirrhotic children are scarce and those that exist have defined hyponatremia as serum sodium < 130 mEq/L lasting for at least 7 days. METHODS We evaluated transplant-free survival (Kaplan-Meier) of children with cirrhosis due to biliary atresia and serum sodium < 130 mEq/L persisting for 1, 2-6, and ≥7 days. This was a single-center, historical cohort that included all patients aged ≤ 18 years on a liver transplantation waiting list. RESULTS We studied 128 patients. The overall frequency of hyponatremia was 30.5% (39/128). Thirteen patients (10.2%) had hyponatremia when put on the list, and 20.3% developed it during follow-up. The Kaplan-Meier overall transplant-free survival rate was 83.3%. Patients with persistent hyponatremia for at least two days had the lowest transplant-free survival. Glomerular filtration rate (P = .00, RR = 0.96, IC 95% = 0.94-0.99), BMI/age Z-score (P = .02, RR = 0.59, IC 95% = 0.39-0.91), INR (P = .00, RR = 1.43, IC 95% = 1.17-1.74), and serum sodium (P = .04, RR = 0.91, IC 95% = 0.84-0.99) were independently associated with transplant-free survival. We did not observe any difference in mortality prediction after adding sodium to the original PELD score. CONCLUSIONS We conclude that persistent hyponatremia lasting at least two days may herald poor prognosis for children with cirrhosis due to biliary atresia.
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Affiliation(s)
- Renata Silva Duarte Dos Santos
- Programa de Pós-Graduação Saúde da Criança e do Adolescente, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Carlos Oscar Kieling
- Unidade de Gastroenterologia e Hepatologia Pediátrica, Programa de Transplante Hepático Infantil, Hospital de Clínicas de Porto Alegre. Serviço de Pediatria, Porto Alegre, Brazil
| | - Marina Rossato Adami
- Unidade de Gastroenterologia e Hepatologia Pediátrica, Programa de Transplante Hepático Infantil, Hospital de Clínicas de Porto Alegre. Serviço de Pediatria, Porto Alegre, Brazil
| | - Renata Rostirola Guedes
- Unidade de Gastroenterologia e Hepatologia Pediátrica, Programa de Transplante Hepático Infantil, Hospital de Clínicas de Porto Alegre. Serviço de Pediatria, Porto Alegre, Brazil
| | - Sandra Maria Gonçalves Vieira
- Programa de Pós-Graduação Saúde da Criança e do Adolescente, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.,Unidade de Gastroenterologia e Hepatologia Pediátrica, Programa de Transplante Hepático Infantil, Hospital de Clínicas de Porto Alegre. Serviço de Pediatria, Porto Alegre, Brazil.,Departamento de Pediatria, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
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17
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de Ville de Goyet Prof J, Grimaldi C, Tuzzolino F, di Francesco F. A paradigm shift in the intention-to-transplant children with biliary atresia: Outcomes of 101 cases and a review of the literature. Pediatr Transplant 2019; 23:e13569. [PMID: 31410937 DOI: 10.1111/petr.13569] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 07/14/2019] [Accepted: 07/23/2019] [Indexed: 12/15/2022]
Abstract
For children with BA who do not benefit from Kasai surgery, the only therapeutic option is liver replacement and transplantation. The very decision to proceed for transplantation is a crucial point in time because it is the first step toward the preparation for the transplantation. The former time point is defined in this analysis as "intent-to-transplant" care pathway. In the life of every BA candidate for liver replacement, this point in time varies and mostly depends on the decision of their primary caring teams-about when to switch from supportive care to transplant, and thus to refer to a transplant center. This intent-to-transplant analysis of a series of 101 consecutive infants that were referred to a single transplant team showed that excellent overall outcome (97% survival) has been achieved overall. However, three deaths occurred that were clearly related to a late referral. This analysis and recent observations from other centers strongly support that the timing for referring these children to a transplant center and/or deciding to list them on the waiting list is currently too late and should be anticipated to what it is currently. This paradigm shift in the intention-to-transplant children is likely necessary for giving a better chance to an increased number of children and impacts positively on the general outcome. Networking and defining new tools for a rapid recognition of the infants who need early transplantation are necessary; centralization of these children may be helpful to achieve better outcomes than currently observed.
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Affiliation(s)
- Jean de Ville de Goyet Prof
- Department for the Treatment and Study of Pediatric Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Via E. Tricomi, Palermo, 90127, Italy
| | - Chiara Grimaldi
- Department of Surgery, Abdominal Transplantation and Hepatobiliopancreatic Surgical Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Fabio Tuzzolino
- Research Office, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Palermo, Italy
| | - Fabrizio di Francesco
- Department for the Treatment and Study of Pediatric Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Via E. Tricomi, Palermo, 90127, Italy
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18
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Jain V, Burford C, Alexander EC, Sutton H, Dhawan A, Joshi D, Davenport M, Heaton N, Hadzic N, Samyn M. Prognostic markers at adolescence in patients requiring liver transplantation for biliary atresia in adulthood. J Hepatol 2019; 71:71-77. [PMID: 30876944 DOI: 10.1016/j.jhep.2019.03.005] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 02/14/2019] [Accepted: 03/04/2019] [Indexed: 01/05/2023]
Abstract
BACKGROUND & AIMS In patients with biliary atresia (BA), the rate of native liver survival (NLS) to adulthood has been reported as 14-44% worldwide. Complications related to portal hypertension (PHT) and cholangitis are common in adulthood. For those requiring liver transplantation (LT), the timing can be challenging. The aim of this study was to identify variables that could predict whether young people with BA would require LT when they are >16 years of age. METHODS This study was a single-centre retrospective analysis of 397 patients who underwent Kasai portoenterostomy (KP) between 1980-96 in the UK. After KP, 111/397 (28%) demonstrated NLS until 16 years of age. At final follow-up, 67 showed NLS when >16 years old (Group 1) and 22 required LT when >16 years old (Group 2). Laboratory, clinical and radiological parameters were collected for both groups at a median age of 16.06 years (13.6-17.4 years). RESULTS The need for LT when >16 years old was associated with higher total bilirubin (hazard ratio 1.03, p = 0.019) and lower creatinine (hazard ratio 0.95, p = 0.040), at 16 years, on multivariate analysis. Receiver-operating characteristic curve analysis demonstrated that a total bilirubin level of ≥21 µmol/L at 16 years old (AUROC = 0.848) predicted the need for LT when >16 years old, with 85% sensitivity and 74% specificity. Cholangitis episode(s) during adolescence were associated with a 5-fold increased risk of needing LT when >16 years old. The presence of PHT or gastro-oesophageal varices in patients <16 years old was associated with a 7-fold and 8.6-fold increase in the risk of needing LT, respectively. CONCLUSIONS BA in adulthood requires specialised management. Adult liver disease scoring models are not appropriate for this cohort. Bilirubin ≥21 µmol/L, PHT or gastro-oesophageal varices at 16 years, and cholangitis in adolescence, can predict the need for future LT in young people with BA. Low creatinine at 16 years also has potential prognostic value. LAY SUMMARY Patients with biliary atresia commonly require liver transplantation before reaching adulthood. Those who reach adulthood with their own liver are still at risk of needing a transplant. This study aimed to identify tests that could help clinicians predict which patients with biliary atresia who reach the age of 16 without a transplant will require one in later life. The study found that the presence of bilirubin ≥21 µmol/L, lower creatinine levels, and a history of portal hypertension or gastro-oesophageal varices at 16 years, as well as cholangitis in adolescence, could predict the future likelihood of needing a liver transplant for young people with biliary atresia.
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Affiliation(s)
- Vandana Jain
- Paediatric Liver, GI and Nutrition Centre and Mowatlabs, Kings College Hospital, London, UK.
| | - Charlotte Burford
- Faculty of Life Sciences and Medicine, Kings College London, London, UK
| | - Emma C Alexander
- Faculty of Life Sciences and Medicine, Kings College London, London, UK
| | - Harry Sutton
- Faculty of Life Sciences and Medicine, Kings College London, London, UK
| | - Anil Dhawan
- Paediatric Liver, GI and Nutrition Centre and Mowatlabs, Kings College Hospital, London, UK
| | - Deepak Joshi
- Institute of Liver Studies, Kings College Hospital, London, UK
| | - Mark Davenport
- Department of Paediatric Surgery, Kings College Hospital, London, UK
| | - Nigel Heaton
- Liver Transplant Surgery, Institute of Liver Studies, Kings College Hospital, London, UK
| | - Nedim Hadzic
- Paediatric Liver, GI and Nutrition Centre and Mowatlabs, Kings College Hospital, London, UK
| | - Marianne Samyn
- Paediatric Liver, GI and Nutrition Centre and Mowatlabs, Kings College Hospital, London, UK
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19
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Zhao H, Zhao R, Hu J, Zhang X, Ma J, Shi Y, Ma W, Sheng J, Li L. Upper gastrointestinal hemorrhage in acute-on-chronic liver failure: prevalence, characteristics, and impact on prognosis. Expert Rev Gastroenterol Hepatol 2019; 13:263-269. [PMID: 30791764 DOI: 10.1080/17474124.2019.1567329] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Upper gastrointestinal hemorrhage (UGH) is a life-threatening complication in patients with cirrhosis; however, data regarding the role of UGH in acute-on-chronic liver failure (ACLF) are limited. METHODS A prospective, observational cohort study was performed from February 2014 to Mach 2015. RESULTS UGH was identified in 170 of 492 cirrhotic patients with acute decompensation (AD) at the time of admission. Logistic regression analysis showed that fecal occult blood test positivity was an independent risk factor for UGH in patients with or without ACLF [OR(95%CI): 8.31(4.89-14.10), p < 0.001; and 6.29 (1.48-26.76), p = 0.031]. Other independent risk factors were a history of gastrointestinal bleeding [OR(95% CI): 13.43 (7.17-25.15), p < 0.001], older age [OR(95% CI): 0.98(0.96-0.99), p = 0.003], greater INR level [OR(95% CI): 0.48(0.28-0.81), p = 0.007] in patients without ACLF. Multivariate Cox proportional hazard model analysis indicated that UGH did not increase mortality at different times in cirrhotic patients with acute decompensation. CONCLUSIONS UGH is a frequent complication in cirrhotic patients with AD, even those with ACLF. Positive fecal occult blood tests and previous GI bleeding were shown to be associated with the risk of UGH. UGH did not significantly increase the risk of mortality in cirrhotic patients with AD or ACLF.
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Affiliation(s)
- Hong Zhao
- a State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, School of Medicine , Zhejiang University , Hangzhou , China
| | - Ruihong Zhao
- a State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, School of Medicine , Zhejiang University , Hangzhou , China
| | - Jianhua Hu
- a State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, School of Medicine , Zhejiang University , Hangzhou , China
| | - Xuan Zhang
- a State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, School of Medicine , Zhejiang University , Hangzhou , China
| | - Jianke Ma
- b Department of Infectious Diseases , Cixi People's Hospital , Cixi , China
| | - Yemin Shi
- c Department of Infectious Diseases , Yuyao People's Hospital , Ningbo , China
| | - Weihang Ma
- a State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, School of Medicine , Zhejiang University , Hangzhou , China
| | - Jifang Sheng
- a State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, School of Medicine , Zhejiang University , Hangzhou , China
| | - Lanjuan Li
- a State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, School of Medicine , Zhejiang University , Hangzhou , China
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20
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Mysore KR, Himes RW, Rana A, Teruya J, Desai MS, Srivaths PR, Zaruca K, Calvert A, Guffey D, Minard CG, Morita E, Hensch L, Losos M, Kostousov V, Hui SKR, Orange JS, Goss JA, Nicholas SK. ABO-incompatible deceased donor pediatric liver transplantation: Novel titer-based management protocol and outcomes. Pediatr Transplant 2018; 22:e13263. [PMID: 30070010 PMCID: PMC6197909 DOI: 10.1111/petr.13263] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 06/18/2018] [Indexed: 12/16/2022]
Abstract
ABO-ILT have re-emerged as an alternate option for select patients awaiting transplant. However, treatment protocols for children undergoing deceased donor ABO-ILT are not standardized. We implemented a novel IS protocol for children undergoing deceased donor ABO-ILT based on pretransplant IH titers. Children with high pretransplant IH titers (≥1:32) underwent an enhanced IS protocol including plasmapheresis, rituximab, IVIG, and mycophenolate, while children with IH titers ≤1:16 received steroids and tacrolimus. We retrospectively assessed our outcomes of ABO-ILT with ABO-compatible recipients of similar age and diagnosis over a 2-year period. Ten children with median age of 8.9 months underwent ABO-ILT, 4 of 10 patients underwent enhanced IS due to high IH titers. Rates of complications (rejection, infections, biliary, and vascular) at both 1 year and up to 3 years post-transplant were comparable between the groups. Patients with ABO-ILT had good graft function with 100% survival at a median follow-up of 3.3 years. In conclusion, IS tailored to pretransplant IH titers in pediatric deceased donor ABO-ILT is feasible and can achieve outcomes similar to ABO-CLT at 1 and 3 years post-transplantation.
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Affiliation(s)
- Krupa R. Mysore
- Section of Pediatric Gastroenterology, Texas Children’s Hospital, Baylor College of Medicine
| | - Ryan W. Himes
- Section of Pediatric Gastroenterology, Texas Children’s Hospital, Baylor College of Medicine
| | - Abbas Rana
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine
| | - Jun Teruya
- Department of Pathology, Transfusion Medicine, Baylor College of Medicine
| | - Moreshwar S. Desai
- Section of Pediatric Critical Care, Texas Children’s Hospital, Baylor College of Medicine
| | | | - Kimberly Zaruca
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine
| | | | - Danielle Guffey
- Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine
| | - Charles G. Minard
- Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine
| | - Eda Morita
- Department of Pathology, Transfusion Medicine, Baylor College of Medicine
| | - Lisa Hensch
- Department of Pathology, Transfusion Medicine, Baylor College of Medicine
| | - Michael Losos
- Department of Pathology, Transfusion Medicine, Baylor College of Medicine
| | - Vadim Kostousov
- Department of Pathology, Transfusion Medicine, Baylor College of Medicine
| | - Shiu-Ki Rocky Hui
- Department of Pathology, Transfusion Medicine, Baylor College of Medicine
| | - Jordan S. Orange
- Section of Pediatric Allergy & Immunology, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas
| | - John A. Goss
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine
| | - Sarah K. Nicholas
- Section of Pediatric Allergy & Immunology, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas
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21
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Bolia R, Srivastava A, Yachha SK, Poddar U. Pediatric CLIF-SOFA score is the best predictor of 28-day mortality in children with decompensated chronic liver disease. J Hepatol 2018; 68:449-455. [PMID: 29024698 DOI: 10.1016/j.jhep.2017.10.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 10/01/2017] [Accepted: 10/02/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND & AIMS Early identification of children with decompensated chronic liver disease (DCLD) at risk of short-term mortality helps improve outcome. We aimed to evaluate the predictors of outcome and role of Child-Pugh, pediatric end-stage liver disease (PELD) and pediatric chronic liver failure sequential organ failure assessment (pCLIF-SOFA) score for prognosticating 28-day mortality in children with DCLD. METHODS DCLD children were prospectively evaluated with a clinico-laboratory proforma and followed for 28 days to determine outcome. Child-Pugh, PELD and pCLIF-SOFA were calculated at admission. Univariate and multivariate analysis was performed to identify the best predictors of outcome. RESULTS A total of 110 children (74 boys, 96 [4-204] months) were enrolled and 37 (33.6%) died at 28 days. Significant risk factors for mortality were a higher international normalized ratio (hazard ratio [HR] 1.17; 95% CI 1.04-1.31; p <0.001) and bilirubin (HR 1.04; 95% CI 1.01-1.08; p <0.001), lower albumin (HR 0.46; 95% CI 0.27-0.77; p = 0.03) and sodium (HR 0.93; 95% CI 0.89-0.98; p = 0.01), absence of treatable etiology (HR 2.00; 95% CI 1.40-2.87; p = 0.001) and presence of organ failure (HR 3.22; 95% CI 1.98-10.58; p <0.001). Organ failure and serum sodium were independent predictors of poor outcome on multivariate analysis. pCLIF-SOFA (16 [9-22] vs. 9 [5-15]), Child-Pugh (11 [9-15] vs. 10 [8-14]) and PELD (22.2 [7.5-45.3] vs. 15.3 [4.5-23.9]) scores were significantly higher in non-survivors. The area under the curve was 0.977 for pCLIF-SOFA, 0.815 for Child-Pugh score, and 0.741 for PELD score. A pCLIF-SOFA score of ≥11 identified 28-day mortality with a sensitivity and specificity of 94.9% and 91.5%, respectively. CONCLUSION Thirty-four percent of children with DCLD have a poor short-term outcome. Organ failure and low serum sodium are independent predictors of outcome. pCLIF-SOFA performs better than Child-Pugh and PELD in prognostication of 28-day mortality. Our study supports the use of scores based on organ failure in prognosticating children with DCLD. LAY SUMMARY The ability to predict the course of a disease is an important part of the assessment, enabling timely interventions that improve outcomes. We evaluated the outcome (death vs. survival) and compared three different scoring systems for their ability to predict mortality within 28 days in children with decompensated chronic liver disease (DCLD). One-third of children with DCLD died within 28 days and the pediatric chronic liver failure sequential organ failure assessment score, which considers the main organ systems of the body (lungs, liver, brain, kidney, blood and cardiac) fared better for identification of children with a poor outcome than the Child-Pugh and pediatric end-stage liver disease score which comprise of only liver-related parameters. Our study supports the use of scores based on organ failure in prognosticating children with DCLD.
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Affiliation(s)
- Rishi Bolia
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Anshu Srivastava
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.
| | - Surender Kumar Yachha
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Ujjal Poddar
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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22
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The first episode of spontaneous bacterial peritonitis is a threat event in children with end-stage liver disease. Eur J Gastroenterol Hepatol 2018; 30:323-327. [PMID: 29303884 DOI: 10.1097/meg.0000000000001046] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Studies on native liver survival (NLS) after the first episode of spontaneous bacterial peritonitis (SBP) are rare. Our objective was to evaluate NLS in children up to 1 year after SBP. METHODS A historical cohort study of 18 children followed after the first episode of SBP was conducted. NLS, in-hospital mortality, causes of death, and rate of multidrug-resistant organisms were reported. RESULTS Biliary atresia was the most prevalent diagnosis (72.2%); all were Child-Pugh C, and the median age was 1.0 year. The probability of NLS was 77.8, 27.8, and 11.1% at 1, 3 and 6 months, respectively. At 9 months, no child had the native liver. In-hospital mortality was 38.9%, and the main causes of death were septic shock and acute-on-chronic liver failure. Escherichia coli was the predominant organism cultured. Multidrug-resistant organisms were not detected. The cumulative probability of NLS was 77.8% at 1 month, 27.8% at 3 months, and 11.1% at 6 months. At 9-month follow-up, none of children had their native liver. Ascites PMN count cell more than 1000 cells/mm, positive ascites culture, and prolonged international normalized ratio reached a significant value as predictive factors of NLS and were selected for multivariate analysis. We did not identify independent predictors of survival. CONCLUSION Development of SBP was a late event in children and had a high effect on NLS.
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23
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Perito ER, Braun HJ, Dodge JL, Rhee S, Roberts JP. Justifying Nonstandard Exception Requests for Pediatric Liver Transplant Candidates: An Analysis of Narratives Submitted to the United Network for Organ Sharing, 2009-2014. Am J Transplant 2017; 17:2144-2154. [PMID: 28141916 PMCID: PMC5519411 DOI: 10.1111/ajt.14216] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 12/21/2016] [Accepted: 01/20/2017] [Indexed: 01/25/2023]
Abstract
Nonstandard exception requests (NSERs), for which transplant centers provide patient-specific narratives to support a higher Model for End-stage Liver Disease/Pediatric End-stage Liver Disease score, are made for >30% of pediatric liver transplant candidates. We describe the justifications used in pediatric NSER narratives 2009-2014 and identify justifications associated with NSER denial, waitlist mortality, and transplant. Using United Network for Organ Sharing data, 1272 NSER narratives from 1138 children with NSERs were coded for analysis. The most common NSER justifications were failure-to-thrive (48%) and risk of death (40%); both associated with approval. Varices, involvement of another organ, impaired quality of life, and encephalopathy were justifications used more often in denied NSERs. Of the 25 most prevalent justifications, 60% were not associated with approval or denial. Waitlist mortality risk was increased when fluid overload or "posttransplant complication outside standard criteria" were cited and decreased when liver-related infection was noted. Transplant probability was increased when the narrative mentioned liver-related infections, and fluid overload for children <2 years old; it decreased when "posttransplant complications outside standard criteria" and primary sclerosing cholangitis were cited. This analysis provides novel insight and suggests targets for future consideration in outcomes research and exception criteria. Changes in the allocation system are needed to ensure equity and optimize outcomes for all pediatric candidates.
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Affiliation(s)
- Emily R. Perito
- Department of Pediatrics, University of California, San Francisco,Department of Epidemiology and Biostatistics, University of California, San Francisco
| | | | | | - Sue Rhee
- Department of Pediatrics, University of California, San Francisco
| | - John P. Roberts
- Department of Surgery, University of California, San Francisco
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24
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Spengler EK, Hunsicker LG, Zarei S, Zimmerman MB, Voigt MD. Transjugular intrahepatic portosystemic shunt does not independently increase risk of death in high model for end stage liver disease patients. Hepatol Commun 2017; 1:460-468. [PMID: 29404473 PMCID: PMC5721420 DOI: 10.1002/hep4.1053] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 04/14/2017] [Accepted: 04/22/2017] [Indexed: 12/15/2022] Open
Abstract
Physicians often exclude patients with a model for end-stage liver disease (MELD) score ≥ 18 from a transjugular intrahepatic portosystemic shunt (TIPS) procedure due to the concern for higher risk of death. We aimed to determine if TIPS increased the risk of death in these patients. We analyzed the interaction between TIPS and MELD in 106 patients with TIPS and 79 with intractable ascites without TIPS. We performed Cox proportional hazard regression, including both TIPS and MELD as time-dependent covariates together with their interaction, to calculate the impact of TIPS on the risk of death associated with a high MELD score. We found a negative interaction between a high MELD score and a history of TIPS, with potentially important effect sizes. Patients with MELD scores ≥18 had a 51% lower incremental risk of death (lower risk than would be expected from the combined independent risks of MELD and needing/receiving TIPS) associated with TIPS than patients with MELD scores <18 (hazard ratio for TIPS, 0.49; 95% confidence interval, 0.10-2.45) in the first 6 months following TIPS. There was an 80% lower incremental risk of death among patients with a MELD score ≥18 (hazard ratio for TIPS, 0.20; 95% confidence interval, 0.03-1.23) 6 months after the TIPS procedure. Conclusion: Risk of death is associated with underlying disease severity as shown by the MELD score and the need for TIPS, and both history of TIPS and high MELD score independently increased the risk of mortality. However, the risk of death after TIPS was progressively lower than expected as the MELD score increased. (Hepatology Communications 2017;1:460-468).
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Affiliation(s)
- Erin K Spengler
- Division of Gastroenterology and Hepatology Department of Internal Medicine, The University of Iowa Hospitals and Clinics Iowa City IA.,University of Wisconsin, School of Medicine and Public Health Madison WI
| | - Lawrence G Hunsicker
- Division of Nephrology Department of Internal Medicine, The University of Iowa Hospitals and Clinics Iowa City IA
| | - Sanam Zarei
- Carver College of Medicine The University of Iowa Hospitals and Clinics Iowa City IA
| | - M Bridget Zimmerman
- Department of Biostatistics The University of Iowa Hospitals and Clinics Iowa City IA
| | - Michael D Voigt
- Division of Gastroenterology and Hepatology Department of Internal Medicine, The University of Iowa Hospitals and Clinics Iowa City IA
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25
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Abstract
Cirrhosis is the end result of nearly all forms of progressive liver disease. The diffuse hepatic process can be characterized as a state of inflammation progressing to fibrosis and resulting in nodular regeneration, ultimately leading to disorganized liver architecture and function. The underlying etiology of cirrhosis in children may often differ from adults owing to specific disease processes that manifest in childhood, including biliary atresia, galactosemia, and neonatal hepatitis. Although basic management strategies in children are similar to those in adults, the care given to children with cirrhosis must keep the child's growth and development of paramount importance. [Pediatr Ann. 2016;45(12):e427-e432.].
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26
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Braun HJ, Perito ER, Dodge JL, Rhee S, Roberts JP. Nonstandard Exception Requests Impact Outcomes for Pediatric Liver Transplant Candidates. Am J Transplant 2016; 16:3181-3191. [PMID: 27214757 PMCID: PMC5083236 DOI: 10.1111/ajt.13879] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 05/10/2016] [Accepted: 05/17/2016] [Indexed: 01/25/2023]
Abstract
Nonstandard exceptions requests (NSERs), in which transplant centers appeal on a case-by-case basis for Pediatric End-Stage Liver Disease/Mayo End-Stage Liver Disease points, have been highly utilized for pediatric liver transplant candidates. We evaluated whether NSE outcomes are associated with waitlist and posttransplant mortality. United Network for Organ Sharing (UNOS) Scientific Registry of Transplant Recipients data on pediatric liver transplant candidates listed in 2009-2014 were analyzed after excluding those granted automatic UNOS exceptions. Of 2581 pediatric waitlist candidates, 44% had an NSE request. Of the 1134 children with NSERs, 93% were approved and 7% were denied. For children 2-18 years at listing, NSER denial increased the risk of waitlist mortality or removal for being too sick (subhazard ratio 2.99, 95% confidence interval [CI] 1.26-7.07, p = 0.01 in multivariate analysis). For children younger than 2 years, NSER denial did not impact waitlist mortality/removal. Children with NSER approved had reduced risk of graft loss 3 years posttransplant in univariate but not multivariable analysis (odds ratio 0.73, 95% CI 0.53-1.01, p = 06). Those with NSER denial had a higher risk of posttransplant death than those with no NSER (hazard ratio 2.43, 95% CI 0.99-5.95, p = 0.05, multivariable analysis), but NSER approval did not impact posttransplant death. Further research on NSER utilization in pediatric liver transplant is needed to optimize organ allocation and outcomes for children.
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Affiliation(s)
| | - Emily R. Perito
- Department of Pediatrics, University of California, San Francisco, Department of Epidemiology and Biostatistics, University of California, San Francisco
| | | | - Sue Rhee
- Department of Pediatrics, University of California, San Francisco
| | - John P. Roberts
- Department of Surgery, University of California, San Francisco
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27
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Leung D, Narang A, Minard C, Hiremath G, Goss J, Shepherd R. A 10-Year united network for organ sharing review of mortality and risk factors in young children awaiting liver transplantation. Liver Transpl 2016; 22:1584-1592. [PMID: 27541809 PMCID: PMC5083224 DOI: 10.1002/lt.24605] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 08/04/2016] [Indexed: 12/21/2022]
Abstract
Young children < 2 years of age with chronic end-stage liver disease (YC2) are a uniquely vulnerable group listed for liver transplantation, characterized by a predominance of biliary atresia (BA). To investigate wait-list mortality, associated risk factors, and outcomes of YC2, we evaluated United Network for Organ Sharing registry data from April 2003 to March 2013 for YC2 listed for deceased donor transplant (BA = 994; other chronic liver disease [CLD] = 221). Overall, wait-list mortality among YC2 was 12.4% and posttransplant mortality was 8%, accounting for an overall postlisting mortality of 19.6%. YC2 demonstrated 12.2%, 18.7%, and 20.6% wait-list mortality by 90, 180, and 270 days, respectively. YC2 with CLD demonstrated significantly higher wait-list mortality compared with BA among YC2 (23.9% versus 9.8%; P < 0.05). Multivariate analyses revealed that listing Pediatric End-Stage Liver Disease [PELD] > 21 (hazard ratio [HR], 3.2; 95% confidence interval [CI], 1.6-6.5), lack of exception (HR, 5.8; 95% CI, 2.8-11.8), listing height < 60.6 cm (HR, 2.1; 95% CI, 1.4-3.1), listing weight > 10 kg (HR, 3.8; 95% CI, 1.5-9.2), and initial creatinine > 0.5 (HR, 6.8; 95% CI, 3.4-13.5) were independent risk factors for YC2 wait-list mortality (P < 0.005 for all). Adjusting for all variables, the risk of death among CLD patients was 2 (95% CI, 1.3-3.1) times greater than patients with BA + surgery (presumed Kasai). Furthermore, the risk of death in BA without surgery was 1.9 (95% CI, 1‐3.4) times greater than BA with presumed Kasai. Our data highlight unacceptably high wait-list and early post-liver transplant mortality in YC2 not predicted by PELD and suggest key risk factors deserving of further study in this age group. Liver Transplantation 22 1584-1592 2016 AASLD.
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Affiliation(s)
- D.H. Leung
- Department of Pediatrics, Baylor College of Medicine, Houston, TX,Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Texas Children's Hospital, Houston, TX
| | - A. Narang
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - C.G. Minard
- Dan L. Duncan Institute for Clinical and Translational Research, Houston, TX
| | - G. Hiremath
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - J.A. Goss
- Division of Abdominal Transplant Surgery, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, United States
| | - R. Shepherd
- Department of Pediatrics, Baylor College of Medicine, Houston, TX,Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Texas Children's Hospital, Houston, TX
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28
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Feier F, Antunes E, D'Agostino D, Varela-Fascinetto G, Jarufe N, Patillo JC, Vera A, Carrasco F, Kondo M, Porta G, Chapchap P, Seda-Neto J. Pediatric liver transplantation in Latin America: Where do we stand? Pediatr Transplant 2016; 20:408-16. [PMID: 26841316 DOI: 10.1111/petr.12679] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/30/2015] [Indexed: 12/11/2022]
Abstract
LT started in LA in 1968, and pediatric LT records are available starting in the 1990s. Currently, eight countries perform pediatric LT in LA. Registries by national organizations fail to report robust data on pediatric LT. The aim of this paper was to report on the pediatric LT activity in LA. Data were gathered retrospectively through information available in the national registries websites and from local centers. Of the eight countries that report pediatric LT activity, Brazil, Argentina, Mexico, and Colombia have adequate registries of the numbers of LT performed. These countries concentrate most of the activity for pediatric LT. A total of 4593 pediatric LT were reported in LA. Websites for national organizations do not provide open data on post-transplant survival rates or waiting list mortality. The information herein is based on reports by local centers. Overall, survival from select centers is similar to that reported on North American and European registries, between 80 and 90% in the first year post-transplant. In conclusion, pediatric LT activity is growing in LA, especially in Brazil and Argentina. However, the lack of an appropriate LA registry restricts the assessment of quality and therefore restricts interventions aimed at quality improvements in different regions.
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Affiliation(s)
- Flavia Feier
- Hepatology and Liver Transplantation Group, Hospital Sirio-Libanes, São Paulo, Brazil.,Hepatology and Liver Transplantation Group, AC Camargo Cancer Center, São Paulo, Brazil
| | - Eduardo Antunes
- Hepatology and Liver Transplantation Group, Hospital Sirio-Libanes, São Paulo, Brazil.,Hepatology and Liver Transplantation Group, AC Camargo Cancer Center, São Paulo, Brazil
| | - Daniel D'Agostino
- Hepatology and Liver Transplantation, Hospital Italiano, Buenos Aires, Argentina
| | | | - Nicolas Jarufe
- Liver Transplantation, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Juan C Patillo
- Liver Transplantation, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Alonso Vera
- Transplant Department, University Hospital Fundación Santa Fe de Bogota, Bogota, Colombia
| | - Felix Carrasco
- Hepatobiliary Surgery Department, Hospital Nacional Guillermo Almenara, Lima, Peru
| | - Mario Kondo
- Hepatology and Liver Transplantation Group, Hospital Sirio-Libanes, São Paulo, Brazil.,Hepatology and Liver Transplantation Group, AC Camargo Cancer Center, São Paulo, Brazil
| | - Gilda Porta
- Hepatology and Liver Transplantation Group, Hospital Sirio-Libanes, São Paulo, Brazil.,Hepatology and Liver Transplantation Group, AC Camargo Cancer Center, São Paulo, Brazil
| | - Paulo Chapchap
- Hepatology and Liver Transplantation Group, Hospital Sirio-Libanes, São Paulo, Brazil
| | - Joao Seda-Neto
- Hepatology and Liver Transplantation Group, Hospital Sirio-Libanes, São Paulo, Brazil.,Hepatology and Liver Transplantation Group, AC Camargo Cancer Center, São Paulo, Brazil
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29
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Prohic D, Mesihovic R, Vanis N, Puhalovic A. Prognostic Significance of Ascites and Serum Sodium in Patients with Low Meld Scores. Med Arch 2016; 70:48-52. [PMID: 26980932 PMCID: PMC4779358 DOI: 10.5455/medarh.2016.70.48-52] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 01/05/2016] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVE to determine ascites and serum sodium significance in short term mortality prediction in patients with advanced liver cirrhosis. METHODS a cohort of 115 cirrhotic patients referred to our Department were followed up for 6 months in non-transplant settings. The c index equivalent to the area under the receiver operating curve (ROC) was calculated and compared to estimate the short-term prognostic accuracy of the following parameters: ascites, serum sodium and MELD score. RESULTS in patients with a MELD score less than 21, ascites and low serum sodium (c index 0,687, p<0 0,001 and 0,748, p<0,001 respectively) showed better prognostic accuracy and were independent predictors of mortality. For MELD scores above 21, only MELD was an independent mortality prognostic factor (c index 0,710, p<0,001). CONCLUSION in our study, sample ascites and low serum sodium help identify patients with advanced liver disease who are at high risk of mortality despite low MELD scores. These parameters should be considered as additional prognostic parameters that could improve available treatment options and outcomes in this group of patients.
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Affiliation(s)
- Dzanela Prohic
- Department of Gastroenterohepatology, University Clinical Center Sarajevo, Bosnia and Herzegovina
| | - Rusmir Mesihovic
- Department of Gastroenterohepatology, University Clinical Center Sarajevo, Bosnia and Herzegovina
| | - Nenad Vanis
- Department of Gastroenterohepatology, University Clinical Center Sarajevo, Bosnia and Herzegovina
| | - Amra Puhalovic
- Department of Gastroenterohepatology, University Clinical Center Sarajevo, Bosnia and Herzegovina
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Sen Sarma M, Yachha SK, Bhatia V, Srivastava A, Poddar U. Safety, complications and outcome of large volume paracentesis with or without albumin therapy in children with severe ascites due to liver disease. J Hepatol 2015; 63:1126-32. [PMID: 26134185 DOI: 10.1016/j.jhep.2015.06.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Revised: 06/19/2015] [Accepted: 06/22/2015] [Indexed: 12/04/2022]
Abstract
BACKGROUND & AIMS There are currently no published data on post-paracentesis circulatory dysfunction (PPCD) or its prevention in children. Our study was aimed to analyze the safety and complications of large volume paracentesis (LVP) in children with severe ascites due to chronic liver disease with or without albumin therapy. METHODS A prospective longitudinal observational study enrolled children with severe ascites who underwent single time LVP at admission. They were divided into albumin infused (AI) and albumin non-infused (ANI) groups. Hemodynamic monitoring and laboratory parameters including plasma renin activity (PRA) were compared between baseline, 48 h and day 6 of LVP. Their outcome at 3 months and maximal follow-up were noted. RESULTS 32 children (AI, n=17; ANI, n=15) had comparable baseline characteristics and 90.6% had high PRA at onset. The incidence of PPCD was 37.5% (ANI: 67%; AI: 12%, p=0.003), occurred if ascitic fluid extraction was >197.5 ml/kg (sensitivity: 90%; specificity: 50%, p=0.01) and if flow rate was higher in ANI group (1224 ± 476 vs. 678 ± 214 ml/h, p=0.009). ANI patients were susceptible to asymptomatic, persistent hyponatremia (baseline vs. day 6, 131 ± 4 vs. 128 ± 6 mEq/L; p=0.04) and had higher rates of recurrent ascites (42%) and hospital readmission (67%) within 3 months. No survival benefit among the AI or non-PPCD groups was demonstrated. CONCLUSIONS LVP is safe in all age groups, best performed under albumin cover to overcome the problems of PPCD and hyponatremia. It is prudent to restrict volume extraction to less than 200 ml/kg actual dry weight for all and flow rate of 680 ml/h in ANI.
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Affiliation(s)
- Moinak Sen Sarma
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Surender Kumar Yachha
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.
| | - Vijayalakshmi Bhatia
- Department of Endocrinology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Anshu Srivastava
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Ujjal Poddar
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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Barakat AAEK, Metwaly AA, Nasr FM, El-Ghannam M, El-Talkawy MD, Taleb HA. Impact of hyponatremia on frequency of complications in patients with decompensated liver cirrhosis. Electron Physician 2015; 7:1349-58. [PMID: 26516441 PMCID: PMC4623794 DOI: 10.14661/1349] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 09/20/2015] [Indexed: 02/06/2023] Open
Abstract
Introduction Hyponatremia is common in cirrhosis. The relationship between hyponatremia and severity of cirrhosis is evidenced by its close association with the occurrence of complications, the prevalence of hepatic encephalopathy, hepatorenal syndrome, spontaneous bacterial peritonitis, refectory ascites, and hepatic hydrothorax. The aim of this study was assess the impact of hyponatremia on the occurrence of both liver-related complications and the hemodynamic cardiovascular dysfunction. Methods This prospective study was conducted in 2015 on 74 patients with liver cirrhosis. The patients were from the Gastroenterology and Hepatology Department of Theodor Bilharz Research Institute in Giza, Egypt. The patients were divided into three groups according to their serum level of sodium. Group 1 included 30 patients with serum sodium >135 meq/L, group 2 included 24 patients with serum sodium between135 and 125 meq/L, and group 3 included 20 patients with serum sodium <125 meq/L. For each of the patients, we conducted aclinical examination, laboratory investigations, chest X-ray, ECG, abdominal sonar, and echocardiography. Results Hyponatremia was found in 59.46% of our cirrhotic patients, and they showed significantly increased Model for End-Stage Liver Disease (MELD) score, MELD-Na score, QTc interval, Pulmonary vascular resistance (PVR) and inferior vena cava (IVC) collapsibility, and decreased SVR and IVC diameter. Also hepatic encephalopathy, ascites, renal failure, infectious complications, and pleural effusion were significantly more common in hyponatremic cirrhotic patients. Conclusion In cirrhosis, hyponatremia is more common in severe cardiovascular dysfunction and associated with increased risk of hepatic encephalopathy, ascites, illness severity scores, renal failure, infectious complications, and pleural effusion. We recommend selective oral administration of vasopressin V2-receptor antagonist, tolvaptan, which acts to increase the excretion of free water, thereby resolving hypervolemic hyponatremia and may have the potential to improve outcomes in these patients.
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Affiliation(s)
| | - Amna Ahmed Metwaly
- Intensive Care Department, Theodor Bilharz Research Institute, Giza, Egypt
| | | | - Maged El-Ghannam
- Gastroenterology and Hepatology Department, Theodor Bilharz Research Institute, Giza, Egypt
| | | | - Hoda Abu Taleb
- Biostatistics and Demography, Medical Statistician, Environment research Department, Theodor Bilharz Research Institute, Giza, Egypt
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Abstract
There is an intricate relationship between the liver and the kidney, with renal physiology and function intimately involved in many primary disorders of pediatric liver disease. The hemodynamic changes of progressive cirrhosis affect and are directly affected by changes in renal blood flow and renal handling of sodium and free water excretion. Resulting complications of worsening ascites, hyponatremia, and acute kidney injury frequently complicate the care of children with advanced liver disease and contribute significant morbidity and mortality. While liver transplantation may restore hemodynamic stability, nearly 40% of pediatric liver transplant recipients develop chronic kidney disease post-transplant and approximately 25% are left with clinical hypertension. This review seeks to provide a basic understanding of this relationship to enable the provision of optimal care to children with liver disease.
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Affiliation(s)
- Robyn Greenfield Matloff
- Division of Pediatric Nephrology, Maria Fareri Children's Hospital of Westchester Medical Center, New York Medical College, Skyline Office # 1N-C12, 40 Sunshine Cottage Road, Valhalla, NY, 10595, USA,
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Duché M, Ducot B, Ackermann O, Jacquemin E, Bernard O. Progression to high-risk gastroesophageal varices in children with biliary atresia with low-risk signs at first endoscopy. J Pediatr Gastroenterol Nutr 2015; 60:664-8. [PMID: 25909866 DOI: 10.1097/mpg.0000000000000710] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Biliary atresia carries a risk of bleeding because of portal hypertension. Our goal was to define the factors associated with the emergence of endoscopic signs carrying a high risk of bleeding in children who did not display these signs at the first upper gastrointestinal endoscopy. METHODS From 1989 to 2013, a total of 225 children with low-risk signs at the first endoscopic examination underwent ≥2 upper gastrointestinal endoscopic examinations. The emergence of high-risk gastroesophageal varices was observed in 76 children in the 10 years following the first endoscopic examination. A survival study using the occurrence of high-risk varices as an event was performed to identify factors related to the emergence of these varices and to describe the probability of their emergence in 2 groups of children ages older than 18 months and 18 months or younger at the time of the first endoscopy. RESULTS High total serum bilirubin concentration, young age, and high number/grade of esophageal varices at the first endoscopy were significantly related to the emergence of high-risk varices. The probability of the emergence of high-risk signs was higher and these signs appeared faster in infants 12 months of age or younger and/or when the first endoscopic examination displayed >1 grade 1 or grade 2 varices. Progression to high-risk varices was also related to bilirubinemia in children older than 18 months at the first endoscopy. CONCLUSIONS The results allow defining a program of repeat endoscopies to detect high-risk varices and to discuss endoscopic primary prophylaxis of bleeding or hasten liver transplantation when these signs are found.
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Affiliation(s)
- Mathieu Duché
- *Hépatologie Pédiatrique and Centre de Référence National de l'atrésie des Voies Biliaires, Hôpital Bicêtre, AP-HP †Santé Publique et Epidémiologie, Hôpital Bicêtre, AP-HP, Orsay, France
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Pinto RB, Schneider ACR, da Silveira TR. Cirrhosis in children and adolescents: An overview. World J Hepatol 2015; 7:392-405. [PMID: 25848466 PMCID: PMC4381165 DOI: 10.4254/wjh.v7.i3.392] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Revised: 12/10/2014] [Accepted: 01/09/2015] [Indexed: 02/06/2023] Open
Abstract
Several conditions, especially chronic liver diseases, can lead to cirrhosis in children and adolescents. Most cases in clinical practice are caused by similar etiologies. In infants, cirrhosis is most often caused by biliary atresia and genetic-metabolic diseases, while in older children, it tends to result from autoimmune hepatitis, Wilson's disease, alpha-1-antitrypsin deficiency and primary sclerosing cholangitis. The symptoms of cirrhosis in children and adolescents are similar to those of adults. However, in pediatric patients, the first sign of cirrhosis is often poor weight gain. The complications of pediatric cirrhosis are similar to those observed in adult patients, and include gastrointestinal bleeding caused by gastroesophageal varices, ascites and spontaneous bacterial peritonitis. In pediatric patients, special attention should be paid to the nutritional alterations caused by cirrhosis, since children and adolescents have higher nutritional requirements for growth and development. Children and adolescents with chronic cholestasis are at risk for several nutritional deficiencies. Malnutrition can have severe consequences for both pre- and post-liver transplant patients. The treatment of cirrhosis-induced portal hypertension in children and adolescents is mostly based on methods developed for adults. The present article will review the diagnostic and differential diagnostic aspects of end-stage liver disease in children, as well as the major treatment options for this condition.
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Affiliation(s)
- Raquel Borges Pinto
- Raquel Borges Pinto, Pediatric Gastroenterology Unit, Hospital da Criança Conceição, Porto Alegre 91340 480, Rio Grande do Sul, Brazil
| | - Ana Claudia Reis Schneider
- Raquel Borges Pinto, Pediatric Gastroenterology Unit, Hospital da Criança Conceição, Porto Alegre 91340 480, Rio Grande do Sul, Brazil
| | - Themis Reverbel da Silveira
- Raquel Borges Pinto, Pediatric Gastroenterology Unit, Hospital da Criança Conceição, Porto Alegre 91340 480, Rio Grande do Sul, Brazil
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Tessier MEM, Harpavat S, Shepherd RW, Hiremath GS, Brandt ML, Fisher A, Goss JA. Beyond the Pediatric end-stage liver disease system: Solutions for infants with biliary atresia requiring liver transplant. World J Gastroenterol 2014; 20:11062-11068. [PMID: 25170195 PMCID: PMC4145749 DOI: 10.3748/wjg.v20.i32.11062] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Revised: 05/13/2014] [Accepted: 06/23/2014] [Indexed: 02/06/2023] Open
Abstract
Biliary atresia (BA), a chronic progressive cholestatic disease of infants, is the leading cause for liver transplant in children, especially in patients under two years of age. BA can be successfully treated with the Kasai portoenterostomy; however most patients still require a liver transplant, with up to one half of BA children needing a transplant by age two. In the current pediatric end-stage liver disease system, children with BA face the risk of not receiving a liver in a safe and timely manner. In this review, we discuss a number of possible solutions to help these children. We focus on two general approaches: (1) preventing/delaying need for transplantation, by optimizing the success of the Kasai operation; and (2) expediting transplantation when needed, by performing techniques other than the standard deceased-donor, whole, ABO-matched organ transplant.
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Ling SC, Avitzur Y. Predicting outcomes for children awaiting liver transplantation: is serum sodium the answer? Hepatology 2014; 59:1678-80. [PMID: 24375691 DOI: 10.1002/hep.26985] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Accepted: 12/17/2013] [Indexed: 01/15/2023]
Affiliation(s)
- Simon C Ling
- Division of Gastroenterology, Hepatology and Nutrition, the Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
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Abstract
Hyponatraemia is a common complication of advanced cirrhosis related to an impairment in the renal capacity for eliminating solute-free water, causing a retention of water that is disproportionate to the retention of sodium, thus leading to a reduction in serum sodium concentration and hypo-osmolality. The main pathogenic factor responsible for hyponatraemia is a non-osmotic hypersecretion of arginine vasopressin (AVP) or antidiuretic hormone from the neurohypophysis, related to circulatory dysfunction. Hyponatraemia in cirrhosis is associated with increased morbidity and mortality. Hyponatraemia is also associated with increased morbidity and impaired short-term survival after transplantation. The current standard of care based on restricting fluids to 1-1.5 L/day is rarely effective. Other approaches, such as albumin infusion and the use of vaptans-which act by specifically antagonizing the effects of AVP on the V2 receptors located in the kidney tubules-have been evaluated for their role in the management of hyponatraemia. The short-term treatment with vaptans is associated with a marked increase in renal solute-free water excretion and improvement of hyponatraemia; however their use in patients with end-stage liver disease is limited by hepatotoxic effects of some of these drugs. Long-term administration of vaptans seems to be effective in maintaining the improvement of serum sodium concentration, but the available information is still limited.
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Affiliation(s)
- Robert J Gianotti
- Department of Gastroenterology, Beth Israel Deaconess Medical Center, Boston MA and GI Unit, Institut Clinic de Malalties Digestives i Metaboliques, Hospital Clinic, University of Barcelona
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