100 consecutive liver transplants in infants and children: an 8-year experience

Pediatric liver retransplantation from living donors can be considered as a therapeutic option for patients with irreversible living donor graft failure

Liver retransplantation (re-LT) is required in patients with irreversible graft failure, but it is a significant issue that remains medically, ethically, and economically controversial, especially in living donor liver transplantation (LDLT). The aim of this study was to evaluate the outcome, morbidity, mortality, safety and prognostic factors to improve the outcome of pediatric living donor liver retransplantation (re-LDLT). Six of 172 children that underwent LDLT between January 2001 and March 2010 received a re-LDLT and one received a second re-LDLT. The overall re-LDLT rate was 3.5%. All candidates had re-LDLT after the initial LDLT. The overall actuarial survival of these patients was 83.3% and 83.3% at one and five yr, respectively. These rates are significantly worse than the rates of pediatric first LDLT. Vascular complications occurred in four patients and were successfully treated by interventional radiologic therapy. There were no post-operative biliary complications. One case expired because of hemophagocytic syndrome after re-LDLT. Although pediatric re-LDLT is medically, ethically, and economically controversial, it is a feasible option and should be offered to children with irreversible graft failure. Further investigations, including multicenter studies, are therefore essential to identify any prognostic factors that may improve the present poor outcome after re-LDLT.

Liver retransplantation in children: the Atlanta experience

Liver retransplantation is routinely offered at our institution. Previous reports document that patient and graft survival is significantly less after pediatric rLT compared to primary LT. This has engendered intense debate regarding optimal allocation of organs. Here, we examine our program's approach to pediatric hepatic retransplantation related to patient factors affecting outcomes. Between 1997 and 2009, 272 LTs were performed in 234 patients (mean survival 1994 +/- 1367 days) at our center. Thirty-four patients required rLT including 10 who received their primary transplant elsewhere and four who required two retransplantations. Patient survival did not differ significantly between rLT and LT at one and three yr (p = 0.56). Graft survival between rLT and LT was also similar (p = 0.606) at one and three yr. No significant difference in graft or patient survival was noted between: Patients retransplanted <30 days after LT vs. those >30 days (p = 0.152); patients transplanted with technical variants vs. whole grafts (p = 0.966); technical variants utilized for LT vs. rLT (p = 0.713); rLT recipient age (< or >5 yr; p = 0.298); or ABOI for rLT and LT (p = 0.650). Retransplantation should be offered to optimize pediatric recipient survival after LT and offers similar survival as primary transplant.

Pediatric liver retransplantation: outcomes and a prognostic scoring tool

Nine to twenty-nine percent of pediatric liver transplant recipients require retransplantation. No previous pediatric study has proposed a prognostic scoring system. We have used the United Network for Organ Sharing transplantation database to conduct a retrospective cohort study of patients who were less than 18 years of age when they received their retransplant (n = 1130). Using a random two-thirds of the subjects, we developed a prognostic scoring system by performing a multivariate Cox analysis with non-laboratory clinical characteristics. The scoring system was verified in the remaining one-third of the subjects. Stratifying the verification group into risk groups by prognostic score demonstrated its predictive value. Those in the low-risk category had survival similar to that of primary liver transplant recipients. Those in the high-risk category had 2.4 (95% confidence interval: 1.6-3.7) times the risk of death or retransplantation as those in the low-risk category. Risk factors in the scoring system included being on life support at the time of retransplant, receiving a split liver graft, and having an original diagnosis of neonatal cholestasis, familial cholestasis, paucity of bile ducts, or congenital abnormalities. Protective factors in the scoring system included older age at the time of transplantation and having acute rejection contribute to graft failure. In conclusion, with simple clinical characteristics, this scoring tool can modestly discriminate between those children at high risk and those children at low risk of poor outcome after liver retransplantation.

Phosphorus-31 MR Spectroscopy in Pediatric Liver Transplant Recipients: A Noninvasive Assessment of Graft Status with Correlation with Liver Function Tests and Liver Biopsy

OBJECTIVE

Noninvasive in vivo hepatic phosphorus-31 MR spectroscopy has recently been shown to provide information about hepatic functional status. We sought to show the correlation of phosphorus-31 MR spectroscopy with blood biochemistry and liver biopsy results in pediatric patients after liver transplantation.

MATERIALS AND METHODS

Eleven pediatric transplant recipients (eight with good graft function, two with chronic hepatitis, and one with acute rejection) and four healthy control subjects were studied with in vivo 31P MR spectroscopy. Ratios of phosphomonoesters (PME) to total phosphorus (TP), phosphodiester (PDE) to TP, nucleotide triphosphates (NTP), inorganic phosphate (Pi), and intracellular acid-base status (pH) were measured. Liver function test (n = 11) and biopsy (n = 3) results were obtained for correlation with spectroscopic findings.

RESULTS

The eight patients with good graft function displayed spectral profiles similar to those of the healthy subjects, and no significant difference in the metabolic ratios of these patients compared with the control subjects was detected. Three patients with abnormal liver function and biopsy-proven hepatic complications showed elevated PME/TP ratios when compared with those of both the control subjects and the group with good graft function.

CONCLUSION

Phosphorus-31 MR spectroscopy is a feasible technique for the noninvasive assessment of host-related complications in pediatric patients after liver transplantation. Our preliminary data suggest that the technique may be integrated with MRI for the investigation of impaired liver function in transplant recipients when neither a biliary complication nor a vascular complication is identified.

Surgical complications and outcome of pediatric liver transplantation in Hong Kong

PURPOSE

The aim of this study was to analyze the early and late results of pediatric liver transplantation, with particular reference to complications that required surgical or radiologic intervention.

METHODS

The records and code sheets of children who underwent liver transplantation in the authors' institution between September 1993 and December 2001 were reviewed.

RESULTS

Twenty-nine children (16 boys and 13 girls) underwent 31 liver transplantations (23 living donor, 8 cadaveric donor) during the study period. The ages of the children ranged from 4 months to 132 months (median, 16 months). Eighteen children had complications that required surgical or radiologic interventional procedures. Complications included, among others, hepatic vein thrombosis (n = 1, 3%), hepatic vein stenosis (n = 2, 7%), portal vein thrombosis (n = 2, 7%), biliary stricture (n = 3, 10%), bile leakage (n = 2, 7%), hepatic artery pseudoaneurysm (n = 1, 3%), jejuno-jejunostomy leakage (n = 1, 3%), graft hepatitis (n = 1, 3%), and posttransplant lymphoproliferative disorder (n = 2, 7%). In addition, 6 children (21%) suffered from intraabdominal bleeding from a variety of causes. After appropriate interventions, at a median follow-up of 38 months (range, 1 to 96 months), patient and graft survival rates were 79% and 74%, respectively. The retransplantation rate was only 7%. There was no incidence of hepatic artery thrombosis. All living donors remain alive and well.

CONCLUSIONS

Complications are inevitable in pediatric liver transplantation. However, with timely recognition and active intervention, a good outcome can be achieved.

Basiliximab in pediatric liver transplantation: a pharmacokinetic-derived dosing algorithm

The pharmacokinetics and immunodynamics of basiliximab were assessed in 37 pediatric de novo liver allograft recipients to rationally design a dose regimen for this age-group. In part one of the study, patients were given 12 mg/m2 basiliximab by bolus intravenous injection after organ perfusion and on day 4 after transplant. An interim pharmacokinetic evaluation supported a fixed-dose approach for part two of the study in which infants and children received two 10-mg doses of basiliximab and adolescents received two 20-mg doses. Blood samples were collected over a 12-week period for screening for anti-idiotype antibodies and analysis of basiliximab and soluble interleukin-2 receptor (IL-2R) concentrations. Basiliximab clearance in infants and children < 9 yr of age (n = 30) was reduced by approximately 50% compared with adults from a previous study and was independent of age to 9 yr, weight to 30 kg, and body surface area to 1.0 m2. Clearance in children and adolescents 9-14 yr of age (n = 7) approached or reached adult values. An average of 15% of the dose was eliminated via drained ascites fluid, and drug clearance via this route averaged 29% of total body clearance. Patients with > 5 L of ascites fluid drainage tended to have lower systemic exposure to basiliximab. CD25-saturating basiliximab concentrations were maintained for 27 +/- 9 days in part one of the study (mg/m2 dosing) with infants exhibiting the lowest durations. CD25 saturation lasted 37 +/- 11 days in part two of the study, based on the fixed-dose regimen (p = 0.004 vs. mg/mg2 dosing), but did not show the age-related bias observed in part one of the study. Anti-idiotype antibodies were detected in four patients, but this did not influence the clearance of basiliximab or duration of CD25 saturation. All 40 enrolled patients were included in the intent-to-treat clinical analysis. Episodes of acute rejection occurred in 22 patients (55%) during the first 12 months post-transplant. Three patients experienced loss of their graft as a result of technical complications, and six patients died during the 12-month study. Basiliximab was well tolerated by intravenous bolus injection, with no cytokine-release syndrome or other infusion-related adverse events. Hence, basiliximab was safe and well tolerated in pediatric patients undergoing orthotopic liver transplantation. To achieve similar basiliximab exposure as is efficacious in adults, pediatric patients < 35 kg in weight should receive two 10-mg doses and those > or = 35 kg should receive two 20-mg doses of basiliximab by intravenous infusion or bolus injection. The first dose should be given within 6 h after organ perfusion and the second on day 4 after transplantation. A supplemental dose may be considered for patients with a large volume of drained ascites fluid relative to body size.

Pediatric liver transplantation. A single center experience spanning 20 years

BACKGROUND

Survival after liver transplantation has improved significantly over the last decade with pediatric recipients faring better than adults. The 20-year experience of pediatric liver transplantation at Children's Hospital of Pittsburgh is reported in terms of patient survival; graft survival in relation to age, gender, and immunosuppressive protocols; causes of death; and indications for retransplantation.

METHOD

From March 1981 to April 1998, 808 children received liver transplants at Children's Hospital of Pittsburgh. All patients were followed until March 2001, with a mean follow-up of 12.2+/-3.9 years (median=12.6; range=2.9-20). There were 405 female (50.2%) and 403 male (49.8%) pediatric recipients. Mean age at transplant was 5.3+/-4.9 years (mean=3.3; range 0.04-17.95), with 285 children (25.3%) being less than 2 years of age at transplant. Cyclosporine (CsA)-based immunosuppression was used before November 1989 in 482 children (50.7%), and the subsequent 326 recipients (40.3%) were treated with tacrolimus-based immunosuppression. Actuarial survival was calculated using the Kaplan-Meier statistical method. Differences in survival were calculated by log-rank analysis.

RESULTS

Overall patient survival at 1, 5, 10, 15, and 20 years was 77.1%, 72.6%, 69.4%, 65.8%, and 64.4%, respectively. There was no difference in survival for male or female patients at any time point. At up to 10 years posttransplant, the survival for children greater than 2 years of age (79.5%, 75.7%, and 71.6% at 1, 5, and 10 years, respectively) was slightly higher than those at less than 2 years of age (72.6%, 66.9%, and 65.3% at 1, 5, and 10 years, respectively). However, at 15 and 20 years posttransplant, survival rates were similar (>2 years=67.3% and 65.8%; <2 years=64.1% and 64.1%). A significant difference in survival was seen in CsA-based immunosuppression (71.2%, 68.1%, 65.4%, and 61%) versus tacrolimus-based immunosuppression (85.8%, 84.7%, 83.3%, and 82.9%) at 1, 3, 5, and 10 years, respectively (P=0.0001). The maximum difference in survival was noted in the first 3 months between CsA and tacrolimus; thus, indicating there may have been other factors (nonimmunological factors) involved in terms of donor and recipient selection and technical issues. The mean annual death rate beyond 2 years posttransplant was 0.47%, with the mean annual death rate for patients who received tacrolimus-based immunosuppression being significantly lower than those who received CsA-based immunosuppression (0.14% vs. 0.8%; P=0.001). The most common etiologies of graft loss were hepatic artery thrombosis (33.4%), acute or chronic rejection (26.6%), and primary nonfunction (16.7%). Of note, retransplantation for graft loss because of acute or chronic rejection occurred only in those patients who received CsA-based immuno-suppression.

CONCLUSION

The overall 20-year actuarial survival for pediatric liver transplantation is 64%. Survival has increased by 20% in the last 12 years with tacrolimus-based immunosuppression. Although this improvement may be the result of several factors, retransplantation as a result of acute or chronic rejection has been completely eliminated in patients treated with tacrolimus.

Diabetic ketoacidosis in a child on FK506 immunosuppression after a liver transplant

The use of immunosuppressive agents is becoming more widespread, especially in the context of organ transplantation. We report a child with a complication, new-onset diabetes mellitus with diabetic ketoacidosis, associated with the use of one such agent, FK506 (tacrolimus).

Graft loss after pediatric liver transplantation

OBJECTIVE

To describe the epidemiology and causes of graft loss after pediatric liver transplantation and to identify risk factors.

SUMMARY BACKGROUND DATA

Graft failure after transplantation remains an important problem. It results in patient death or retransplantation, resulting in lower survival rates.

METHODS

A series of 157 transplantations in 120 children was analyzed. Graft loss was categorized as early (within 1 month) and late (after 1 month). Risk factors were identified by analyzing recipient, donor, and transplantation variables.

RESULTS

Kaplan-Meier 1-month and 1-, 3-, and 5-year patient survival rates were 85%, 82%, 77%, and 71%, respectively. Graft survival rates were 71%, 64%, 59%, and 53%, respectively. Seventy-one of 157 grafts (45%) were lost: 18 (25%) by death of patients with functioning grafts and 53 (75%) by graft-related complications. Forty-five grafts (63%) were lost early after transplantation. Main causes of early loss were vascular complications, primary nonfunction, and patient death. Main cause of late graft loss was fibrosis/cirrhosis, mainly as a result of biliary complications or unknown causes. Child-Pugh score, anhepatic phase, and urgent transplantation were risk factors for early loss. Donor age, donor/recipient weight ratio, blood loss, and technical-variant liver grafts were risk factors for late loss.

CONCLUSIONS

To prevent graft loss after pediatric liver transplantation, potential recipients should be referred early so they can be transplanted in an earlier phase of their disease. Technical-variant liver grafts are risk factors for graft survival. The logistics of the operation need to be optimized to minimize the length of the anhepatic phase.

Predictive factors for portal fibrosis in pediatric liver transplant recipients

BACKGROUND

Recent histopathological studies showed an unexpected high incidence of pathological changes in asymptomatic survivors after pediatric liver transplantation. The aim of this study was to analyze the occurrence of histological abnormalities, to assess the clinical significance, and to identify predictive factors for these pathological changes.

METHODS

The first annual protocol graft biopsies of 84 consecutive liver transplants were analyzed and correlated with concomitant liver function tests. Identification of predictive factors for the histological abnormalities in the biopsies was performed by a multivariate logistic regression analysis.

RESULTS

The incidence of portal fibrosis (PF) was 31%. Liver function tests showed except for the albumin level, an increase in the PF group compared with the group without PF. Mean values of alkaline phosphatase and direct bilirubin were 264 U/liter and 3 micromol/liter, respectively, in the normal group, and 435 U/liter and 23 micromol/liter, respectively, in the PF group (P=0.043 and 0.037). Eight of 19 univariantly tested variables were entered into a logistic regression model: cold ischemia time, preservation solution, type of allograft, cytomegalovirus recipient status, type of biliary reconstruction, biliary complications, graft complications, and rejection. A significant positive correlation with PF was found for cold ischemia time, biliary complications, and cytomegalovirus status. Acute rejection showed a negative correlation.

CONCLUSIONS

The incidence of PF within 1 year post liver transplantation was 31%. This finding was accompanied by cholestatic liver function test abnormalities. Factors predisposing to PF were a prolonged cold ischemia time, biliary complications, and a positive cytomegalovirus recipient status. Acute rejection seemed to prevent for PF.

A descriptive analysis of 290 liver transplant patient visits to an emergency department

OBJECTIVE

To provide a descriptive analysis of emergency department (ED) presentations and management of orthotopic liver transplant (OLT) patients.

METHODS

A retrospective chart review was performed of OLT patients presenting to the University of California at Los Angeles (UCLA) ED during 1995. The sole inclusion criterion was receiving an OLT within three years prior to the ED visit. Data describing chief complaint(s), history of present illness, physical findings, laboratory results, imaging studies, and final diagnoses were collected.

RESULTS

One hundred forty-three patients accounted for a total of 290 ED visits. The patients had a mean age of 37 years (range 3 months to 74 years) and presented at mean post-OLT duration of 9 months (range 2 weeks to 34 months). There were 660 presenting complaints, of which abdominal (39%), fever (17%), respiratory (13%), and neurologic (11%) symptoms were the most common. There were 478 final diagnoses, of which abdominal (27%), infectious (24%), and metabolic (11%) disorders were the most common. Eighty-four percent of ED visits resulted in extensive diagnostic testing and 69% resulted in hospitalization.

CONCLUSIONS

Serious illnesses with nonspecific presentations were frequently encountered in this study population. These factors resulted in a majority of the patients' undergoing extensive diagnostic evaluations and being hospitalized.

Bile duct size does not predict success of portoenterostomy for biliary atresia

BACKGROUND/PURPOSE

Presence of large bile ducts (>200 microm) at the portal end-plate has been suggested to predict success after portoenterostomy. The authors reviewed their patients with biliary atresia to test the hypothesis that bile duct size in patients with successful portoenterostomy was no different than in the patients with unsuccessful portoenterostomy.

METHODS

The authors reviewed the patients at their institution from 1989 to 1998 who had the diagnosis of biliary atresia (n = 38). A pathologist blinded to the results of the operation confirmed the measurements of the bile duct remnants.

RESULTS

Five of the 38 patients did not have a portoenterostomy. They underwent cholangiogram and liver biopsy and were evaluated for liver transplantation. All patients who underwent surgery (n = 33) had a Roux-en-y hepaticojejunostomy. Twenty-one patients had successful surgery (64%) and 12 patients (36%) had unsuccessful surgery. The average age at operation in the successful group was 50.9 +/- 3 days and in failures, 57.9 +/- 4 days (P = .16). Duct size at the portal end-plate was not different between the successes and failures. Two of the patients in the success group had no evidence of bile ducts grossly or histologically.

CONCLUSION

Children presenting early in infancy (<3 months) with biliary atresia should undergo a portoenterostomy regardless of the size of the bile ducts at the time of exploration.

The oral microbiota of children undergoing liver transplantation

This study investigated the oral microbiota of children undergoing liver transplantation. Oral swabs were taken using a standardized procedure from 27 children before liver transplantation and at 3 and 100 days post-transplantation and from 27 healthy controls at baseline and 90 days. Viridans streptococci, yeasts, staphylococci, enterococci and Enterobacteriaceae were enumerated and identified using conventional techniques. The oral microbiota of the patients changed significantly immediately post-transplantation, but by the final examination, it had returned to baseline levels. The oral microbiota of the controls did not change significantly. The numbers and proportions of Streptococcus salivarius, Streptococcus sanguis and Streptococcus gordonii as percentages of the total streptococcal counts and of the total anaerobic counts decreased significantly 3 days post-transplantation (P < or = 0.006). There were no significant changes in the numbers and proportions of Streptococcus oralis and Streptococcus mitis isolated pre- and post-transplantation. The isolation frequencies and numbers of yeasts were significantly higher in patients than controls. Staphylococci were isolated in low numbers from all children. Enterococci and Enterobacteriaceae were isolated infrequently from patients.

Outcome of liver retransplantation in children

Irreversible liver graft failure is a life-threatening complication. We reviewed the first 200 pediatric liver transplantations in Birmingham. Forty-one children developed primary graft failure, 9 of whom developed secondary graft failure. The main indications for graft failure were primary nonfunction (PRNF; 8 patients), vascular complications (VASC; 23 patients), and chronic rejection (CHRE; 19 patients). Thirty-two children underwent retransplantation (ReTx) (21 children received reduced grafts; 11 children, whole hepatic grafts). Patient survival was significantly worse for retransplant recipients compared with children receiving a single graft (63% v 76. 5% actuarial patient survival at 1 year; P <.05). Primary graft 1-year actuarial survival was 74% in first grafts compared with 47% for regrafts (P <.05), but improved with time. The graft 1-year survival rate was 55% for whole grafts and 45% for reduced and/or split grafts in the first 100 grafts compared with 83% and 66% in the second 100 grafts, respectively (P <.01). Emergency ReTx within a month of transplantation was associated with more complications and a worse outcome (1-year survival rate, 37%) compared with patients who underwent ReTx later (1-year survival rate, 72%; P <. 01). The incidence of primary graft failure decreased from 33% in the first 100 grafts to 16% in the second 100 grafts (P <.01), as did the incidence of PRNF, which decreased from 8% to 0% (P <.05). Although the rates of graft failure from VASC decreased from 15% to 8% (P =.2) and CHRE decreased from 11% to 8% (P =.6), neither reached statistical significance. The improved results overall are because of advances in surgical techniques, intensive care management, and graft preservation and refinements in immunosuppression. We conclude that ReTx for a child with primary graft failure is justified.

Analysis of survival and morbidity after pediatric liver transplantation with full-size and technical-variant grafts

BACKGROUND

To alleviate the shortage of size-matched whole-donor organs, too-large-for-size cadaveric donor grafts are modified by liver resection techniques. These modifications result in technical-variant liver transplantation (TVLTx). Patient and graft survival rates after TVLTx are considered comparable to those after full-size liver transplantation (FSLTx). However, morbidity after TVLTx is often underexposed. The aim of this study was to analyze the results of FSLTx and TVLTx in terms of patient and graft survival rates and morbidity.

METHODS

A consecutive series of 97 primary and elective pediatric liver transplantations performed in a single center was retrospectively analyzed. Forty-seven children had a FSLTx and 50 a TVLTx (38 reduced-size liver grafts and 12 split-liver grafts). The overall median follow-up period was 3.5 years.

RESULTS

There were no differences in patient and graft survival rates between FSLTx and TVLTx. However, after TVLTx there was a significantly higher complication rate (1.42 vs. 0.81 after FSLTx). TVLTx is more hampered by biliary complications (30% vs. 17%), expressed by a higher incidence of cholangitis and leakage of bile. These complications led to a significantly higher incidence of sepsis (44% vs. 19%) and a significantly higher intervention rate (0.40 vs. 1.28) after TVLTx. There was no difference in the incidence of retransplantations between FSLTx and TVLTx.

CONCLUSIONS

Both FSLTx and TVLTx offer the same prognosis in terms of patient and graft survival rates for children after a primary and elective liver transplantation. However, TVLTx has a higher morbidity.

Percutaneous endoscopic gastrostomy for continuous feeding in children with chronic cholestasis

BACKGROUND

Malnutrition associated with chronic cholestasis in children often requires continuous enteral feeding through a nasogastric tube, which may be poorly tolerated.

METHOD

Percutaneous endoscopic gastrostomy was performed in five children (age range, 20 months to 13 years) with severe cholestasis (Alagille syndrome in four; biliary atresia in one) and severe malnutrition (mean weight, -2.6 standard deviations; mean height, -2.7 standard deviations) who were awaiting liver transplantation. The pull-through technique was used in patients under general anesthesia, and the button was set within 2 months.

RESULTS

Minor wound infection required antibiotic therapy in one patient. In the four children with Alagille syndrome, enteral feeding by means of percutaneous endoscopic gastrostomy was used until liver transplantation for a mean period of 14 months with a mean weight gain of 350 g/mo and a mean height gain of 0.53 cm/mo. Seventeen months to 3 years, 3 months after liver transplantation, all four children were alive and in good clinical condition with normal readings in liver function tests. The technique had to be discontinued in the child with biliary atresia because of secondary occurrence of ascites, gastric intolerance, and refractory wound infection.

CONCLUSION

Percutaneous endoscopic gastrostomy may be a valuable alternative to nasogastric tube for nutritional support in children with cholestasis and mild portal hypertension.

Current results and evolving indications for liver transplantation in children

Liver transplantation continues to be successful and effective treatment for acute and chronic liver failure, and many important lessons have been learned. The development of innovative operative techniques has much reduced the waiting list mortality rate and has extended transplantation to younger and sicker children and to those with functionally normal livers who may benefit from auxiliary liver transplantation. The incidence and range of postoperative complications have improved with increased medical and surgical expertise. As information on long-term outcome for liver transplantation is gained, it is clear that many children will benefit from early elective liver transplantation before the development of significant growth or psychosocial retardation. Early transplantation is also indicated in children with cirrhosis and intrapulmonary shunting or cystic fibrosis with moderate lung disease. During the same period, evolving medical therapy has altered the natural history, patient selection, and timing of transplantation in children with tyrosinaemia type I, primary bile acid disorders, neonatal haemochromatosis, and potentially, cystic fibrosis. It is now clear that children with significant multisystem disease, such as mitochondrial disorders or severe systemic oxalosis, are no longer suitable candidates for liver transplantation. The successful development of liver transplantation has brought good quality life to many children and their families. There are still many lessons to learn and there are future challenges such as the ever-increasing problems of donor scarcity and the search for potent but less toxic immunosuppressive agents.

An analysis of hepatic retransplantation in children

BACKGROUND

The limited supply of organ donors has led some groups to reconsider the role of retransplantation. Historically, except for children with malignancies, extrahepatic sources of sepsis, or severe irreversible neurologic injuries, our institution has offered all children with failing liver grafts the option of retransplantation regardless of their current severity of illness. The purpose of this study was to examine the outcome of hepatic retransplantation in children in an attempt to identify factors predictive of outcome and to assess the results of our approach to retransplantation.

METHODS

Between October 1984 and December 1995, 314 children less than 15 years of age underwent a total of 441 liver transplants. Data were obtained retrospectively by review of hospital records.

RESULTS

With a mean follow-up period of 5.3+/-2.7 years, the overall patient survival rates at 1 and 5 years were 77.1% and 67.1%, respectively. Primary allograft survival rates were 65.6% and 56.5%, respectively. Of the 137 patients who developed failure of their primary allograft, 92 underwent retransplantation (29.3% of all primary transplants). Both patient and allograft survival rates were significantly decreased after retransplantation (P<0.0001 versus primary transplants). Univariate and multivariate analysis of retransplanted patients revealed only two factors that were statistically related to patient and graft survival: age at the time of retransplantation (P<0.02 univariate and P<0.05 multivariate) and retransplantation with a reduced-size allograft (P<0.005 univariate and P<0.05 multivariate). In this series, the effect on patient survival of differences in medical condition as reflected by United Network for Organ Sharing (UNOS) status approached, but did not achieve, significance (P=0.08 for UNOS 1 versus UNOS 2 and 3). UNOS status did not affect graft survival. Neither the cause of primary allograft loss or the timing of retransplantation relative to the first transplant were related to outcome.

CONCLUSIONS

These data demonstrate that the failure of primary hepatic allografts remains a major problem in pediatric liver transplantation and that the overall results of retransplantation were significantly worse than those associated with primary transplants. We have identified a group of children who experienced a significantly worse outcome after retransplantation. This group consisted of children less than 3 years of age retransplanted using reduced-size grafts. Based on this finding, we now attempt to avoid retransplanting young children with reduced-size grafts. By using this approach, we hope to be able to offer children the option of retransplantation with improved results and simultaneously minimize the negative impact on patients awaiting primary transplants.

Biliary atresia: should all patients undergo a portoenterostomy?

PURPOSE

The management of noncorrectable extra hepatic biliary atresia includes portoenterostomy, although the results of the surgery are variable. This study was done to develop criteria that could successfully predict the outcome of surgery based on preoperative data, including percutaneous liver biopsy, allowing a more selective approach to the care of these babies.

METHODS

The charts and biopsy results of 31 patients who underwent a Kasai procedure for biliary atresia between 1984 and 1994 were reviewed. Values for preoperative albumin, bilirubin, age of patient at Kasai, and lowest postoperative bilirubin were recorded. Surgical success was defined as postoperative bilirubin that returned to normal. A pathologist blinded to the child's eventual outcome graded the pre-Kasai needle liver biopsy results according to duct proliferation, ductal plate lesion, bile in ducts, lobular inflammation, giant cells, syncitial giant cells, focal necrosis, bridging necrosis, hepatocyte ballooning, bile in zone 1, 2, and 3, cholangitis, and end-stage cirrhosis. Clinical outcome was then predicted.

RESULTS

Success after portoenterostomy could not reliably be predicted based on gender, age at Kasai, preoperative bilirubin or albumin levels. Histological criteria, however, predicted outcome in 27 of 31 patients (P < .01). Fifteen of 17 clinical successes were correctly predicted; as were 12 of 14 clinical failures (sensitivity, 86%; specificity, 88%). Individually, the presence of syncitial giant cells, lobular inflammation, focal necrosis, bridging necrosis, and cholangitis, were each associated with failure of the portoenterostomy (P < .05). Bile in zone 1 was associated with clinical success of the procedure (P < .05).

CONCLUSIONS

Based on the predictive information available in a liver biopsy, we conclude that those patients who will not benefit from a Kasai procedure can be identified preoperatively, and channeled immediately to transplantation.

Liver transplantation in children: the experience of Queen Mary Hospital, Hong Kong

Seven living-related liver transplants (LRLT) and two reduced-size liver transplants (RSLT) were performed on eight children who suffered from end-stage liver disease, having previously undergone one to three abdominal operations. Their ages at initial transplantation ranged from 8 months to 11 years (mean 35 months, median 12 months). Excluding the two older children aged 7 and 11 years, respectively, the rest of the children weighed 6 to 9.5 kg (mean 7.3 kg) at the time of the initial transplantation. Seven left lateral segments (S2 + 3) and two left lobes (S2 + 3 + 4) were used; of these the smallest graft had a graft-to-recipient body weight ratio of 0.9%. The volunteer living donors were four mothers, two fathers and one sister who were selected after medical and psychiatric evaluations, and their suitability was confirmed by hematological, biochemical, and radiological criteria. During a follow-up period of 3 to 30 months, all eight children are alive and well with normal liver function, one of them having undergone a retransplant LRLT because of hepatitis of undetermined etiology following a RSLT 1.5 years earlier. All seven donors had an uneventful postoperative course and were discharged on day 4 to 7 postoperatively. They have all resumed normal day-to-day activities. There were no complications in the donor group. A variety of complications occurred in the recipients, all of which were overcome. Operating microscope was used to perform all the arterial anastomoses using microvascular techniques. This method has proven to be a major factor in preventing arterial thrombosis even with the smallest of arterial anastomosis where a 1.5-mm diameter recipient artery was anastomosed to a 2.5-mm diameter donor hepatic artery.