Health Related Quality of Life and Neurocognitive Outcomes in the First Year after Pediatric Acute Liver Failure

Finance, race, ethnicity, and spoken language impact clinical outcomes for children with acute liver failure

BACKGROUND

Pediatric acute liver failure (PALF) is an emergency, necessitating prompt referral and management at an experienced liver transplant center. Social determinants of health (SDOH) drive healthcare disparities and can affect many aspects of disease presentation, access to care, and ultimately clinical outcomes. Potential associations between SDOH and PALF outcomes, including spontaneous recovery (SR), liver transplant (LT) or death, are unknown. This study aims to investigate how SDOH may affect PALF and therefore identify areas for intervention to mitigate unrecognized disparities.

METHODS

A retrospective, single-center cohort was analyzed and then compared and validated with data from the multicenter National Institutes of Health PALF Study Group. The single-center review included 145 patients admitted with PALF using diagnostic codes. Medical records were reviewed to extract patient demographics, family structure, inpatient social worker assessments, and clinical outcomes. Data were stratified by outcome.

RESULTS

This analysis determined that level of family support (p = .02), caretaker employment (p = .02), patient age, race, and language (p = .01) may impact clinical outcomes. Specifically, the cohort of children that died had the largest proportion of non-English speaking patients with limited support systems and parents who worked full-time. Conversely, patients who underwent LT more often belonged to English-speaking families with a homemaker and extensive support systems.

CONCLUSION

This study suggests that SDOH impact PALF outcomes and highlights patient populations facing additional challenges during an already complex healthcare emergency. These associations may indicate unconscious biases held by transplant teams when evaluating waitlist candidacy, as well as barriers to healthcare access. Strategies to better understand the broader applicability of our findings and, if confirmed, efforts to mitigate social disparities, may improve clinical outcomes in PALF.

Predictors of Social-Emotional Development and Adaptive Functioning in School-Age Children with Intestinal Failure

OBJECTIVES

Despite a focus on neurocognition in pediatric intestinal failure (IF) to date, we examined social-emotional and adaptive functioning.

METHODS

Children (N = 63) in our IF rehabilitation program underwent neuropsychological assessments including caregiver- and teacher-reported questionnaires. Results were compared to norms using z-tests. Caregiver and teacher reports were compared using t tests. Medical and demographic factors were examined in an exploratory manner using correlation and targeted regression analyses, adjusting for gestational age and full-scale IQ.

RESULTS

Caregiver and teacher reports indicated poorer executive, internalizing, behavioral, and adaptive functioning compared to norms. Teachers reported more executive dysfunctions than caregivers. Necrotizing enterocolitis diagnosis predicted internalizing emotional problems. Immigrant status predicted poorer social and practical adaptive functioning. Living with biological parents predicted fewer externalizing emotional and behavioral problems.

CONCLUSIONS

The group displayed social-emotional and adaptive functioning concerns. Identifying medical and demographic risks can allow for screening and intervention.

Pediatric acute liver failure: Reexamining key clinical features, current management, and research prospects

This review aims to synthesize the most updated research, outcomes, and trends in the field of pediatric liver transplantation (LT), specifically focusing on children who have suffered from acute liver failure. Pediatric acute liver failure is a dynamic, life-threatening condition that can either self-resolve or lead to death. LT is a lifesaving intervention. With the introduction of technical variant grafts and recent immunosuppression modifications, overall patient survival, graft survival, and waitlist mortality have improved. Furthermore, recent advances in the knowledge of immunologic mediators of acute liver failure offer the possibility of more detailed understanding of the pathophysiology and new areas for research. Given the success of living donor LT for pediatric patients with acute liver failure, this option should continue to be actively considered as an alternative treatment option for patients who are listed for transplantation and are managed at a multidisciplinary tertiary care transplant center.

Neurological impairment in children with acute liver failure following liver transplantation-A single-center experience

BACKGROUND

Although overall survival of ALF has improved, neurological restoration after recovery from ALF may not always be satisfactory. The purpose of this study was to investigate the occurrence and possible causes of NI in children with ALF following LT.

METHODS

We retrospectively examined all children younger than 16 years old with ALF who subsequently underwent LT at our center between January 2005 and December 2016. NI was assessed in December 2016 using the six-point Pediatric Cerebral Performance Category score and was defined as any increase in the score.

RESULTS

There were 62 children with median age 10 months (quartile range 5-34). The etiology of ALF was indeterminate in 47 children (75.8%). The median duration from admission to LT was 5.5 days (quartile range 4-7), and 96.8% (60/62) received living donor LT. The overall survival was 83.9% (52/62) in a median follow-up period of 4.2 years. Mild-to-moderate NI was observed in 23.1% (12/52) of the survivors. Possible causes of NI were underlying systemic disease (n = 3), perioperative brain lesion (n = 2), and unclassified (n = 7). All seven patients with unclassified NI were less than 12 months old. The unclassified NI causes were presumed to be ALF, its perioperative care, and the vulnerable infant brain.

CONCLUSIONS

NI in children with ALF following LT was not rare and should be prevented. Further investigations are required to clarify the characteristics of the patients with unclassified NI.

Impaired Neurocognitive Performance in Children after Liver Transplantation

OBJECTIVES

To assess longitudinal neurocognitive development after liver transplantation and evaluate factors associated with neurocognitive performance.

STUDY DESIGN

Data from neurocognitive testing of 65 children (aged <18 years) who underwent liver transplantation at Oslo University Hospital between 1995 and 2018 were collected from the testing program after transplantation. The parent-reported version of the Behavior Rating Inventory of Executive Function was used to assess executive function.

RESULTS

A total of 104 neurocognitive tests were conducted on 65 patients. At the first test, conducted at a median of 4.1 years (IQR, 1.5-5.3 years) after transplantation and at a median age of 6.7 years (IQR, 5.4-10.5 years), the mean full-scale IQ (FSIQ) was 91.7 ± 14, and the mean verbal comprehension index was 92.0 ± 14.5. In the 30 patients tested more than once, there was no significant difference in FSIQ between the first test at a median age of 5.8 years (IQR, 5.2-8.5 years) and the last test at a median age of 10.8 years (IQR, 9.8-12.9 years) (87.4 ± 12.9 vs 88.5 ± 13.2; P = .58). Compared with the patients who underwent transplantation a age >1 year (n = 35), those who did so at age <1 year (n = 30) had a lower FSIQ (87.1 ± 12.6 vs 96.6 ± 13.8; P = .005) and lower verbal comprehension index (87.3 ± 13.8 vs 95.4 ± 13.0; P = .020). Age at transplantation (P = .005; adjusted for cholestasis: P = .038) and transfusion of >80 mL/kg (P = .004; adjusted for age at transplantation: P = .046) were associated with FSIQ.

CONCLUSIONS

Young age at transplantation and large blood transfusions during transplantation are risk factors for poor neurocognitive performance later in life. Children who undergo transplantation before 1 year of age have significantly lower neurocognitive performance compared with those who do so later in childhood. Cognitive performance did not improve over time after transplantation.

Proceedings of the European Society for Pediatric Gastroenterology, Hepatology and Nutrition Monothematic Conference, 2020: "Acute Liver Failure in Children": Treatment and Directions for Future Research

OBJECTIVES

The Hepatology Committee of the European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) aims to educate pediatric gastroenterologists, members of ESPGHAN and professionals from other specialties promoting an exchange of clinical expertise in the field of pediatric hepatology.

METHODS

The 2020 single topic ESPGHAN monothematic 3-day conference on pediatric liver disease, was organized in Athens, Greece and was entitled " Acute Liver Failure" (ALF). ALF is a devastating disease with high mortality and in a considerable fraction of patients, the cause remains unresolved. As knowledge in diagnosis and treatment of ALF in infants and children has increased in the past decades, the objective was to update physicians in the field with developments in medical therapy and indications for liver transplantation (LT) and to identify areas for future research in clinical and neurocognitive outcomes in ALF.

RESULTS

We recently reported the epidemiology, diagnosis, and initial intensive care management issues in separate manuscript. Herewith we report on the medical treatment, clinical lessons arising from pediatric studies, nutritional and renal replacement therapy (RRT), indications and contraindications for LT, neurocognitive outcomes, new techniques used as bridging to LT, and areas for future research. Oral presentations by experts in various fields are summarized highlighting key learning points.

CONCLUSIONS

The current report summarizes the current insights in medical treatment of pediatric ALF and the directions for future research.

Desenvolvimento neuropsicomotor e habilidades funcionais em pré-escolares com doenças hepáticas

Resumo Introdução Crianças com doenças hepáticas crônicas são expostas a fatores de risco biológicos e/ou ambientais que podem comprometer suas aquisições neuromotoras e o desenvolvimento de suas habilidades funcionais. Objetivo Descrever o desenvolvimento neuropsicomotor (DNPM) e habilidades funcionais de crianças com doenças hepáticas crônicas. Métodos Estudo seccional, descritivo e exploratório realizado com crianças de até 6 anos, que foram selecionadas em um hospital de referência do estado da Bahia, Brasil, no período de novembro de 2019 a março de 2020. Foram consideradas elegíveis para o estudo crianças em atendimento ambulatorial, com diagnóstico clínico, laboratorial e histológico compatíveis com doença hepática crônica. O instrumento de avaliação do desenvolvimento neuropsicomotor foi o Denver II. As habilidades funcionais foram obtidas pela aplicação do Inventário de Avaliação Pediátrica de Incapacidade Testagem Computadorizada Adaptativa (PEDI-CAT) aos pais ou cuidadores principais, versão rápida (Speedy-CAT). Resultados Das 34 crianças com hepatopatias crônicas, 52,9% eram do sexo feminino, com idade entre 4 e 6 anos (64%). Os resultados do teste de Denver II demonstraram que 68,7% (22/32) da amostra apresentaram risco para DNPM. No PEDI-CAT, os escores das crianças hepatopatas com risco para DNPM foram de 60,7 ± 9,1 nos domínios atividade diária, 57,6 ± 11,8 em mobilidade e 48,3 ± 6,2 em social/cognitivo. Conclusão Crianças com hepatopatias crônicas apresentam risco para DNPM, apesar de não possuírem comprometimento de suas habilidades funcionais quando avaliadas pelo PEDI-CAT.

Environmental characteristics, nutritional and executive functions in children of 6 to 7 years

This study aimed to analyze the socio-environmental characteristics, executive and nutritional functions in children aged 6 to 7 years, from public schools in Alagoas, Brazil. A quantitative, cross-sectional and descriptive study was performed involving 64 children of the mentioned age group, from public schools located in Alagoas: Maceió, on the coast; Major Isidoro, in the hinterland and Palmeira dos Índios, in the country. Such analyzes were made through the application of neuropsychological tests and anthropometric assessment with children and food and socio-environmental surveys with their parents. As for the type of housing, 100% were made of masonry, with a bathroom present in 98.4%. All children reported with the habit of bathing in the river / lagoon, presented some pathology. There was no significant difference between cities in terms of the sociodemographic characteristics evaluated, with the same result occurring with the factors associated with the occurrence of diseases in children. The subtests of WISC-IV, were below the average in all municipalities, and the TAC and SCC were classified within the average. However, even though the ranking were divided between below average and average, it is possible to identify from the subtests of WISC-IV, that the general IQ showed a cognitive level below the average. There was also no significant difference in the anthropometric assessment (weight, height, BMI and IMCI) between the evaluated students. The average weight was 23.3 kg to 25 kg, the height between 1.23 m to 1.24 m, the BMI between 16.4 to 17; the IMCI from 2.8 to 3.0. Children were classified within the average. Regarding micronutrients (Ca, Fe, K, Mg and Na, and vitamins A, C, D, B1, B9 and B12) and calories, there was also no significant difference between the cities evaluated. The same occurred with macronutrients (proteins, carbohydrates and lipids). This study showed that in general there was no difference between the students of the three municipalities. Probably, even though they are all public schools and from different cities, children have similar social conditions.

NEUROPSYCHOMOTOR DEVELOPMENT IN CHILDREN AND ADOLESCENTS WITH LIVER DISEASES: SYSTEMATIC REVIEW WITH META-ANALYSIS

BACKGROUND

The nature of liver disease, the evolutionary course and duration of liver diseases, as well as the degree of severity and disability can trigger multiple outcomes with repercussions on neuromotor acquisition and development.

OBJECTIVE

To systematically review and conduct a meta-analysis to evaluate the effects of liver disease on the neuropsychomotor development of children and adolescents with their native livers and those who underwent liver transplantation.

METHODS

Observational studies published since the early 1980s until June 2019 were sought in the PubMed and Scopus databases. An α value of 0.05 was considered significant. The statistical heterogeneity of the treatment effect between the studies was assessed by the Cochran's Q test and the I2 inconsistency test, in which values above 25 and 50% were considered indicative of moderate and high heterogeneity, respectively. Analyses were performed with Review Manager 5.3.

RESULTS

Twenty-five studies met the eligibility criteria, including 909 children and adolescents with liver disease. Meta-analyses showed deficits in total IQ -0.41 (95%CI: -0.51 to -0.32; N: 9,973), verbal IQ -0.38 (95%CI: -0.57 to -0.18; N: 10,284) and receptive language -0.85 (95%CI: -1.16 to -0.53; N: 921) in liver transplantation, and those with native livers who had symptoms early had total and verbal IQ scores (85±8.8; 86.3±10.6 respectively) lower than the scores of those with late manifestations (99.5±13.8; 96.2±9.2). Gross motor skill was reduced -46.29 (95%CI: -81.55 to -11.03; N: 3,746).

CONCLUSION

Acute or chronic liver disease can cause declines in cognitive, motor and language functions. Although the scores improve after liver transplantation, children remain below average when compared to healthy children.

Identification of Impaired Executive Functioning after Pediatric Liver Transplantation Using Two Short and Easily Applicable Tests: Cognitive Functioning Module PedsQL and Children's Color Trail Test

We aimed to assess executive functioning in children after liver transplantation compared with healthy controls and in relation to real-life school performance using the PedsQL^TM Cognitive Functioning Scale (CogPedsQL) and the Childrens’ Color Trail Test (CCTT). One hundred and fifty five children (78f, median age 10.4 (1.2–18.3) years) underwent testing with CogPedsQL and/or CCTT 4.9 (0.1–17.0) years after transplantation. Results were compared to those of 296 healthy children (165f, median age 10.0 (2.0–18.0) years). Liver transplanted children displayed significantly reduced scores for cogPedsQL and CCTT1&2 compared to healthy controls. Overall, school performance was lower in patients compared to controls. In both patients and controls, results of CCTT2 and CogPedsQL correlated strongly with school performance. In contrast to controls, school performance in patients correlated with the level of maternal but not paternal primary education degree (r = −0.21, p = 0.03). None of the patient CCTT or CogPedsQL test results correlated with parental school education. Conclusion: CogPedsQL and CCTT 1&2 were easily applicable in children after OLT and revealed reduced executive functioning compared to controls. Results reflect real life school performance. The association of parental education with school performance is reduced in transplanted children, which possibly indicates the overriding impact of transplant-associated morbidity on cognitive outcomes.

Long-term Effects of Cholestatic Liver Disease in Childhood on Neuropsychological Outcomes and Neurochemistry

OBJECTIVES

Children with liver disease have increased risk of long-term cognitive deficits. We differentiated between the effects of chronic liver disease from that associated with transplantation by recruiting children with cholestatic liver disease (CLD) with and without transplantation.

METHODS

Psychometric measures and magnetic resonance spectroscopy were obtained for 3 groups of children: stable liver disease without transplantation; CLD from birth with transplantation; and individuals healthy to 18 months of age, before transplantation for acute liver failure.

RESULTS

Cognitive outcomes between children with different disease histories were significantly associated with the duration of liver disease but not the effects of transplantation, including that of immunosuppression. Lower intellectual ability was most frequently observed in the CLD group, whereas all of the acute liver failure group scored within the normal range. Myoinositol and glutamate/glutamine concentrations in cortex were significantly associated with disease duration across the cohort. Neurometabolite profiles in stable liver disease were consistent with subclinical encephalopathy. Impaired growth in early childhood was associated with later cognitive performance.

CONCLUSION

Children with prolonged liver disease had the poorest cognitive outcomes despite successful transplantation, suggesting that prolonged cholestasis before transplantation adversely affects neurodevelopment, and reinforces the need for timely interventions.