Hepatic failure and liver transplant: Working Group report of the second World Congress of Pediatric Gastroenterology, Hepatology, and Nutrition

Pediatric acute liver failure in Saudi Arabia: prognostic indicators, outcomes and the role of genetic testing

OBJECTIVE

The objective of this study was to determine the etiologies, outcomes, prognostic indicators and the role of genetic testing in children with acute liver failure (ALF).

METHODS

This retrospective study included 46 patients with pediatric acute liver failure (PALF) according to the PALF study group definition, admitted to King Fahad Specialist Hospital-Dammam, Saudi Arabia, between January 2014 and December 2021. Patients who survived with supportive therapy were designated as the recovery group, whereas those who died or underwent liver transplantation were designated as the death/transplant group.

RESULTS

There were 26 (56.5%) patients in the recovery group and 20 (43.5%) patients in the death/transplant group. Four patients (8.7%) underwent liver transplantation. After indeterminate causes (45.6%), genetic-metabolic diseases and drug-induced liver injury (DILI) were the most common cause with 15.2 and 13%, respectively. Genetic testing had a high yield of (6/31) in identifying monogenic disease associated with ALF. Younger age, lower Glasgow Coma Scale and higher international normalized ratio (INR) on admission were predictors for poor prognosis. The death/transplant group had longer intensive care unit stay ( P  < 0.001), and on admission they had more advanced hepatic encephalopathy ( P  < 0.005), more prolonged prothrombin time ( P  < 0.001), higher lactate ( P  < 0.006), higher total and direct bilirubin ( P  < 0.008) and ( P  < 0.001), respectively.

CONCLUSION

Genetic, metabolic and DILI causes constituted the most common cause of PALF after indeterminate causes. The use of genetic testing can improve diagnostic rates in special cases, but we could not assess the effect of genetic testing on prognosis. The overall survival rate in our study was 65.2%. Younger age, higher admission INR and lower Glasgow coma scale were indicators of poor prognosis.

Surveillance for infectious complications in pediatric acute liver failure - a prospective study

OBJECTIVE

To prospectively evaluate infectious complications (IC) in pediatric acute liver failure (PALF) by employing surveillance cultures.

METHODS

From 2011 to 2013, children with PALF in a tertiary care centre received a standard protocolised management. Prophylactic parenteral antibiotics were used without antifungals. Surveillance cultures of blood, urine, ascites and tracheal aspirates were sent. Biochemical and clinical parameters and outcomes were compared between children with and without IC.

RESULTS

Of the 29 children with PALF admitted during the study period (median age 36 mo, range 12-90 mo), 13.8 % had blood stream infections (BSI) at admission. Organisms were isolated in 8.8 % (12/136) of the blood cultures, 13.7 % (11/80) of the urine cultures, 30.8 % (8/26) of the tracheal aspirates and 7.1 % (1/14) of the ascitic fluid cultures. Gram negative bacteriae (n = 17) were the commonest, followed by fungi (n = 13) and gram positive bacteriae (n = 2). Klebsiella pneumoniae and Candida nonalbicans group were the commonest bacteria and fungi respectively. After admission, fungal BSI and urinary tract infections were diagnosed at a median time of 4 d (range 3-8 d) and 3.5 d (range 3-6 d) respectively. ICs were not associated with other complications and increased mortality but with longer hospital and pediatric intensive care unit (PICU) stay.

CONCLUSIONS

In this study BSI was a common finding at admission in PALF. Inspite of prophylactic antibiotics, break through gram negative bacterial and fungal ICs were common. Empirical treatment of IC should include broad spectrum antibiotics. Fungal IC occurred beyond 48 h. Prophylactic antifungals at admission may be considered to decrease their frequency. IC prolongs PICU and hospital stay.

Indocyanine green plasma disappearance rate: a new tool for the classification of paediatric patients with acute liver failure

BACKGROUND & AIMS

Pediatric acute liver failure is a rare disorder which results in death or the need for liver transplantation in 25-50% of cases. The adults scores are unable to predict survival without liver transplantation of pediatric patients. The present study assessed the use the of indocyanine green plasma disappearance rate as a tool to predict the evolution of pediatric patients with acute liver failure.

PATIENTS AND METHODS

All patients met the criteria of acute liver failure according to the Pediatric Acute Liver Failure Study Group. King's College, Clichy's criteria and ICG-PDR were obtained on admission or when acute liver failure was diagnosed and repeated every 12-24 hours, respectively.

RESULTS

Thirteen out of 48 patients suffered an irreversible liver damage. Seven of them underwent a liver transplantation and 6 died on the waiting. A total of 154 ICG-PDR measurements were taken during the study (Median 12.4 %/min, r:6.2 - 26.3). The ICG-PDR was significantly lower in patients who suffered irreversible liver damage compared with those who survived without liver transplantation (median ICG-PDR 4.1 %/min; r:4.0 - 5.7 vs median ICG-PDR 20.3 %/min; r: 9.1 - 30.1; respectively. P < 0.001). Using a ROC curve the cutoff of ICG-PDR for assessing the need for liver transplantation was set at 5.9 %/min (sensitivity 92.3%, specificity 97.1%). Sensitivity, specificity, PPV, NPV and DA for ICG-PDR were higher than the King's College and Clichy's criteria.

CONCLUSIONS

ICG-PDR is a powerful tool that would improve the categorization of patients with pediatric acute liver failure.

Intravenous N-acetylcysteine in pediatric patients with nonacetaminophen acute liver failure: a placebo-controlled clinical trial

N-acetylcysteine (NAC) was found to improve transplantation-free survival in only those adults with nonacetaminophen (non-APAP) acute liver failure (ALF) and grade 1-2 hepatic encephalopathy (HE). Because non-APAP ALF differs significantly between children and adults, the Pediatric Acute Liver Failure (PALF) Study Group evaluated NAC in non-APAP PALF. Children from birth through age 17 years with non-APAP ALF enrolled in the PALF registry were eligible to enter an adaptively allocated, doubly masked, placebo-controlled trial using a continuous intravenous infusion of NAC (150 mg/kg/day in 5% dextrose in water [D5W]) or placebo (D5W) for up to 7 days. The primary outcome was 1-year survival. Secondary outcomes included liver transplantation-free survival, liver transplantation (LTx), length of intensive care unit (ICU) and hospital stays, organ system failure, and maximum HE score. A total of 184 participants were enrolled in the trial with 92 in each arm. The 1-year survival did not differ significantly (P = 0.19) between the NAC (73%) and placebo (82%) treatment groups. The 1-year LTx-free survival was significantly lower (P = 0.03) in those who received NAC (35%) than those who received placebo (53%), particularly, but not significantly so, among those less than 2 years old with HE grade 0-1 (NAC 25%; placebo 60%; P = 0.0493). There were no significant differences between treatment arms for hospital or ICU length of stay, organ systems failing, or highest recorded grade of HE.

CONCLUSION

NAC did not improve 1-year survival in non-APAP PALF. One-year LTx-free survival was significantly lower with NAC, particularly among those <2 years old. These results do not support broad use of NAC in non-APAP PALF and emphasizes the importance of conducting controlled pediatric drug trials, regardless of results in adults.

Pediatric viral hepatitis: avoiding liver failure

Acute liver failure (ALF) is defined as a multisystem disorder of severe impairment of liver function, with or without encephalopathy, which is associated with hepatocellular necrosis (reflected as liver synthetic failure in patients with no recognized chronic liver disease), and can lead to death. ALF can be due to hepatotoxic drugs, natural toxins, autoimmune disease, severe bacterial infection and some neoplastic processes, or ALF can be idiopathic. In the pediatric group, the most frequent cause is viral agents; hepatitis A is the most common among these. The pathophysiologic changes in ALF consist of alterations in coagulation, elevated serum ammonia, hypoalbuminemia and hypoglycemia. In recent years, N-acetylcysteine has been utilized to treat this condition. Using this drug during the early stages of the disease has the potential to improve outcomes for the patient, including the avoidance liver transplantation. This article focuses on the criteria that help to identify ALF and emphasizes accessible alternative medical treatments.

Fulminant autoimmune hepatitis in a girl with 22q13 deletion syndrome: a previously unreported association

We report a 7-year-old girl with 22q13 deletion syndrome, 46,XX,Ish del(22)(q13.3)(ARSA-; D22S1726), who developed a fulminant autoimmune hepatitis requiring orthotopic liver transplantation. Recently, it has been suggested that the Shank3 gene product, whose deficiency is responsible for the features observed in this syndrome, could play a role in immunological response. Despite an increased incidence of respiratory infections, autoimmune diseases have thus far not been reported in patients with this syndrome. This is the first case of fulminant autoimmune hepatitis associated with the 22q13 deletion syndrome. The possible relationships between immune system dysfunctions peculiar of this syndrome and autoimmune hepatitis are discussed.

Detection of hepatitis A virus RNA from children patients with acute and fulminant hepatitis of unknown etiology in Vietnam: Genomic characterization of Vietnamese HAV strain

BACKGROUND

Although it is thought that Vietnam is a high endemic region of hepatitis A virus (HAV) infection, there is no report on genomic characterization of HAV spread in Vietnam. The purpose of the present paper was therefore to identify various virus infections from 33 children with acute or fulminant hepatitis of unknown etiology admitted to Children's Hospital No.1 in Ho Chi Minh City, Vietnam.

METHODS

Anti-HAV IgM and IgG were assayed by ELISA. Viral RNA and DNA were determined by PCR method. HAV genes isolated by PCR were sequenced and characterized by phylogenetic analysis.

RESULTS

Anti-HAV IgM was detected in 18 of 26 acute hepatitis (69.2%) and one of seven (14.3%) fulminant hepatitis patients. Furthermore, HAV-RNA in serum was identified in five of 26 acute (19.2%) and two of seven (28.6%) fulminant hepatitis patients, respectively, on nested reverse transcription-polymerase chain reaction. Among the seven HAV-RNA-positive patients tested, two (28.6%) were negative for anti-HAV IgM. We also obtained seven isolates containing the HAV genome with the viral protein 1 (VP1) region sequence. All Vietnamese HAV isolates formed a cluster and belonged to genotype IA according to phylogenetic analysis based on the short sequences of VP1-2A junction region.

CONCLUSION

HAV is an important agent with regard to fulminant hepatitis among children in Vietnam. To the authors' knowledge this is the first report on Vietnamese HAV strain confirmed on sequencing.

Evaluation of a scoring system for assessing prognosis in pediatric acute liver failure

BACKGROUND & AIMS

Pediatric acute liver failure (PALF) results in death or need for liver transplantation (LT) in up to 50% of patients. A scoring system for predicting death or LT (Liver Injury Units [LIU] score) in PALF was previously derived by our group, and used peak values during hospital admission of total bilirubin, prothrombin time/international normalized ratio, and ammonia as significant predictors of outcome. The aims of this study were to test the predictive value of the LIU score in a subsequent validation set of patients and to derive a hospital admission LIU (aLIU) score predictive of outcome.

METHODS

Data were obtained from 53 children admitted with PALF from 2002 to 2006. Outcome was defined at 16 weeks as alive without LT, death, or LT.

RESULTS

Survival without LT at 16 weeks for each LIU score quartile was 92%, 44%, 60%, and 12%, respectively (P < .001). The receiver operating characteristic C index for predicting death or LT by 4 weeks was 86.3. An admission LIU score was derived using admission total bilirubin and prothrombin time/international normalized ratio. Survival without LT at 16 weeks for each quartile using the aLIU score was 85%, 77%, 69%, and 31% (P = .001). The receiver operating characteristic C index for predicting death or LT by 4 weeks was 83.7.

CONCLUSIONS

The original LIU score is a valid predictor of outcome in PALF. The aLIU score is promising and needs to be validated in subsequent patients.

Paediatric acute liver failure and transplantation: The University of Essen experience

To report our experience with 17 children who underwent a liver transplantation (LT) for acute liver failure (ALF). All LT procedures (deceased and living donor) were offered. Since 2003 Molecular Adsorbents Recycling System (MARS) was proposed as bridging procedure. We monitored the perioperative course and the short- and long-term outcomes. All children developed pretransplant hepatic encephalopathy (mostly grades II and III); six needed ventilator support and three haemodialysis. Median PELD/MELD score was 30. MARS was used in five children with poor pretransplant prognostic factors: all five survived the LT without sequelae. We performed 13 deceased donor LT (seven whole, five split and onr reduced) and four left lateral LDLT. Postoperative complications were observed in 10 children, requiring re-operation in seven. Two children developed irreversible neurological disorders. After a median follow up of 45 months, 16 children are still alive. About 1- and 5-year cumulative patient survival rates are 94% with a corresponding graft survival of 88% and 81%, respectively. The combination of experienced paediatric ICU management, the application of new liver support devices, and the capacity to offer both living and deceased donor transplant alternatives in a timely fashion represent the best formula to achieve optimal results in children with ALF.

Acute liver failure in children: the first 348 patients in the pediatric acute liver failure study group

OBJECTIVES

To determine short-term outcome for children with acute liver failure (ALF) as it relates to cause, clinical status, and patient demographics and to determine prognostic factors.

STUDY DESIGN

A prospective, multicenter case study collecting demographic, clinical, laboratory, and short-term outcome data on children from birth to 18 years with ALF. Patients without encephalopathy were included if the prothrombin time and international normalized ratio remained > or = 20 seconds and/or >2, respectively, despite vitamin K. Primary outcome measures 3 weeks after study entry were death, death after transplantation, alive with native liver, and alive with transplanted organ.

RESULTS

The cause of ALF in 348 children included acute acetaminophen toxicity (14%), metabolic disease (10%), autoimmune liver disease (6%), non-acetaminophen drug-related hepatotoxicity (5%), infections (6%), other diagnosed conditions (10%); 49% were indeterminate. Outcome varied between patient sub-groups; 20% with non-acetaminophen ALF died or underwent liver transplantation and never had clinical encephalopathy.

CONCLUSIONS

Causes of ALF in children differ from in adults. Clinical encephalopathy may not be present in children. The high percentage of indeterminate cases provides an opportunity for investigation.

Transplantation for acute liver failure in children

We reviewed the clinical data of 30 children-hospitalized for acute liver failure in the last 6 years. Ten patients were not listed for liver transplantation OLTX. Their clinical conditions gradually improved and they are all alive without deficit. Among 20 patients listed, 15 underwent urgent OLTX. Two children died on the waiting list and three were suspended from waiting list after few days because of improvement. Survival according to age class was analyzed dividing the patients into two groups: A, age 1 year or less versus B, age between 1 and 16 years. The patient survival was 86% at 6 months and 61% both at 1 and 2 years. Survival at 6 months and 1 and 2 years was 88%, 67%, and 45% for the patients in group A and 83%, 83%, and 83% for the patients in group B (P = NS). Observing graft-to-recipient weight ratio and donor-to-recipient weight ratio most patients received an optimal sized graft. The split-liver technique is considered the preferred method of liver transplantation even in the pediatric patients with acute liver failure; especially in the setting of a cooperative system in which all livers that are suitable for split-liver transplantation are shared between centers. In order to have the best chance for survival, children with acute liver failure should be referred as soon as possible to an highly specialized pediatric liver transplantation center that can offer all the treatment modalities that are currently available.