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Ruan W, Galvan NTN, Dike P, Koci M, Faraone M, Fuller K, Koomaraie S, Cerminara D, Fishman DS, Deray KV, Munoz F, Schackman J, Leung D, Akcan-Arikan A, Virk M, Lam FW, Chau A, Desai MS, Hernandez JA, Goss JA. The Multidisciplinary Pediatric Liver Transplant. Curr Probl Surg 2023; 60:101377. [PMID: 37993242 DOI: 10.1016/j.cpsurg.2023.101377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 08/29/2023] [Indexed: 11/24/2023]
Affiliation(s)
- Wenly Ruan
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Nhu Thao N Galvan
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Department of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX.
| | - Peace Dike
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Melissa Koci
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Department of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Marielle Faraone
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Kelby Fuller
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | | | - Dana Cerminara
- Department of Pharmacy, Texas Children's Hospital, Houston, TX
| | - Douglas S Fishman
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Kristen Valencia Deray
- Department of Pediatrics, Department of Pharmacy, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Flor Munoz
- Department of Pediatrics, Department of Pharmacy, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Julie Schackman
- Division of Anesthesiology, Perioperative, & Pain Medicine, Department of Anesthesiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Daniel Leung
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Ayse Akcan-Arikan
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Manpreet Virk
- Division of Critical Care, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Fong W Lam
- Division of Critical Care, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Alex Chau
- Division of Interventional Radiology, Department of Radiology, Edward B. Singleton Department of Radiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Moreshwar S Desai
- Division of Critical Care, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Jose A Hernandez
- Division of Interventional Radiology, Department of Radiology, Edward B. Singleton Department of Radiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - John A Goss
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Department of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
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2
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Chung YH, Jung J, Kim SH. Mortality scoring systems for liver transplant recipients: before and after model for end-stage liver disease score. Anesth Pain Med (Seoul) 2023; 18:21-28. [PMID: 36746898 PMCID: PMC9902634 DOI: 10.17085/apm.22258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 01/13/2023] [Indexed: 02/01/2023] Open
Abstract
The mortality scoring systems for patients with end-stage liver disease have evolved from the Child-Turcotte-Pugh score to the model for end-stage liver disease (MELD) score, affecting the wait list for liver allocation. There are inherent weaknesses in the MELD score, with the gradual decline in its accuracy owing to changes in patient demographics or treatment options. Continuous refinement of the MELD score is in progress; however, both advantages and disadvantages exist. Recently, attempts have been made to introduce artificial intelligence into mortality prediction; however, many challenges must still be overcome. More research is needed to improve the accuracy of mortality prediction in liver transplant recipients.
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Affiliation(s)
| | | | - Sang Hyun Kim
- Corresponding Author: Sang Hyun Kim, M.D., Ph.D. Department of Anesthesiology and Pain Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, 170 Jomaru-ro, Wonmi-gu, Bucheon 14584, Korea Tel: 82-32-621-5328 Fax: 82-32-621-5322 E-mail:
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3
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Østensen AB, Skarbø AB, Sanengen T, Line PD, Almaas R. Impaired Neurocognitive Performance in Children after Liver Transplantation. J Pediatr 2022; 243:135-141.e2. [PMID: 34953814 DOI: 10.1016/j.jpeds.2021.12.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 12/06/2021] [Accepted: 12/17/2021] [Indexed: 12/31/2022]
Abstract
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.
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Affiliation(s)
- Anniken B Østensen
- Division of Pediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Anne-Britt Skarbø
- Division of Pediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Truls Sanengen
- Division of Pediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Pål-Dag Line
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Runar Almaas
- Division of Pediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Pediatric Research, Oslo University Hospital, Oslo, Norway.
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4
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Yu H, Yu W, Zhu M, Zhang G, Shi Y, Sun Y. Changes in NSE and S-100β during the perioperative period and effects on brain injury in infants with biliary atresia undergoing parent donor liver transplantation. Exp Ther Med 2021; 22:724. [PMID: 34007333 PMCID: PMC8120510 DOI: 10.3892/etm.2021.10156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 07/23/2020] [Indexed: 12/02/2022] Open
Abstract
The present study aimed to investigate the effects of parental donor liver transplantation on the perioperative changes of serum calcium-binding protein β (S-100β) and neuron-specific enolase (NSE) levels, two markers of brain injury, and on postoperative cognitive function. The present study was a prospective observational study of infants with congenital biliary atresia who underwent selective liver transplantation in 2017 at Tianjin First Central Hospital (Tianjin, China). Blood samples were collected prior to, during and following surgery, and S-100β and NSE levels were measured using ELISA. The pediatric patients were assessed using the Bayley Scales of Infant Development 1 day prior to and 3 months after surgery. Additionally, the pediatric anesthesia emergence delirium scores were evaluated. The results demonstrated that serum NSE and S100β were increased during and after surgery compared with prior to surgery (P<0.05). Furthermore, serum S-100β and NSE levels peaked 1 h after the neohepatic phase compared with prior to surgery (P<0.05). Compared with 1 day before surgery, mental development index (MDI) and psychomotor development index (PDI) were decreased 3 months after surgery (MDI, 87.7±8.4 vs. 84.5±8.5, P=0.015; PDI, 82.9±8.7 vs. 79.6±8.8, P=0.016). In conclusion, parental donor liver transplantation may cause a certain degree of brain injury in pediatric patients with end-stage liver disease, as revealed by increased serum NSE and S100β levels.
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Affiliation(s)
- Hongli Yu
- Department of Anesthesiology, Tianjin First Center Hospital, Tianjin 300192, P.R. China
| | - Wenli Yu
- Department of Anesthesiology, Tianjin First Center Hospital, Tianjin 300192, P.R. China
| | - Min Zhu
- Department of Anesthesiology, Tianjin First Center Hospital, Tianjin 300192, P.R. China
| | - Guicheng Zhang
- Department of Anesthesiology, Tianjin First Center Hospital, Tianjin 300192, P.R. China
| | - Yiwei Shi
- Department of Anesthesiology, Tianjin First Center Hospital, Tianjin 300192, P.R. China
| | - Ying Sun
- Department of Anesthesiology, Tianjin First Center Hospital, Tianjin 300192, P.R. China
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5
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Ohnemus D, Neighbors K, Rychlik K, Venick RS, Bucuvalas JC, Sundaram SS, Ng VL, Andrews WS, Turmelle Y, Mazariegos GV, Sorensen LG, Alonso EM. Health-Related Quality of Life and Cognitive Functioning in Pediatric Liver Transplant Recipients. Liver Transpl 2020; 26:45-56. [PMID: 31509650 DOI: 10.1002/lt.25634] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 08/08/2019] [Indexed: 12/24/2022]
Abstract
The goal of this work was to examine the change in health-related quality of life (HRQOL) and cognitive functioning from early childhood to adolescence in pediatric liver transplantation (LT) recipients. Patients were recruited from 8 North American centers through the Studies of Pediatric Liver Transplantation consortium. A total of 79 participants, ages 11-18 years, previously tested at age 5-6 years in the Functional Outcomes Group study were identified as surviving most recent LT by 2 years and in stable medical follow-up. The Pediatric Quality of Life 4.0 Generic Core Scale, Pediatric Quality of Life Cognitive Function Scale, and PROMIS Pediatric Cognitive Function tool were distributed to families electronically. Data were analyzed using repeated measures and paired t tests. Predictive variables were analyzed using univariate regression analysis. Of the 69 families contacted, 65 (94.2%) parents and 61 (88.4%) children completed surveys. Median age of participants was 16.1 years (range, 12.9-18.0 years), 55.4% were female, 33.8% were nonwhite, and 84.0% of primary caregivers had received at least some college education. Median age at LT was 1.1 years (range, 0.1-4.8 years). The majority of participants (86.2%) were not hospitalized in the last year. According to parents, adolescents had worse HRQOL and cognitive functioning compared with healthy children in all domains. Adolescents reported HRQOL similar to healthy children in all domains except psychosocial, school, and cognitive functioning (P = 0.02; P < 0.001; P = 0.04). Participants showed no improvement in HRQOL or cognitive functioning over time. For cognitive and school functioning, 60.0% and 50.8% of parents reported "poor" functioning, respectively (>1 standard deviation below the healthy mean). Deficits in HRQOL seem to persist in adolescence. Over half of adolescent LT recipients appear to be at risk for poor school and cognitive functioning, likely reflecting attention and executive function deficits.
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Affiliation(s)
- Daniella Ohnemus
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Katie Neighbors
- Division of Gastroenterology, Hepatology and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Karen Rychlik
- Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Robert S Venick
- Department of Pediatrics, Division of Gastroenterology, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - John C Bucuvalas
- Jack and Lucy Clark Department of Pediatrics, Mount Sinai Kravis Children's Hospital Recanati/Miller Transplantation Institute, New York, NY
| | - Shikha S Sundaram
- Section of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics and the Digestive Health Institute, Children's Hospital of Colorado and University of Colorado School of Medicine, Aurora, CO
| | - Vicky L Ng
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Transplant and Regenerative Medicine Center, Toronto, Ontario, Canada
| | - Walter S Andrews
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO
| | - Yumi Turmelle
- Section of Hepatology, Department of Pediatrics, Washington University, St. Louis, MO
| | - George V Mazariegos
- Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Lisa G Sorensen
- Department of Child and Adolescent Psychiatry, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Estella M Alonso
- Division of Gastroenterology, Hepatology and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
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6
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Montenovo MI, Bambha K, Reyes J, Dick A, Perkins J, Healey P. Living liver donation improves patient and graft survival in the pediatric population. Pediatr Transplant 2019; 23:e13318. [PMID: 30450729 DOI: 10.1111/petr.13318] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 08/13/2018] [Accepted: 10/12/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND The utilization of living donor grafts resulted in an increased availability of liver for pediatric recipients, and accordingly, this was associated with a significantly decreased waiting time before liver transplantation as well as reduced pre-transplant mortality. We hypothesized that the use of living donors in pediatric LT may lead to improved graft and patient survival, when compared to LT using deceased donors. METHODS Retrospective cohort analysis of pediatric recipients (aged <18 years) registered in the UNOS database who received a primary liver transplant between February 2002 and December 2016. Covariates predictive of survival by multivariable analyses were included in the Cox proportional hazards regression models to determine predictors of patient and graft survival. RESULTS A total of 6312 children received a primary LT from a LD (n = 800) or a deceased donor (n = 5517; partial graft n = 1784 and whole graft n = 3733). Vascular and biliary complications were similar. Kaplan-Meier graft and patient survival rates were superior in LD recipients compared with recipients of deceased whole and reduced graft (Figures 1 and 2). In the multivariable analysis, LD were an independent predictor of improved patient and graft survival. CONCLUSION The use of LD in children is associated with improved patient and graft survival. The option of LD should be introduced early on in the evaluation of every pediatric patient being evaluated for liver transplant.
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Affiliation(s)
- Martin I Montenovo
- Division of Transplantation, Department of Surgery, University of Washington, Seattle, Washington
| | - Kiran Bambha
- Division of Hepatology, Department of Internal Medicine, University of Washington, Seattle, Washington
| | - Jorge Reyes
- Division of Transplantation, Department of Surgery, University of Washington, Seattle, Washington.,Division of Hepatology, Department of Internal Medicine, University of Washington, Seattle, Washington.,Division of Transplantation, Seattle Children's Hospital, Seattle, Washington
| | - Andre Dick
- Division of Transplantation, Seattle Children's Hospital, Seattle, Washington
| | - James Perkins
- Division of Transplantation, Department of Surgery, University of Washington, Seattle, Washington
| | - Patrick Healey
- Division of Transplantation, Seattle Children's Hospital, Seattle, Washington
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7
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Al Sayyed MH, Shamsaeefar A, Nikeghbalian S, Dehghani SM, Bahador A, Dehghani M, Rasekh R, Gholami S, Khosravi B, Malek Hosseini SA. Single Center Long-Term Results of Pediatric Liver Transplantation. EXP CLIN TRANSPLANT 2018; 18:65-70. [PMID: 29676701 DOI: 10.6002/ect.2017.0110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES Liver replacement continues to be the only definitive mode of therapy for children with end-stage liver disease. However, it remains challenging because of the rare donor organs, complex surgical demands, and the necessity to prevent long-term complications. Our objectives were to analyze 16 years of experience in the Shiraz University Organ Transplant Center. MATERIALS AND METHODS We retrospectively analyzed the records of 752 patients (< 18 years old) who underwent orthotopic liver transplant at our center over a 16-year period. Mean age was 90 months, and male-to-female ratio was 1.25. Of the 752 transplants, 354 were whole organs, 311 were from living related donors, and 87 were in situ split liver allografts. Patient and graft survival rates were determined at 1, 3, and 5 years, and results between groups were compared. RESULTS Overall mortality was 31.8%. The 1-, 3-, and 5-year patient survival rates were 77%, 69%, and 66%, respectively, whereas the respective graft survival rates were 75%, 68%, and 65%. We observed significant differences in survival according to graft type (log-rank test, P < .001). We also observed significant differences in survival probabilities according to age (log-rank test, P < .001). Cox regression was used to simultaneously analyze effects of age and graft type on survival. Both graft type and age significantly affected survival (P < .001). The 1-, 3, and 5-year survival rates for patients having whole organ transplants were 88%, 81%, and 78%. Patients who received living donor grafts had respective survival rates of 66%, 60%, and 58%, with rates of 65%, 47%, and 47% for patients who received split grafts. CONCLUSIONS Our results were similar to those observed in the literature in terms of indication for transplant and posttransplant survival.
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Affiliation(s)
- Mohammad Hussein Al Sayyed
- From the Shiraz Organ Transplant Center, Namazi Teaching Hospital, Shiraz University of Medical Sciences, Shiraz, I. R. Iran
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8
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Wrenn SM, Callas PW, Kapoor T, Aunchman AF, Paine AN, Pineda JA, Marroquin CE. Increased risk organ transplantation in the pediatric population. Pediatr Transplant 2017; 21. [PMID: 28921748 DOI: 10.1111/petr.13041] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/28/2017] [Indexed: 12/16/2022]
Abstract
IRD organs are classified by the Public Health Service to be at above-average risk for harboring human immunodeficiency virus, hepatitis C, and hepatitis B. Traditionally underutilized, there exists even greater reluctance for their use in pediatric patients. We performed a retrospective analysis via the United Network for Organ Sharing database of all pediatric renal and hepatic transplants performed from 2004 to 2008 in the United States. Primary outcomes were patient and graft survival. Proportional hazards regression was performed to control for potentially confounding factors. Waitlist time, organ acceptance rates, and infectious transmissions were analyzed. There were 1830 SRD renal, 92 IRD renal, 1695 SRD hepatic, and 59 IRD hepatic transplants. There were no statistically significant differences in allograft or patient survival in either group. Acceptance rates of IRD organs were lower for kidney (1.5% IRD vs 4.82% SRD) and liver (1.99% IRD vs 4.51% SRD). One transmission of a bloodborne pathogen involving a pediatric recipient out of 7797 unique transplants was reported from 2008 to 2015. IRD organs appear to have equivalent outcomes. Increasing their utilization may improve access to transplant while decreasing wait times and circumventing waitlist morbidity and mortality.
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Affiliation(s)
- Sean M Wrenn
- Department of Surgery, Larner College of Medicine at The University of Vermont, Burlington, VT, USA.,Division of Transplant Surgery, University of Vermont Medical Center, Burlington, VT, USA
| | - Peter W Callas
- Department of Surgery, Larner College of Medicine at The University of Vermont, Burlington, VT, USA.,Division of Transplant Surgery, University of Vermont Medical Center, Burlington, VT, USA
| | - Trishul Kapoor
- Department of Surgery, Larner College of Medicine at The University of Vermont, Burlington, VT, USA.,Department of General Surgery, Mayo Clinic Rochester, Rochester, MN, USA
| | - Alia F Aunchman
- Department of Surgery, Larner College of Medicine at The University of Vermont, Burlington, VT, USA.,Division of Transplant Surgery, University of Vermont Medical Center, Burlington, VT, USA
| | - Adam N Paine
- Department of Surgery, Larner College of Medicine at The University of Vermont, Burlington, VT, USA.,Division of Transplant Surgery, University of Vermont Medical Center, Burlington, VT, USA
| | - Jaime A Pineda
- Department of Surgery, Larner College of Medicine at The University of Vermont, Burlington, VT, USA.,Division of Transplant Surgery, University of Vermont Medical Center, Burlington, VT, USA
| | - Carlos E Marroquin
- Department of Surgery, Larner College of Medicine at The University of Vermont, Burlington, VT, USA.,Division of Transplant Surgery, University of Vermont Medical Center, Burlington, VT, USA
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9
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Ekong UD, McKiernan P, Martinez M, Lobritto S, Kelly D, Ng VL, Alonso EM, Avitzur Y. Long-term outcomes of de novo autoimmune hepatitis in pediatric liver transplant recipients. Pediatr Transplant 2017; 21:10.1111/petr.12945. [PMID: 28556542 PMCID: PMC5570622 DOI: 10.1111/petr.12945] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/26/2017] [Indexed: 12/16/2022]
Abstract
The long-term course and outcome of DAIH is unknown. A retrospective multicenter study assessing associations and long-term consequences of DAIH developing in a transplanted allograft is presented. Children with DAIH were followed from diagnosis until death, re-LT, or transfer of care and for a minimum of 1 year. A total of 31 patients of 1833 (1.7%) LT were identified; 29 followed for a median of 7.1 years (range, 1.6-15); 52% had no rejection preceding diagnosis of DAIH. Transaminases fell following treatment with steroids and antimetabolites (ALT 108 vs 39 U/L (P=.002); AST 112 vs 52 U/L (P=.003); GGT 72 vs 36 U/L (P=.03), but this was not universally sustained. Transaminases >2X ULN observed in 38% of patients at last follow-up; commonly GGT, attributed to bile duct injury and ductopenia. Portal hypertension (PHT) was seen in four patients and associated with severe fibrosis and cirrhosis. Re-LT occurred in two patients for chronic rejection (CR) and uncontrolled PHT with gastrointestinal bleeding, respectively. No deaths from DAIH were reported. DAIH is an uncommon complication following pediatric LT requiring prolonged and augmented immunosuppression. It is associated with continued allograft dysfunction and may lead to bile duct injury, CR, and PHT necessitating re-LT.
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Affiliation(s)
- UD Ekong
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| | - P McKiernan
- Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA,The Liver Unit, Birmingham Children’s Hospital and University of Birmingham, Birmingham, UK
| | - M Martinez
- Department of Pediatrics, Columbia University, New York, NY, USA
| | - S Lobritto
- Department of Pediatrics, Columbia University, New York, NY, USA
| | - D Kelly
- The Liver Unit, Birmingham Children’s Hospital and University of Birmingham, Birmingham, UK
| | - VL Ng
- Department of Pediatrics, University of Toronto, Ontario, Canada
| | - EM Alonso
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Y Avitzur
- Department of Pediatrics, University of Toronto, Ontario, Canada
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10
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Marseglia A, Ginammi M, Bosisio M, Stroppa P, Colledan M, D'Antiga L. Determinants of large drain losses early after pediatric liver transplantation. Pediatr Transplant 2017; 21. [PMID: 28417522 DOI: 10.1111/petr.12932] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/17/2017] [Indexed: 12/21/2022]
Abstract
The goal of this study was to evaluate postoperative ascites to correlate it with graft dysfunction and other complications. We therefore reviewed the files of patients transplanted between 2009 and 2014 to correlate drain losses with indication, patient and organ size, PELD, graft type, GRWR, NRBW, NGWD, cold ischemia time, histologically proven graft dysfunction, and surgical complications. Of 120 LTs in 104 patients, 48 (40%) were complicated by graft dysfunction, 43 (36%) by surgical complications, and 25 (21%) by cellular rejection. Large drain losses correlated with younger age (P=.05), graft dysfunction (P<.01), surgical complications (P<.01), chylous ascites (P=.05); there was no association with PELD, GRWR, NRBW, or NGWD. Graft dysfunction was predicted by >20 mL/kg/d of ascites at age 0-2 years (AUROC 0.671), and >10 mL/kg/d above 2 years (AUROC 0.710). The measurement of drain losses after pediatric LT could be used as a non-invasive marker of graft dysfunction. Younger recipients tend to develop larger amounts of ascites, and its persistence is associated with early complications.
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Affiliation(s)
- Antonio Marseglia
- Paediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Marco Ginammi
- Paediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Michela Bosisio
- Paediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Paola Stroppa
- Paediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Michele Colledan
- Department of Transplant Surgery, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Lorenzo D'Antiga
- Paediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, Bergamo, Italy
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11
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Recent Trends in the Diagnosis and Management of Biliary Atresia in Developing Countries. Indian Pediatr 2016; 52:871-9. [PMID: 26499012 DOI: 10.1007/s13312-015-0735-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
NEED AND PURPOSE OF REVIEW Biliary atresia is a progressive obstructive cholangiopathy and is fatal if left untreated within 2 years of life. Delay in referral is because of difficulties in differentiating it from physiologic jaundice and identifying an abnormal stool color. This paper presents an overview on the diagnosis and discusses the current strategies in the management of this disease in developing countries. METHODS Articles were retrieved from the PubMed database using the terms biliary atresia, Kasai portoenterostomy and pediatric liver transplantation. Contents of the article are also based on personal experience of the authors. CONCLUSION A national screening program using stool color cards as part of standard care in the neonatal period will greatly improve early detection of biliary atresia. Outcomes will improve if it is diagnosed at the earliest after birth, the child is referred to an experienced pediatric hepatobiliary unit for evaluation, and undergoes an early Kasai procedure. If an early Kasai portoenterostomy is performed, nearly half of all children survive into adolescence, and about one-third are likely to have a long-term, symptom-free life with normal liver biochemistry. Sequential treatment combining Kasai as first line and liver transplantation as second line results in 90% survival for children with biliary atresia.
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12
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Feldman AG, Neighbors K, Mukherjee S, Rak M, Varni JW, Alonso EM. Impaired physical function following pediatric LT. Liver Transpl 2016; 22:495-504. [PMID: 26850789 PMCID: PMC5129748 DOI: 10.1002/lt.24406] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 01/14/2016] [Accepted: 01/19/2016] [Indexed: 01/13/2023]
Abstract
The purpose of this article is to investigate the spectrum of physical function of pediatric liver transplantation (LT) recipients 12-24 months after LT. Review data were collected through the functional outcomes group, an ancillary study of the Studies of Pediatric Liver Transplantation registry. Patients were eligible if they had survived LT by 12-24 months. Children ≥ 8 years and parents completed the Pediatric Quality of Life Inventory™ 4.0 generic core scales, which includes 8 questions assessing physical function. Scores were compared to a matched healthy child population (n = 1658) and between survivors with optimal versus nonoptimal health. A total of 263 patients were included. Median age at transplant and survey was 4.8 years (interquartile range [IQR], 1.3-11.4 years) and 5.9 years (IQR, 2.6-13.1 years), respectively. The mean physical functioning score on child and parent reports were 81.2 ± 17.3 and 77.1 ± 23.7, respectively. Compared to a matched healthy population, transplant survivors and their parents reported lower physical function scores (P < 0.001); 32.9% of patients and 35.0% of parents reported a physical function score <75, which is > 1 standard deviation below the mean of a healthy population. Physical functioning scores were significantly higher in survivors with optimal health than those with nonoptimal health (P < 0.01). There was a significant relationship between emotional functioning and physical functioning scores for LT recipients (r = 0.69; P < 0.001). In multivariate analysis, primary disease, height z score < -1.64 at longterm follow-up (LTF) visit, > 4 days of hospitalization since LTF visit, and not being listed as status 1 were predictors of poor physical function. In conclusion, pediatric LT recipients 1-2 years after LT and their parents report lower physical function than a healthy population. Findings suggest practitioners need to routinely assess physical function, and the development of rehabilitation programs may be important.
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Affiliation(s)
- Amy G. Feldman
- University of Colorado School of Medicine, and Digestive Health Institute, Children’s Hospital Colorado, Aurora, CO, USA; Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics
| | - Katie Neighbors
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA; Pediatrics
| | - Shubra Mukherjee
- Rehabilitation Institute of Chicago, Chicago, IL, USA; Pediatric and Adolescent Rehabilitation
| | - Melanie Rak
- Rehabilitation Institute of Chicago, Chicago, IL, USA; Pediatric and Adolescent Rehabilitation
| | - James W. Varni
- Texas A&M University, College Station, TX, USA; Pediatrics
| | - Estella M. Alonso
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA; Pediatrics
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13
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Liver and intestinal transplant in the paediatric population. An Pediatr (Barc) 2015. [DOI: 10.1016/j.anpede.2015.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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14
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de la Rosa G, Matesanz R. [Liver and intestinal transplant in paediatric population]. An Pediatr (Barc) 2015; 83:441.e1-8. [PMID: 26611879 DOI: 10.1016/j.anpedi.2015.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 11/04/2015] [Indexed: 11/26/2022] Open
Abstract
Our organizational model allows an annual 1,000 liver transplants. Pediatric liver transplantation constitutes 5% of such activity and provides, in children with severe, progressive and irreversible liver disease, a 1 year-survival of 90% and more than 80% after 15 years of follow-up. The main indication is biliary atresia followed by metabolic liver disease and acute liver failure. Around half of the procedures are performed in children under two years and 25-30% in the first year of life. The waiting list remains at around 35 patients, with an average of 100 patients enrolled annually and 60 of them finally transplanted after an average of 136.3 days on the waiting list. The prioritization of the candidates uses the PELD as an objective tool for decision-making. However, the progressive aging of donors, with a profile increasingly different from the requirements of the pediatric patients included in the waiting list, requires strategies such as living donor liver transplantation and the split liver transplantation, to increase the probability of transplant while reducing both time and mortality on the waiting list at the same time. Pediatric intestinal transplantation registers a low indication but involves strict requirements that outline a very uncommon donor in our country which, together with the absence of alternatives that outweigh the impact of these difficulties, penalizes the chances of transplant for these patients.
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Affiliation(s)
- G de la Rosa
- Organización Nacional de Trasplantes, Ministerio de Sanidad, Servicios Sociales e Igualdad, Madrid, España.
| | - R Matesanz
- Organización Nacional de Trasplantes, Ministerio de Sanidad, Servicios Sociales e Igualdad, Madrid, España
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15
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Underwood PW, Cron DC, Terjimanian MN, Wang SC, Englesbe MJ, Waits SA. Sarcopenia and failure to rescue following liver transplantation. Clin Transplant 2015; 29:1076-80. [DOI: 10.1111/ctr.12629] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2015] [Indexed: 12/12/2022]
Affiliation(s)
- Patrick W. Underwood
- Morphomic Analysis Group; University of Michigan Medical School; Ann Arbor MI USA
| | - David C. Cron
- Morphomic Analysis Group; University of Michigan Medical School; Ann Arbor MI USA
| | | | - Stewart C. Wang
- Morphomic Analysis Group; University of Michigan Medical School; Ann Arbor MI USA
- Department of Surgery; University of Michigan Medical School; University of Michigan; Ann Arbor MI USA
| | - Michael J. Englesbe
- Morphomic Analysis Group; University of Michigan Medical School; Ann Arbor MI USA
- Department of Surgery; University of Michigan Medical School; University of Michigan; Ann Arbor MI USA
| | - Seth A. Waits
- Department of Surgery; University of Michigan Medical School; University of Michigan; Ann Arbor MI USA
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16
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Laurence JM, Sapisochin G, DeAngelis M, Seal JB, Miserachs MM, Marquez M, Zair M, Fecteau A, Jones N, Hrycko A, Avitzur Y, Ling SC, Ng V, Cattral M, Grant D, Kamath BM, Ghanekar A. Biliary complications in pediatric liver transplantation: Incidence and management over a decade. Liver Transpl 2015; 21:1082-90. [PMID: 25991054 DOI: 10.1002/lt.24180] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Revised: 04/03/2015] [Accepted: 04/28/2015] [Indexed: 02/06/2023]
Abstract
This study analyzed how features of a liver graft and the technique of biliary reconstruction interact to affect biliary complications in pediatric liver transplantation. A retrospective analysis was performed of data collected from 2001 to 2011 in a single high-volume North American pediatric transplant center. The study cohort comprised 173 pediatric recipients, 75 living donor (LD) and 98 deceased donor (DD) recipients. The median follow-up was 70 months. Twenty-nine (16.7%) patients suffered a biliary complication. The majority of leaks (9/12, 75.0%) and the majority of strictures (18/22, 81.8%) were anastomotic. There was no difference in the rate of biliary complications associated with DD (18.4%) and LD (14.7%) grafts (P = 0.55). Roux-en-Y (RY) reconstruction was associated with a significantly lower rate of biliary complications compared to duct-to-duct reconstruction (13.3% versus 28.2%, respectively; P = 0.048). RY anastomosis was the only significant factor protecting from biliary complications in our population (hazard ratio, 0.30; 95% confidence interval, 0.1-0.85). The leaks were managed primarily by relaparotomy (10/12, 83.3%), and the majority of strictures were managed by percutaneous biliary intervention (14/22, 63.6%). Patients suffering biliary complications had inferior graft survival (P = 0.04) at 1, 5, and 10 years compared to patients without biliary complications. Our analysis demonstrates a lower incidence of biliary complications with RY biliary reconstruction, and patients with biliary complications have decreased graft survival.
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Affiliation(s)
- Jerome M Laurence
- Liver Transplant Program.,Multi-Organ Transplant Program.,Division of General Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Gonzalo Sapisochin
- Liver Transplant Program.,Multi-Organ Transplant Program.,Division of General Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | | | - John B Seal
- Liver Transplant Program.,Multi-Organ Transplant Program.,Division of General Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Mar M Miserachs
- Liver Transplant Program.,Divisions of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Max Marquez
- Liver Transplant Program.,Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Murtuza Zair
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Annie Fecteau
- Liver Transplant Program.,Divisions of General Surgery
| | - Nicola Jones
- Liver Transplant Program.,Divisions of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Alexander Hrycko
- Liver Transplant Program.,Divisions of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Yaron Avitzur
- Liver Transplant Program.,Divisions of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Simon C Ling
- Liver Transplant Program.,Divisions of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Vicky Ng
- Liver Transplant Program.,Divisions of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Mark Cattral
- Liver Transplant Program.,Divisions of General Surgery.,Multi-Organ Transplant Program.,Division of General Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - David Grant
- Liver Transplant Program.,Divisions of General Surgery.,Multi-Organ Transplant Program.,Division of General Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Binita M Kamath
- Liver Transplant Program.,Divisions of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Anand Ghanekar
- Liver Transplant Program.,Divisions of General Surgery.,Multi-Organ Transplant Program.,Division of General Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada
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17
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Clinical and histological outcomes following living-related liver transplantation in children. Clin Res Hepatol Gastroenterol 2014; 38:164-71. [PMID: 24290247 DOI: 10.1016/j.clinre.2013.10.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Revised: 09/10/2013] [Accepted: 10/02/2013] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Living-related liver transplantation (LRLT) was developed to increase the donor pool of size-matched organs for children. In the UK only one centre performed LRLT between 1993 and 2008. This study reports the clinical and histological outcomes following adult-to-paediatric LRLT at our centre. METHODS Forty-six LRLTs were reviewed. Recipients had a mean age, weight and PELD score of 2.4years (range 0.5-11years), 11.0kg (3.7-32.3kg) and 11.7 (-20.3 to 49.1) respectively. The incidence of post-transplant paediatric morbidity, abnormal liver function tests and histological abnormalities was reviewed. RESULTS Patient and graft survival rates were 97.8%, 95.1% and 95.1%, and 97.8%, 92.1% and 71.7% at 1, 5 and 10years post-transplant respectively. Three children were re-transplanted at 44, 100 and 119months post-transplant. Nine children developed neuropsychological problems, 6 experienced educational difficulties, 5 developed post-transplant lymphoproliferative disorder and 5 suffered height or weight growth<2 centile. Normal LFTs were found in 41.7%, 50%, 68% and 64.7% of children at median follow-up of 6, 13, 61 and 85months respectively. Liver histology showed hepatitis, acute rejection, non-specific changes, biliary pathology, vascular pathology and chronic rejection in 32.9%, 29.5%, 13.4%, 10.1%, 6% and 2% of biopsies respectively. CONCLUSIONS The prevalence of paediatric morbidity and histological abnormalities emphasize the need for specialist and long-term follow-up following LRLT in children.
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18
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Rajanayagam J, Frank E, Shepherd RW, Lewindon PJ. Artificial neural network is highly predictive of outcome in paediatric acute liver failure. Pediatr Transplant 2013; 17:535-42. [PMID: 23802584 DOI: 10.1111/petr.12100] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/29/2013] [Indexed: 12/28/2022]
Abstract
Current prognostic models in PALF are unreliable, failing to account for complex, non-linear relationships existing between multiple prognostic factors. A computational approach using ANN should provide superior modelling to PELD-MELD scores. We assessed the prognostic accuracy of PELD-MELD scores and ANN in PALF in children presenting to the QLTS, Australia. A comprehensive registry-based data set was evaluated in 54 children (32M, 22F, median age 17 month) with PALF. PELD-MELD scores calculated at (i) meeting PALF criteria and (ii) peak. ANN was evaluated using stratified 10-fold cross-validation. Outcomes were classified as good (transplant-free survival) or poor (death or LT) and predictive accuracy compared using AUROC curves. Mean PELD-MELD scores were significantly higher in non-transplanted non-survivors (i) 37 and (ii) 46 and transplant recipients (i) 32 and (ii) 43 compared to transplant-free survivors (i) 26 and (ii) 30. Threshold PELD-MELD scores ≥27 and ≥42, at meeting PALF criteria and peak, gave AUROC 0.71 and 0.86, respectively, for poor outcome. ANN showed superior prediction for poor outcome with AUROC 0.96, sensitivity 82.6%, specificity 96%, PPV 96.2% and NPV 85.7% (cut-off 0.5). ANN is superior to PELD-MELD for predicting poor outcome in PALF.
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Affiliation(s)
- J Rajanayagam
- Department of Pediatric Gastroenterology Hepatology and Nutrition, Starship Children's Hospital, Auckland, New Zealand
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19
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Narkewicz MR, Green M, Dunn S, Millis M, McDiarmid S, Mazariegos G, Anand R, Yin W. Decreasing incidence of symptomatic Epstein-Barr virus disease and posttransplant lymphoproliferative disorder in pediatric liver transplant recipients: report of the studies of pediatric liver transplantation experience. Liver Transpl 2013; 19:730-40. [PMID: 23696264 PMCID: PMC5001558 DOI: 10.1002/lt.23659] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2012] [Accepted: 04/12/2013] [Indexed: 12/12/2022]
Abstract
UNLABELLED Posttransplant lymphoproliferative disorder (PTLD) causes significant morbidity and mortality in pediatric recipients of liver transplantation (LT). OBJECTIVE Describe the incidence of PTLD and symptomatic Epstein-Barr virus (SEBV) disease in a large multicenter cohort of children who underwent LT with a focus on the risk factors and changes in incidence over time. SEBV and PTLD were prospectively determined in 2283 subjects who had undergone LT for the first time with at least 1 year of follow-up in the Studies of Pediatric Liver Transplantation database. SEBV was defined with specific criteria, and PTLD required tissue confirmation. The incidence of SEBV and PTLD was determined with a Kaplan-Meier analysis. Univariate and multivariate modeling of risk factors was performed with standard methods. SEBV occurred in 199 patients; 174 (87.4%) were EBV-negative at LT. Seventy-five patients developed PTLD, and 64 (85.3%) of these patients were EBV-negative at LT. Among the 2048 patients with at least 2 years of follow-up, 8.3% developed SEBV by the second year after LT, and 2.8% developed PTLD. There were lower rates of SEBV (5.9% versus 11.3%, P < 0.001) and PTLD (1.7% versus 4.2%, P = 0.001) in 2002-2007 versus 1995-2001. In 2002-2007, tacrolimus and cyclosporine trough blood levels in the first year after LT were significantly lower, and fewer children were receiving steroids. Biliary atresia, and recipient EBV status were correlated. In a multivariate analysis, era of LT, recipient EBV status, and frequent rejection episodes were associated with SEBV and PTLD. The incidence of SEBV and PTLD is decreasing in pediatric LT recipients concomitantly with a reduction in immunosuppression. Younger recipients and those with multiple rejections remain at higher risk for SEBV and PTLD.
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Affiliation(s)
- Michael R Narkewicz
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA.
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20
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Rajanayagam J, Coman D, Cartwright D, Lewindon PJ. Pediatric acute liver failure: etiology, outcomes, and the role of serial pediatric end-stage liver disease scores. Pediatr Transplant 2013; 17:362-8. [PMID: 23586473 DOI: 10.1111/petr.12083] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/13/2013] [Indexed: 02/03/2023]
Abstract
To describe etiology, short-term outcomes and prognostic accuracy of serial PELD scores in PALF. Retrospective analysis of children aged ≤16 yr, admitted with PALF under the QLTS, Brisbane, Australia, between 1991 and 2011. PELD-MELD scores were ascertained at three time points (i) admission (ii), meeting PALF criteria, and (iii) peak value. Fifty-four children met criteria for PALF, median age 17 months (1 day-15.6 yr) and median weight 10.2 kg (1.9-57 kg). Etiology was known in 69%: 26% metabolic, 15% infective, 13% drug-induced, 6% autoimmune, and 9% hemophagocytic lymphohistiocytosis. Age <3 months and weight <4.7 kg predicted poor survival in non-transplanted children. Significant independent predictors of poor outcome (death or LT) were peak bilirubin > 220 μm/L and peak INR > 4. Serial PELD-MELD scores were higher in the 17 (32%) transplant recipients (mean: [i] 26.8, [ii] 31.8, [iii] 42.6); highest in the 12 (22%) non-transplanted non-survivors (mean: [i] 31.6, [ii] 37.2, [iii] 45.7) compared with the 25 (46%) transplant-free survivors (mean: [i] 25.3, [ii] 26.0, [iii] 30.3). PELD-MELD thresholds of ≥27 and ≥42 at (ii) meeting PALF criteria and (iii) peak predicted poor outcome (p < 0.001). High peak bilirubin and peak INR predict poor outcome and serial PELD-MELD is superior to single admission PELD-MELD score for predicting poor outcome.
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Affiliation(s)
- Jeremy Rajanayagam
- Department of Pediatric Gastroenterology, Royal Children's Hospital, Herston, Brisbane, QLD 4006, Australia
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21
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Young S, Kwarta E, Azzam R, Sentongo T. Nutrition assessment and support in children with end-stage liver disease. Nutr Clin Pract 2013; 28:317-29. [PMID: 23466471 DOI: 10.1177/0884533612474043] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Malnutrition is a treatable complication in children with end-stage liver disease (ESLD). Biliary atresia and other cholestatic disorders are the most frequent cause of ESLD in children. No single variable provides adequate information about nutrition status, yet effective nutrition support is the one intervention known to improve pre- and posttransplant outcomes. A proactive approach consisting of screening anthropometry interpreted using appropriate growth references, recognition of clinical manifestations associated with micronutrient deficiency, and timely aggressive nutrition support is of a paramount importance to maximize anabolism and optimize outcomes. This article presents the principles of nutrition assessment, intervention, and monitoring in children with ESLD.
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Affiliation(s)
- Sona Young
- University of Chicago, Chicago, IL 60637, USA
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22
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23
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Sehr D, Kayser O, Moritz J, Burdelski M. Farbkodierte Duplexsonographie vor und nach Lebertransplantation bei Kindern. Monatsschr Kinderheilkd 2011. [DOI: 10.1007/s00112-011-2437-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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24
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von Heesen M, Hülser M, Seibert K, Scheuer C, Dold S, Kollmar O, Wagner M, Menger MD, Schilling MK, Moussavian MR. Split-liver procedure and inflammatory response: improvement by pharmacological preconditioning. J Surg Res 2011; 168:e125-35. [PMID: 21435665 DOI: 10.1016/j.jss.2011.01.036] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2010] [Revised: 01/17/2011] [Accepted: 01/19/2011] [Indexed: 01/10/2023]
Abstract
BACKGROUND Final outcome of split-liver (SL) transplantation is impaired due to an increased rate of vascular complications and primary non-function. Herein, we hypothesized that an in situ split-liver procedure induces an inflammatory response and a deterioration of graft quality. We further studied whether graft quality can be improved by pharmacologic preconditioning. MATERIAL AND METHODS SL-procedure was performed in rats. One group (SL-HPP; n = 8) was pretreated according to a defined protocol [Homburg preconditioning protocol (HPP)], including pentoxyphylline, glycine, deferoxamine, N-acetylcysteine, erythropoietin, melatonin, and simvastatin. A second SL group (SL-Con; n = 8) received NaCl. Untreated non-SL served as controls (Sham; n = 8). Cytokines release, leukocyte invasion, endothelial activation and liver morphology were studied directly after liver harvest and after 8 h cold storage. Lung tissue was studied to determine remote injury. RESULTS The SL-procedure induced an increase of TNF-α concentration, intercellular-adhesion-molecule 1 (ICAM-1) expression, leukocytic-tissue infiltration and vacuolization. This was associated with an increased number of apoptotic hepatocytes. HPP reduced TNF-α release, ICAM-1 expression, the number of infiltrated leukocytes, as well as hepatocellular vacuolization and apoptosis. In lung tissue, the SL-procedure caused an increased IL-1 and IL-6 concentration and leukocyte infiltration. CONCLUSIONS HPP was capable of abrogating cytokine-mediated leukocytic response. Pharmacologic preconditioning of liver donors prevents the SL procedure-mediated inflammatory response, resulting in an improved graft quality.
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Affiliation(s)
- Maximilian von Heesen
- Department of General, Vascular and Pediatric Surgery, University of Saarland, Homburg/Saar, Germany
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25
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Sorensen L, Neighbors K, Martz K, Zelko F, Bucuvalas J, Alonso E. Cognitive and academic outcomes after pediatric liver transplantation: Functional Outcomes Group (FOG) results. Am J Transplant 2011; 11:303-11. [PMID: 21272236 PMCID: PMC3075835 DOI: 10.1111/j.1600-6143.2010.03363.x] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
This multicenter study examined prevalence of cognitive and academic delays in children following liver transplant (LT). One hundred and forty-four patients ages 5-7 and 2 years post-LT were recruited through the SPLIT consortium and administered the Wechsler Preschool and Primary Scale of Intelligence, 3rd Edition (WPPSI-III), the Bracken Basic Concept Scale, Revised (BBCS-R), and the Wide Range Achievement Test, 4th edition (WRAT-4). Parents and teachers completed the Behavior Rating Inventory of Executive Function (BRIEF). Participants performed significantly below test norms on intelligence quotient (IQ) and achievement measures (Mean WPPSI-III Full Scale IQ = 94.7 ± 13.5; WRAT-4 Reading = 92.7 ± 17.2; WRAT-4 Math = 93.1 ± 15.4; p < 0001). Twenty-six percent of patients (14% expected) had 'mild to moderate' IQ delays (Full Scale IQ = 71-85) and 4% (2% expected) had 'serious' delays (Full Scale IQ ≤ 70; p < 0.0001). Reading and/or math scores were weaker than IQ in 25%, suggesting learning disability, compared to 7% expected by CDC statistics (p < 0.0001). Executive deficits were noted on the BRIEF, especially by teacher report (Global Executive Composite = 58; p < 0.001). Results suggest a higher prevalence of cognitive and academic delays and learning problems in pediatric LT recipients compared to the normal population.
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Affiliation(s)
- L.G. Sorensen
- Child & Adolescent Psychiatry, Children's Memorial Hospital, Chicago, IL
| | - K. Neighbors
- Pediatrics, Children's Memorial Hospital, Chicago, IL
| | - K. Martz
- The EMMES Corporation, Rockville, MD
| | - F. Zelko
- Child & Adolescent Psychiatry, Children's Memorial Hospital, Chicago, IL
| | - J.C. Bucuvalas
- Pediatric Liver Care Center, Cincinnati Children’s Hospital, Cincinnati, OH
| | - E.M. Alonso
- Pediatrics, Children's Memorial Hospital, Chicago, IL
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26
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Small Bowel Obstruction after Pediatric Liver Transplantation: The Unusual Is the Usual. J Am Coll Surg 2011; 212:62-7. [DOI: 10.1016/j.jamcollsurg.2010.09.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2010] [Revised: 09/20/2010] [Accepted: 09/21/2010] [Indexed: 11/19/2022]
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27
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Arnon R, Kerkar N, Davis MK, Anand R, Yin W, González-Peralta RP. Liver transplantation in children with metabolic diseases: the studies of pediatric liver transplantation experience. Pediatr Transplant 2010; 14:796-805. [PMID: 20557477 DOI: 10.1111/j.1399-3046.2010.01339.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Metabolic diseases are the second largest indication for LT in children after BA. There are limited data on the long-term post-transplant outcome in this unique group of patients. Therefore, our aim was to assess post-liver transplant outcomes and to evaluate risk factors for mortality and graft loss in children with metabolic disorders in comparison to those with non-metabolic diagnoses. We reviewed all patients enrolled in the SPLIT registry. Between 1995 and 2008, 446 of 2997 (14.9%) children enrolled in SPLIT underwent liver transplant for metabolic diseases. One-yr and five-yr patient survival for children with metabolic diseases was 94.6% and 88.9% and for those with other diseases 90.7% and 86.1% (log-rank p = 0.05), respectively. One-yr and five-yr graft survival for children with metabolic disorders was 90.8% and 83.8%, and for those with other diseases 85.4% and 78.0% (log-rank p = 0.005), respectively. Children with metabolic diseases were less likely to experience gastrointestinal complications (5.6% vs. 10.7%, p = 0.001), portal vein thrombosis (2.9% vs. 5.2%, p = 0.04), and reoperations within 30 days post-transplant (33.4% vs. 37.8%, p = 0.05) than those with other indications. In conclusion, children who underwent liver transplant for metabolic disease had similarly excellent patient survival as, and better graft survival than, those who received a liver allograft for other indications.
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Affiliation(s)
- Ronen Arnon
- Department of Pediatrics, Mount Sinai Medical Center, Mount Sinai School of Medicine, New York, NY 10029, USA
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Evaluation of a post-operative thrombin inhibitor replacement protocol to reduce haemorrhagic and thrombotic complications after paediatric liver transplantation. Thromb Res 2010; 126:191-4. [PMID: 20541794 DOI: 10.1016/j.thromres.2010.05.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2009] [Revised: 05/14/2010] [Accepted: 05/14/2010] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Bleeding and thrombotic complications contribute to morbidity and mortality following paediatric orthotopic liver transplantation (OLT). However, the pathophysiology of haemostasis during paediatric OLT is not well understood. This report consists of two complimentary studies examining the frequency of haemostatic complications before and after the introduction of a post-operative thrombin inhibitor replacement therapy protocol at a single institution. MATERIALS AND METHODS A retrospective study of 40 patients who underwent 43 liver transplants between July 1992 and July 2002, identified bleeding to be the most frequent complication associated with OLT (30%), however thrombotic complications were also common (12.5%). In 2003, following a detailed analysis of haemostatic profiles of children undergoing OLT, a thrombin inhibitor replacement protocol was introduced. A prospective clinical outcome audit was undertaken from April 2003 to September 2008 to determine the effect of the new protocol on haemostasis. RESULTS Commencement of the thrombin inhibitor replacement protocol significantly reduced the incidence of thrombosis (from 5 to 1, p<0.05), graft loss (from 4 to none, p<0.05), mortality due to thrombosis or bleeding (from 3 to none, p<0.05) and was associated with a 50% reduction in frequency of major bleeding. CONCLUSION In conclusion, the introduction of a post-operative thrombin inhibitor replacement therapy protocol following paediatric OLT significantly improved haemostasis-related morbidity and mortality outcomes in children.
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Turmelle YP, Nadler ML, Anderson CD, Doyle MB, Lowell JA, Shepherd RW. Towards minimizing immunosuppression in pediatric liver transplant recipients. Pediatr Transplant 2009; 13:553-9. [PMID: 19067920 DOI: 10.1111/j.1399-3046.2008.01061.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Immunosuppression regimens after liver transplantation focus mainly on preventing rejection and subsequent graft loss. However, in children, morbidity and mortality rates from infections exceed those from rejection after transplant, and immunosuppression can hinder growth, renal function, and graft tolerance. We hypothesized that early steroid withdrawal, with a primary aim of TAC monotherapy would yield no penalty in terms of rejection and graft loss, while reducing risks of infection and maximizing growth. We prospectively evaluated 64 consecutive pediatric liver transplant recipients. One yr patient/graft survival was 93/90%, respectively. At one yr post-transplant, 75.4% of patients were on TAC monotherapy. No deaths or graft losses were caused by infection. Sixty-one percent of patients had at least one episode of rejection, most within three months following transplant and 3.8% were treated for chronic rejection. One non-compliant adolescent died from chronic rejection. CMV, EBV, and lymphoproliferative disease rates were 3.1%, 5.3%, 1.8%, respectively. Pretransplant and one yr post-transplant glomerular filtration rates were unchanged. One yr improved catch-up growth was observed. We conclude that immunosuppression minimization after pediatric liver transplant yields no serious complications from rejection, and might confer advantages with respect to infection, renal function, growth, and is deserving of wider application and study.
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Affiliation(s)
- Yumirle P Turmelle
- Department of Pediatric Gastroenterology and Nutrition, Washington University School of Medicine, St Louis, MO, USA.
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Ng VL, Fecteau A, Shepherd R, Magee J, Bucuvalas J, Alonso E, McDiarmid S, Cohen G, Anand R. Outcomes of 5-year survivors of pediatric liver transplantation: report on 461 children from a north american multicenter registry. Pediatrics 2008; 122:e1128-35. [PMID: 19047213 DOI: 10.1542/peds.2008-1363] [Citation(s) in RCA: 185] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Although liver transplantation has been the standard of care therapy for life-threatening liver diseases for >20 years, data on the long-term impact of liver transplantation in children have been primarily limited to single-center experiences. The objective of this study was to characterize and evaluate the clinical course of children who have survived >or=5 years after pediatric liver transplantation in multiple centers across North America. PATIENTS AND METHODS Patients enrolled in the Studies of Pediatric Liver Transplantation database registry who had undergone liver transplantation at 1 of 45 pediatric centers between 1996 and 2001 and survived >5 years from liver transplantation were identified and their clinical courses retrospectively reviewed. RESULTS The first graft survival for 461 five-year survivors was 88%, with 55 (12%) and 10 (2%) children undergoing a second and third liver transplantation. At the 5-year anniversary clinic visit, liver function was preserved in the majority with daily use of immunosuppression therapy, including a calcineurin inhibitor and oral prednisone, reported by 97% and 25% of children, respectively. The probability of an episode of acute cellular rejection occurring within 5 years after liver transplantation was 60%. Chronic rejection occurred in 5% patients. Posttransplant lymphoproliferative disease was diagnosed in 6% children. Calculated glomerular filtration rate was <90 mL/minute per 1.73 m2 in 13% of 5-year survivors. Age- and gender-adjusted BMI>95th percentile was noted in 12%, with height below the 10th percentile in 29%. CONCLUSIONS Children who are 5-year survivors of liver transplantation have good graft function, but chronic medical conditions and posttransplantation complications affect extrahepatic organs. A comprehensive approach to the management of these patients' multiple unique needs requires the expertise and commitment of health care providers both beyond and within transplant centers to further optimize long-term outcomes for pediatric liver transplant recipients.
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Affiliation(s)
- Vicky Lee Ng
- SickKids Transplant Center, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Hospital for Sick Children, University of Toronto, 555 University Ave, Toronto, Ontario, M5G 1X8, Canada.
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Affiliation(s)
- Estella M Alonso
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Children's Memorial, Hospital, Chicago, IL 60614, USA.
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Leonis MA, Balistreri WF. Evaluation and management of end-stage liver disease in children. Gastroenterology 2008; 134:1741-51. [PMID: 18471551 DOI: 10.1053/j.gastro.2008.02.029] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2007] [Revised: 02/05/2008] [Accepted: 02/11/2008] [Indexed: 12/11/2022]
Abstract
End-stage liver disease in children presents a challenging array of medical and psychosocial problems for the health care delivery team. Many of these problems are similar to those encountered by caregivers of adults with end-stage liver disease, such as the development of complications of cirrhosis, including ascites, spontaneous bacterial peritonitis, and esophageal variceal hemorrhage. However, the natural history of disease progression in children and their responses to medical therapy can differ significantly from that of their adult counterparts. Children with end-stage liver disease are especially vulnerable to nutritional compromise; if not effectively managed, this can seriously impact long-term outcomes and survival both before and after liver transplantation. Moreover, close attention must be given to vaccination status and the clinical setting at which health care is delivered to optimize outcomes and the delivery of high-quality pediatric health care. In this review, we address important components of the evaluation and management of children with chronic end-stage liver disease.
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Affiliation(s)
- Mike A Leonis
- Pediatric Liver Care Center, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio 45229, USA
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Alonso EM, Neighbors K, Barton FB, McDiarmid SV, Dunn SP, Mazariegos GV, Landgraf JM, Bucuvalas JC. Health-related quality of life and family function following pediatric liver transplantation. Liver Transpl 2008; 14:460-8. [PMID: 18383090 DOI: 10.1002/lt.21352] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This multicenter study compared health-related quality of life (HRQOL) and family function of pediatric liver transplant recipients to those of healthy children to determine if this population differed from a healthy population and to distinguish which pretransplant and posttransplant factors impact HRQOL and family function. HRQOL data from 102 patients achieving 2-year survival were collected with the Infant Toddler Quality of Life Instrument or the Child Health Questionnaire Parent Form 50 parent surveys. Family functioning was assessed with the Family Assessment Device (FAD) completed by each participant's family members. Demographic and clinical information were retrieved from the Studies of Pediatric Liver Transplant database. Recipients 5 years of age and older scored lower than a normative sample in physical health (P < 0.001), general health (P < 0.001), parental emotional impact (P < 0.001), and disruption of family activities (P < 0.001). Younger children, 2 to 5 years of age, scored lower than controls in global health (P = 0.004) and general health perceptions (P < 0.001) but did not differ in subscales measuring physical and psychosocial outcomes. Univariate analysis among the subscales identified demographic but not clinical variables as significant predictors of HRQOL. Mean scores of FAD scales were below published thresholds indicating healthy family functioning. As reported in previous studies, parents of older recipients reported higher levels of stress, although their level of family function appears normal. Significant associations were also observed between FAD scores and demographic variables, suggesting that further investigation of the impact of race, parental marital status, and socio-economic status on the patient rehabilitation process is needed.
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Freeman RB. Model for end-stage liver disease (MELD) for liver allocation: a 5-year score card. Hepatology 2008; 47:1052-7. [PMID: 18161047 DOI: 10.1002/hep.22135] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Richard B Freeman
- Division of Transplantation, Tufts-New England Medical Center, Boston, MA, USA.
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Affiliation(s)
- Benjamin L Shneider
- Department of Pediatrics, Thomas E. Starzl Transplantation Institute, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA.
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Guariso G, Visonà Dalla Pozza L, Manea S, Salmaso L, Lodde V, Facchin P. Italian experience of pediatric liver transplantation. Pediatr Transplant 2007; 11:755-63. [PMID: 17910653 DOI: 10.1111/j.1399-3046.2007.00739.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The SIGENP Group has created an Italian Liver Transplantation database. The study considers all patients under 18 yr of age on the waiting list or transplanted between 1984 and 2005. Demographic and clinical data were collected and a descriptive analysis was conducted. Kaplan-Meier survival curves were calculated and Cox's proportional-hazards regression analysis were performed to identify predictors of death after transplantation. Twenty-two Italian centers took part and data were collected on 622 cases: only 53.8% of the transplants performed up until 1998 were carried out in Italy, while this was true of 97.7% of the operations performed between 1999 and 2005. Recipient survival curve analysis revealed one-, two- and five-yr survival rates of 88, 87 and 84%, respectively, and a significant improvement in survival after 1998 (p = 0.0322). Cox's analysis identified the following risk factors for death after liver transplantation, i.e. transplantation before 1998, neoplasms or fulminant hepatic failure as indications, being in intensive care at the time of transplantation and retransplantation. The center where the transplant is performed also revealed an influence on patient survival. Thanks to a better patient follow-up and more cooperation between specialists, the mean survival after liver transplantation is improving and Italian children can be transplanted in Italy.
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Affiliation(s)
- Graziella Guariso
- Gastroenterology, Department of Pediatrics, University of Padua, Padua, Italy.
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Brolese A, Vitale A, Zanus G, Boccagni P, Neri D, Gringeri E, D'Amico F, Valmasoni M, Ciarleglio FA, Carraro A, Zancan L, Guariso G, D'Antiga L, D'Amico DF, Cillo U. Pediatric Liver Transplantation: The University of Padua Experience. Transplant Proc 2007; 39:1939-41. [PMID: 17692659 DOI: 10.1016/j.transproceed.2007.05.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The objective of this study was to analyze experience on pediatric liver transplantation (LT) between June 1993 and September 2006, including split liver transplantation (SLT), living donor liver transplantation (LDLT), and auxiliary partial orthotopic liver transplantation (APOLT). Furthermore, hepatocyte transplantation (HT) had a role in one patient with metabolic disease. METHODS From November 1990 to September 2006, 657 LTs were performed including 63 pediatric LTs (9.6%) in 57 patients (32 boys and 25 girls). Six were retransplantations (9.5%). Thirty-two patients (57%) were younger than 5 years. The types of graft included the following: 26 whole organs (41%), 32 in situ split organs (51%), 4 reduced-size organs (6%), and 1 graft from a living donor (2%). Two patients received an APOLT, 4 patients received a combined kidney-liver transplantation (CKLT), and 1 patient received HT. Of the 63 pediatric LTs, 16 were behaved to be highly urgent (25%). RESULTS Overall 1-, 3-, 5-, and 10-year patient survival rates were 82%, 82%, 78%, and 78%, respectively. Overall 1-, 3-, 5-, and 10-year graft survival rates were 76%, 76%, 72%, and 72%, respectively. In patients younger than 1 year, the 5-year survival rate was 100%. Perioperative mortality was 8.8%. Vascular complications occurred in 4 patients (6.3%). Six children required retransplantation due to primary nonfunction (PNF) in 4 cases (7%) and vascular thrombosis in 2 cases (3.5%). CONCLUSIONS Cholestatic liver disease and age younger than 1 year were the best prognostic factors for excellent survival.
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Affiliation(s)
- A Brolese
- Hepato-Biliary and Liver Transplantation Unit, University of Padua, Padua, Italy.
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Abstract
Organ transplantation is a procedure that can save and prolong the life of individuals with end-stage heart, lung, liver, kidney, pancreas and small bowel diseases. The goal of transplantation is not only to ensure their survival, but also to offer patients the sort of health they enjoyed before the disease, achieving a good balance between the functional efficacy of the graft and the patient's psychological and physical integrity. Quality of life (QoL) assessments are used to evaluate the physical, psychological and social domains of health, seen as distinct areas that are influenced by a person's experiences, beliefs, expectations and perceptions, and QoL is emerging as a new medical indicator in transplantation medicine too. This review considers changes in overall QoL after organ transplantation, paying special attention to living donor transplantation, pediatric transplantation and particular aspects of QoL after surgery, e.g. sexual function, pregnancy, schooling, sport and work.
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Affiliation(s)
- Patrizia Burra
- Gastroenterology Section, Department of Surgical and Gastroenterological Sciences, Padua University, Padua, Italy.
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McDiarmid SV, Merion RM, Dykstra DM, Harper AM. Use of a pediatric end-stage liver disease score for deceased donor allocation: the United States experience. Indian J Pediatr 2007; 74:387-92. [PMID: 17476086 DOI: 10.1007/s12098-007-0066-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The Pediatric end-stage liver disease (PELD) score was developed as a measure of the severity of chronic liver disease that would predict mortality or children awaiting liver transplant. From multivariate analyses a model was derived that included five objective factors which together comprise the PELD score. The factors are growth failure, age less than 1 year, international normalized ratio (INR), serum albumin and total bilirubin.
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Affiliation(s)
- Sue V McDiarmid
- Department of Pediatrics and Surgery, David Geffen School of Medicine at University of California, Los Angeles, CA 90095, USA.
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40
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Grabhorn E, Richter A, Burdelski M, Rogiers X, Ganschow R. Neonatal hemochromatosis: long-term experience with favorable outcome. Pediatrics 2006; 118:2060-5. [PMID: 17079579 DOI: 10.1542/peds.2006-0908] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Neonatal hemochromatosis is a severe, often fatal multiorgan disorder of iron metabolism. Liver transplantation can be curative; the benefit of antioxidant treatment is discussed controversially. We summarize our experience with neonatal hemochromatosis over the past 13 years. METHODS A retrospective study was performed of 16 patients with acute liver failure attributable to neonatal hemochromatosis between 1992 and 2004. RESULTS Median age at the onset of neonatal hemochromatosis was 2 days (range: 0-21 days). Median weight at the time of diagnosis was 2900 g (range: 1520-4200 g). All patients had elevated ferritin levels (median: 4179 microg/L), and transferrin saturation (median: 99%). Fourteen patients (87.5%) showed significant hepatocyte siderosis in biopsies; 4 children had additional iron deposition in extrahepatic tissue. Four patients were diagnosed by MRI. Seven infants received liver transplants, 5 of them in combination with a preceding antioxidant treatment. Four children (25%) received antioxidants without the necessity of liver transplantation and were in good clinical condition at the time of this evaluation. Five patients (31.3%) died, 3 of them without any treatment because of initial fulminant multiorgan failure. In September 2005, 68.7% of the patients were still alive after a median follow-up of 5 years. CONCLUSIONS Neonatal hemochromatosis is a severe metabolic disease, but early antioxidant treatment and liver transplantation in addition to optimal medical care can improve the outcome dramatically. Children with moderate liver failure can survive without liver transplantation, but should be monitored closely for deterioration.
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Affiliation(s)
- Enke Grabhorn
- Department of Pediatrics, Pediatric Gastroenterology and Hepatology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany.
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Abstract
Growth is an important feature of childhood, but it is usually impaired before and after organ transplantation. Modest catch-up growth often occurs after renal transplantation. Nevertheless, patients remain short due to the effects of steroids used for immunosuppression. Children with chronic liver failure are also growth impaired, although not to the same extent. They also frequently have poor catch up growth after transplantation, again due to steroids. There are several randomized controlled clinical trials reporting growth hormone (GH) use after renal transplantation. These consistently show a beneficial effect of GH on linear growth. Patients with histories of frequent acute rejections before GH may have increased risk of acute rejection during treatment. Few data exist on liver transplant patients, although GH also appears effective. GH use may be safe and effective for renal transplant recipients who have been stable without acute rejection episodes. There needs to be long-term study of GH use in liver and renal transplant patients. It is critical to focus efforts on improving growth in renal failure before transplantation through GH use and to improve posttransplant growth in all recipients by minimizing steroid exposure.
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Affiliation(s)
- John S Fuqua
- Section of Pediatric Endocrinology and Diabetology, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, Indiana 46202, USA.
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Liu CL, Fan ST, Lo CM, Wei WI, Chan SC, Yong BH, Wong J. Operative outcomes of adult-to-adult right lobe live donor liver transplantation: a comparative study with cadaveric whole-graft liver transplantation in a single center. Ann Surg 2006; 243:404-10. [PMID: 16495707 PMCID: PMC1448929 DOI: 10.1097/01.sla.0000201544.36473.a2] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To evaluate and compare the operative and survival outcomes of patients who underwent right lobe live donor liver transplantation (RLDLT) and cadaveric whole-graft liver transplant (CWLT) recipients in a single institution. SUMMARY BACKGROUND DATA Current data suggest that RLDLT has an inferior graft survival outcome when compared with CWLT. PATIENTS AND METHODS A prospective study was performed on 180 consecutive adult patients who underwent primary liver transplantation from January 2000 to February 2004. The operative and survival outcomes of RLDLT (n = 124) were compared with those of CWLT (n = 56). RESULTS Fifty-five (44%) and 16 (29%) patients were on high-urgency list in the RLDLT group and the CWLT group, respectively (P = 0.045). The preoperative Model for End-Stage Liver Disease scores were comparable in both groups. The waiting time for liver transplantation was significantly shorter in the RLDLT group. The graft weight to estimated standard liver weight ratio was significantly lower in the RLDLT group. The postoperative hospital stay and hospital mortality were comparable in the RLDLT group (1.6%) and the CWLT group (5.4%). Thirty-one (25%) patients in the RLDLT group and 3 (5%) patients in the CWLT group developed biliary stricture on follow-up (P = 0.002). At a median follow-up of 27 months, the actuarial graft and patient survival rates were 88% and 90%, respectively, in the RLDLT group, and both were 84% in the CWLT group. CONCLUSION RLDLT results in favorable operative outcomes comparable with those of CWLT. However, there is a significantly higher incidence of biliary stricture associated with RLDLT.
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Affiliation(s)
- Chi Leung Liu
- Centre for the Study of Liver, University of Hong Kong, Pokfulam, Hong Kong, China
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Jhaveri R, Grant W, Kauf TL, McHutchison J. The burden of hepatitis C virus infection in children: estimated direct medical costs over a 10-year period. J Pediatr 2006; 148:353-8. [PMID: 16615966 DOI: 10.1016/j.jpeds.2005.10.031] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2005] [Revised: 09/02/2005] [Accepted: 10/11/2005] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To quantify the burden of pediatric hepatitis C virus (HCV) disease over the coming decade. STUDY DESIGN Using national Census results and published and unpublished data, we constructed estimates of HCV prevalence, incidence, rate of vertical transmission, sustained viral response (SVR), and severe complications of infection. Using these figures, we generated a projection model for pediatric HCV outcomes, and we then performed a sensitivity analysis by altering the rates of fibrosis development and SVR. RESULTS A prevalence of 23,048 to 42,296 pediatric patients with chronic HCV combined with 7200 new cases from vertical transmission was used for further calculations. Over the next decade, estimated screening costs were 26 million US dollars, monitoring costs ranged from 117 million US dollars to 206 million US dollars, and treatment costs ranged from 56 million US dollars to 104 million US dollars. CONCLUSIONS To date, pediatric HCV has received relatively little attention, but it will have a significant economic impact over the next 10 years if changes in practice are not made.
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Affiliation(s)
- Ravi Jhaveri
- Division of Infectious Diseases, Department of Pediatrics, Duke University Medical Center, Durham, NC 27705, USA.
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Ganschow R, Grabhorn E, Schulz A, Von Hugo A, Rogiers X, Burdelski M. Long-term results of basiliximab induction immunosuppression in pediatric liver transplant recipients. Pediatr Transplant 2005; 9:741-5. [PMID: 16269045 DOI: 10.1111/j.1399-3046.2005.00371.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
It has been shown that an induction therapy with the monoclonal anti-interleukin-2 receptor antibody basiliximab (Simulect) is capable to reduce the incidence of acute graft rejection in adult and pediatric liver transplantation (Ltx). However, data on long-term results using basiliximab in children post-Ltx are still pending. Therefore, the objective of our study was to report on the long-term results of basiliximab induction therapy in pediatric liver transplant recipients. A total of 54 children received two single doses of basiliximab in addition to cyclosporine and prednisolone following Ltx. We analyzed the incidence of acute and chronic graft rejection that of post-transplant lymphoproliferative disease (PTLD), and patient and graft survival. The follow-up was 22-46 months. The historical control group (matched controls) consisted of 54 patients treated with a cyclosporine and prednisolone dual therapy. Patient survival was 53 of 54 in the treatment group and 51 of 54 in the controls. One patient was retransplanted in the treatment group vs. three patients in the control group. The incidence of acute graft rejection was 16.6% compared with 53.7% in the control group (p < 0.001), that of chronic rejection was comparable in both groups (one of 54 vs. one of 54). The incidence of steroid resistant rejection was four of 54 vs. six of 54 that of PTLD were one of 54 vs. zero of 54. There were no adverse effects observed, which could be related to the antibody treatment. We conclude that basiliximab provides safe and effective induction immunosuppression in pediatric liver graft recipients. Short- and even long-term results are excellent.
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Oswari H, Lynch SV, Fawcett J, Strong RW, Ee LC. Outcomes of split versus reduced-size grafts in pediatric liver transplantation. J Gastroenterol Hepatol 2005; 20:1850-4. [PMID: 16336443 DOI: 10.1111/j.1440-1746.2005.03926.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
BACKGROUND Split-liver transplantation, where two grafts are created from a single donor organ, is a means of overcoming donor organ scarcity. There are few data comparing outcomes of split with reduced-size liver grafts, which is the most common type of cadaveric graft in pediatric liver transplantation. The aims of the present paper were to compare survival and complication rates between split and reduced-size cadaveric grafts in pediatric patients receiving a liver transplant in Brisbane. METHODS Review of the Queensland Liver Transplant Service database was undertaken. All pediatric patients who received either a cadaveric split or reduced-size graft between 1985 and 2000 were examined. The incidence of patient and graft survival, vascular complications and biliary complications were identified. RESULTS A total of 251 liver transplants were performed of which 138 were reduced-size grafts and 30 were split grafts. There were no differences in etiology of liver disease, mean age, weight, and urgency of transplant between the two groups. One-year patient and graft survivals were comparable at 73% and 67%, respectively, in both groups. There was no difference in the incidence of vascular complications between groups. Biliary complications were significantly more common after split grafts when compared with reduced-size grafts (21%vs 4%, P < 0.0001) but did not affect patient or graft survival. CONCLUSIONS Survival and vascular complications after split-liver grafts were comparable to outcomes after reduced-size grafts. Biliary complications occur more commonly with split-liver grafts but did not affect patient or graft survival. It is recommended that every pediatric recipient be considered for a split-liver graft.
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Affiliation(s)
- Hanifah Oswari
- Queensland Liver Transplant Service, Royal Children's Hospital, Brisbane, Queensland, Australia
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Barshes NR, Lee TC, Balkrishnan R, Karpen SJ, Carter BA, Goss JA. Orthotopic liver transplantation for biliary atresia: the U.S. experience. Liver Transpl 2005; 11:1193-200. [PMID: 16184564 DOI: 10.1002/lt.20509] [Citation(s) in RCA: 92] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Biliary atresia is the most common indication for orthotopic liver transplantation (OLT) in the pediatric population. The outcomes of liver transplantation for biliary atresia, however, have not been formally examined on a national scale. The objective of this study was to identify pretransplant variables that predict patient survival after primary liver transplantation for biliary atresia. A cohort of 1,976 pediatric patients undergoing primary liver transplantation for biliary atresia between 1/1988 to 12/2003 was enrolled from the United Network for Organ Sharing database after excluding patients with a history of multiorgan transplant or previous liver transplant. Follow-up data up to 16 years post-OLT was available. The 5- and 10-year actuarial survival rates of patients that underwent liver transplantation for biliary atresia in the United States are 87.2% and 85.8%, respectively, and the 5- and 10-year graft actuarial survival rates are 76.2% and 72.7%, respectively. Early deaths (< or =90 days post-OLT) were more often caused by graft failure (P = 0.01), whereas late deaths (>90 days post-OLT) were more often due to malignancy (P < 0.01). An analysis of outcomes over time demonstrated a decrease in post-OLT survival and an increase in the number of OLTs done for biliary atresia at an increasing number of centers. A multivariate analysis revealed that cadaveric partial/reduced liver grafts, a history of life support at the time of OLT, and decreased age were independent predictors of increased post-OLT mortality. In conclusion, OLT is an effective treatment for biliary atresia. Certain pretransplant variables may help predict patient survival following liver transplantation for biliary atresia.
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Affiliation(s)
- Neal R Barshes
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA
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Jara P, Hierro L. [Pediatric liver transplantation]. GASTROENTEROLOGIA Y HEPATOLOGIA 2005; 28:493-508. [PMID: 16185585 DOI: 10.1157/13079008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
There are no differences in results between pediatric liver transplantation and liver transplantation in adults. The reverts of the liver disease prior to transplantation (particularly the need of intensive care is the best predictor of perspective mortality. Therefore, liver transplantation in children should be indicated prior a severe decompensation of the disease.
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Affiliation(s)
- P Jara
- Servicio de Hepatología y Trasplantes, Hospital Infantil Universitario La Paz, Madrid, Spain.
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Abstract
Complications involving the biliary tract after orthotopic liver transplantation (OLT) have been a common problem since the early beginning of this technique. Biliary complications have been reported to occur at a relatively constant rate of approximately 10-15% of all deceased donor full size OLTs. There is a wide range of potential biliary complications which can occur after OLT. Their incidence varies according to the type of graft, type of donor, and the type of biliary anastomosis performed. The spectrum of biliary complications has changed over the past decade because of the establishment of split liver, reduced-size, and living donor liver transplantation. Apart from technical developments, novel diagnostic methods have been introduced and evaluated in OLT, the most prominent being magnetic resonance imaging (MRI). Treatment modalities have also changed over the past years towards a primarily nonoperative, endoscopy-based strategy, leaving the surgical intervention for lesions which otherwise are not curable. The management of biliary complications after OLT requires a multidisciplinary approach. Conservative, interventional, and endoscopic treatment options have to be weighed up against surgical re-intervention. In the following the spectrum of specific bile duct complications after OLT and their treatment options will be reviewed.
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Affiliation(s)
- Andreas Pascher
- Department of General, Visceral, and Transplantation Surgery, Universitätsmedizin Berlin, Berlin, Germany.
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Utterson EC, Shepherd RW, Sokol RJ, Bucuvalas J, Magee JC, McDiarmid SV, Anand R. Biliary atresia: clinical profiles, risk factors, and outcomes of 755 patients listed for liver transplantation. J Pediatr 2005; 147:180-5. [PMID: 16126046 DOI: 10.1016/j.jpeds.2005.04.073] [Citation(s) in RCA: 161] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2004] [Revised: 02/09/2005] [Accepted: 04/19/2005] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To test the hypothesis that risk analysis from the time of listing for liver transplantation (LT) focuses attention on areas where outcomes can be improved. STUDY DESIGN Competing outcomes and multivariate models were used to determine significant risk factors for pretransplantation and posttransplantation mortality and graft failure in patients with biliary atresia (BA) listed for LT and enrolled in the Studies of Pediatric Liver Transplantation (SPLIT) registry. RESULTS Of 755 patients, most were infants (age < 1 year). Significant waiting list mortality risk factors included infancy and pediatric end-stage liver disease (PELD) score > or = 20, whose components were also continuous risk factors. Survival posttransplantation (n=567) was 88% at 3 years. Most deaths were from infection (37%). Posttransplantation mortality risk factors included infant recipients, height/weight < -2 standard deviations (SD), use of cyclosporine versus tacrolimus and retransplantation. Graft failure risks included height/weight < -2 SD, cadaveric partial donors, donor age < or = 5 months, use of cyclosporine versus tacrolimus, and rejection. CONCLUSIONS Referral for LT should be anticipatory for infants with BA with failed portoenterostomies. Failing nutrition should prompt aggressive support. Post-LT risk factors are mainly nonsurgical, including nutrition, the relative risk of infection over rejection, and the choice of immunosuppression.
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Affiliation(s)
- Elizabeth C Utterson
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri 63110, USA
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