Medical management of children after liver transplantation

Burnout, mental health symptoms, and empathy in healthcare workers who care for children treated in a liver transplant center

OBJECTIVE

The healthcare workers in pediatric liver transplantation units are exposed to various stresses; however, their burnout has not been clarified yet. This study aimed to determine burnout, psychological symptoms and empathy levels in healthcare workers, to examine the relationship between these variables and to investigate the predictors of burnout.

METHOD

This cross-sectional study was conducted on healthcare workers in Turgut Özal Medical Center Pediatric Liver Transplant Institute. The participants filled out a questionnaire that investigating demographic and occupational characteristics, and including questions from Toronto Empathy Questionnaire, Maslach Burnout Inventory, and Brief Symptom Inventory.

RESULTS

Fifty healthcare workers participated in the study. Based on moderate and higher severity scores, 48% of the participants were emotionally exhausted, 22% of them were depersonalized. All of them had a high perception of personal accomplishment. There was a correlation between psychological symptoms level and emotional exhaustion and personal accomplishment as well as empathy and personal accomplishment. Not choosing the profession and the department willingly, age, education level, marital status, duration of profession, unit, not receiving in-service training, empathy, depressive symptoms and hostility scores predicted different aspects of burnout.

CONCLUSION

Considering that burnout and psychological stress lead to reduced professional abilities and the development of serious complications, the results obtained can guide managers on the measures to be taken.

Short- and long-term results of liver transplantation according to age at transplant: a single-center experience of 351 children

Pediatric liver transplantation (PLT) has very good results at experienced transplant centers. However, there is still an ongoing discussion about inferior outcomes, especially in young infants. The aim of this retrospective study was to evaluate outcomes of infants compared to older recipients in a single center over 20 years. We conducted a retrospective study of children who received liver transplants at our center between 1991 and 2011. Only patients without other limiting organ involvement were included and compared according to age. The inclusion criteria were fulfilled by 351 patients (173 vs. 178). The most common indication in both groups was biliary atresia (82.1% vs. 49.4%). The 1-, 5-, and 10-year patient survivals were 93.8%/91.8%/91.1% and 93%/90.8%/90.1%, and the graft survivals were 90.4%/83.5%/79.6% and 89.4%/81.8%/77.5%, respectively. Complications such as postoperative bleeding, biliary complications, or perfusion impairment occurred more often in infants. Leading indications for retransplantation (vascular complications/primary nonfunction) and leading causes of death (sepsis/multiorgan failure) were the same in both groups. Significant predictors for patient loss were decade of transplantation, retransplantation, postoperative bleeding, and infections for infants. Predictors for graft loss were bowel perforation, arterial thrombosis, and age >12 months. Children can have excellent results, independent of age at PLT.

Immune cell function assays in the diagnosis of infection in pediatric liver transplantation: an open-labeled, two center prospective cohort study

BACKGROUND

Limited studies have been performed in assessment of immune status of pediatric liver transplants (PLTs). We conducted this study to evaluate Cylex immune cell function assay in diagnosis of infection and its potential clinical application in Chinese infant PLTs.

METHODS

In this prospective cohort study, 227 infant PLTs from two medical centers were enrolled, and 216 completed the study. Cylex ATP values were measured before and after liver transplantation (LT) at week 1, 2, 3, 4, 8, 12 and 24 respectively. Accordingly, patients' clinical records, including demographic data, liver function results, tacrolimus dosages and concentrations were collected and analyzed.

RESULTS

One hundred and sixty of 216 PLTs (74.1%) were diagnosed infection based on the parameters including abnormal vital signs, imaging changes, and pathogens detection, while 44 (20.4%) were clinically stable and 12 (5.6%) experienced acute rejection. The median Cylex ATP value in infant PLTs post-surgery reduced significantly in infection group compared to stable group (median, 137 vs. 269 ng/mL, P<0.001). Receiver operating characteristic (ROC) curve analysis determined that the cut-off value of Cylex ATP was 152 ng/mL in diagnosis of infection [area under the curve (AUC): 0.784, 95% CI: 0.720-0.848]. Meanwhile, Cylex ATP value showed no correlation to tacrolimus dosage, blood concentration, dose-normalized concentration/dose ratio or Kaup index. However, it tended to correlate weakly with the white blood cell (WBC) number (R =0.462, P<0.0001) and lymphocyte counts (R =0.363, P<0.0001).

CONCLUSIONS

In this study, we demonstrated that low Cylex ATP represented partly over-immunosuppression and had diagnostic value in infant PLTs with infections, which might assist individualized immunosuppression in PLT patients.

Clinical Outcomes of Allogeneic Ocular Surface Stem Cell Transplantation in Pediatric Patients

PURPOSE

To describe the outcomes of allograft ocular surface stem cell transplantation (OSST) and the complication profile of systemic immunosuppression (SI) in pediatric patients with limbal stem cell deficiency.

METHODS

This was a retrospective interventional case series from a single tertiary referral institution of 20 eyes from 13 patients who 1) underwent allograft OSST surgery, 2) were 18 years or less at time of OSST, and 3) received SI with 4) a minimum of 12-months follow-up. The main outcome measures were ocular surface stability, visual acuity, and SI adverse events.

RESULTS

The mean age of patients was 15.1 ± 3.2 years (range 9-18 years). The mean follow-up was 5.6 ± 5.0 years after OSST. At the last follow-up, 15 eyes (75%) had a stable ocular surface, 1 eye (5%) developed partial failure, and 4 eyes (20%) developed total surface failure. Preoperative mean logarithm of the minimum angle of resolution visual acuity 1.5 improved to 1.1 at the last follow-up (P = 0.1); when 4 eyes of 3 nonadherent patients were excluded, the results were more pronounced and statistically significant (1.5 improved to 1.0, P = 0.002). SI was tolerated well by all patients with minimal adverse events.

CONCLUSIONS

OSST provides a stable ocular surface and is a successful treatment option for pediatric patients with limbal stem cell deficiency. SI is well-tolerated with a minimal complication profile.

Disease-specific Hospitalizations Among 5-Year Survivors of Hepatoblastoma: A Nordic Population-based Cohort Study

INTRODUCTION

The long-term risk of somatic disease in hepatoblastoma survivors has not been thoroughly evaluated in previous studies. In this population-based study of 86 five-year HB survivors, we used inpatient registers to evaluate the risk for a range of somatic diseases.

METHODS

In total, 86 five-year survivors of hepatoblastoma were identified in the Nordic cancer registries from 1964 to 2008 and 152,231 population comparisons were selected. Study subjects were followed in national hospital registries for somatic disease classified into 12 main diagnostic groups. Standardized hospitalization rate ratios (RRs) and absolute excess risks were calculated.

RESULTS

After a median follow-up of 11 years, 35 of the 86 five-year hepatoblastoma survivors had been hospitalized with a total of 69 hospitalizations, resulting in an RR of 2.7 (95% confidence interval [CI], 2.2-3.5) and an overall absolute excess risk of 4.2 per 100 person-years. Highest risk was seen for benign neoplasms (RR=16) with 6 hospitalizations for benign neoplasms in the colon and one in rectum.

CONCLUSIONS

The pattern of hospitalizations found in this first comprehensive follow-up of hepatoblastoma survivors seems reassuring. Less than 50% of the 5-year survivors had been hospitalized and often for diseases that were not severe or life-threatening.

Liver transplantation for pediatric inherited metabolic disorders: Considerations for indications, complications, and perioperative management

LT is an effective therapeutic option for a variety of IEM. This approach can significantly improve the quality of life of patients who suffer from severe disease manifestations and/or life-threatening metabolic decompensations despite medical/dietary management. Due to the significant risks for systemic complications from surgical stressors, careful perioperative management is vital. Even after LT, some disorders require long-term dietary restriction, medical management, and monitoring of metabolites. Successful liver transplant for these complex disorders can be achieved with disease- and patient-specific strategies using a multidisciplinary approach. In this article, we review indications, complications, perioperative management, and long-term follow-up recommendations for IEM that are treatable with LT.