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Kwon YK, Valentino PL, Healey PJ, Dick AAS, Hsu EK, Perkins JD, Sturdevant ML. Optimizing pediatric liver transplantation: Evaluating the impact of donor age and graft type on patient survival outcome. Pediatr Transplant 2024; 28:e14771. [PMID: 38702924 DOI: 10.1111/petr.14771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 03/05/2024] [Accepted: 04/15/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND We examined the combined effects of donor age and graft type on pediatric liver transplantation outcomes with an aim to offer insights into the strategic utilization of these donor and graft options. METHODS A retrospective analysis was conducted using a national database on 0-2-year-old (N = 2714) and 3-17-year-old (N = 2263) pediatric recipients. These recipients were categorized based on donor age (≥40 vs <40 years) and graft type. Survival outcomes were analyzed using the Kaplan-Meier and Cox proportional hazards models, followed by an intention-to-treat (ITT) analysis to examine overall patient survival. RESULTS Living and younger donors generally resulted in better outcomes compared to deceased and older donors, respectively. This difference was more significant among younger recipients (0-2 years compared to 3-17 years). Despite this finding, ITT survival analysis showed that donor age and graft type did not impact survival with the exception of 0-2-year-old recipients who had an improved survival with a younger living donor graft. CONCLUSIONS Timely transplantation has the largest impact on survival in pediatric recipients. Improving waitlist mortality requires uniform surgical expertise at many transplant centers to provide technical variant graft (TVG) options and shed the conservative mindset of seeking only the "best" graft for pediatric recipients.
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Affiliation(s)
- Yong K Kwon
- Division of Transplantation, Department of Surgery, University of Washington, Seattle, Washington, USA
- Division of Transplantation, Seattle Children's Hospital, Seattle, Washington, USA
- Department of Surgery, Clinical and Bio-Analytics Transplant Laboratory, University of Washington, Seattle, Washington, USA
| | - Pamela L Valentino
- Division of Gastroenterology and Hepatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington, USA
| | - Patrick J Healey
- Division of Transplantation, Department of Surgery, University of Washington, Seattle, Washington, USA
- Division of Transplantation, Seattle Children's Hospital, Seattle, Washington, USA
- Department of Surgery, Clinical and Bio-Analytics Transplant Laboratory, University of Washington, Seattle, Washington, USA
| | - Andre A S Dick
- Division of Transplantation, Department of Surgery, University of Washington, Seattle, Washington, USA
- Division of Transplantation, Seattle Children's Hospital, Seattle, Washington, USA
- Department of Surgery, Clinical and Bio-Analytics Transplant Laboratory, University of Washington, Seattle, Washington, USA
| | - Evelyn K Hsu
- Division of Gastroenterology and Hepatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington, USA
| | - James D Perkins
- Department of Surgery, Clinical and Bio-Analytics Transplant Laboratory, University of Washington, Seattle, Washington, USA
| | - Mark L Sturdevant
- Division of Transplantation, Department of Surgery, University of Washington, Seattle, Washington, USA
- Department of Surgery, Clinical and Bio-Analytics Transplant Laboratory, University of Washington, Seattle, Washington, USA
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Kulkarni SS, Vachharajani NA, Hill AL, Kiani AZ, Stoll JM, Nadler ML, Chapman WC, Doyle MM, Khan AS. Utilization of older deceased donors for pediatric liver transplant may negatively impact long-term survival. J Pediatr Gastroenterol Nutr 2024; 78:898-908. [PMID: 38591666 DOI: 10.1002/jpn3.12106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 11/30/2023] [Accepted: 12/08/2023] [Indexed: 04/10/2024]
Abstract
BACKGROUND Multiple adult studies have investigated the role of older donors (ODs) in expanding the donor pool. However, the impact of donor age on pediatric liver transplantation (LT) has not been fully elucidated. METHODS UNOS database was used to identify pediatric (≤18 years) LTs performed in the United States during 2002-22. Donors ≥40 years at donation were classified as older donors (ODs). Propensity analysis was performed with 1:1 matching for potentially confounding variables. RESULTS A total of 10,024 pediatric liver transplantation (PLT) patients met inclusion criteria; 669 received liver grafts from ODs. Candidates receiving OD liver grafts were more likely to be transplanted for acute liver failure, have higher Model End-Stage Liver Disease/Pediatric End-Stage Liver Disease (MELD/PELD) scores at LT, listed as Status 1/1A at LT, and be in the intensive care unit (ICU) at time of LT (all p < 0.001). Kaplan-Meier (KM) analyses showed that recipients of OD grafts had worse patient and graft survival (p < 0.001) compared to recipients of younger donor (YD) grafts. KM analyses performed on candidates matched for acuity at LT revealed inferior patient and graft survival in recipients of deceased donor grafts (p < 0.001), but not living donor grafts (p > 0.1) from ODs. Cox regression analysis demonstrated that living donor LT, diagnosis of biliary atresia and first liver transplant were favorable predictors of recipient outcomes, whereas ICU stay before LT and transplantation during 2002-12 were unfavorable. CONCLUSION Livers from ODs were used for candidates with higher acuity. Pediatric recipients of livers from ODs had worse outcome compared to YDs; however, living donor LT from ODs had the least negative impact on recipient outcomes.
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Affiliation(s)
- Sakil S Kulkarni
- Department of Pediatrics, Division of Pediatric Hepatology, St. Louis Children's Hospital, St. Louis, Missouri, USA
| | - Neeta A Vachharajani
- Department of Surgery, Division of Abdominal Transplant Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Angela L Hill
- Department of Surgery, Division of Abdominal Transplant Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Amen Z Kiani
- Department of Surgery, Division of Abdominal Transplant Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Janis M Stoll
- Department of Pediatrics, Division of Pediatric Hepatology, St. Louis Children's Hospital, St. Louis, Missouri, USA
| | - Michelle L Nadler
- Department of Pediatrics, Division of Pediatric Hepatology, St. Louis Children's Hospital, St. Louis, Missouri, USA
| | - William C Chapman
- Department of Surgery, Division of Abdominal Transplant Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Maria M Doyle
- Department of Surgery, Division of Abdominal Transplant Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Adeel S Khan
- Department of Surgery, Division of Abdominal Transplant Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
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3
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Spada M, Angelico R, Trapani S, Masiero L, Puoti F, Colledan M, Cintorino D, Romagnoli R, Cillo U, Cardillo M. Tailoring allocation policies and improving access to paediatric liver transplantation over a 16-year period. J Hepatol 2024; 80:505-514. [PMID: 38122833 DOI: 10.1016/j.jhep.2023.11.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 11/13/2023] [Accepted: 11/16/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND & AIMS Mortality on the paediatric liver transplantation (pLT) waiting list (WL) is still an issue. We analysed the Italian pLT WL to evaluate the intention-to-treat (ITT) success rate and to identify factors influencing success. METHODS All children (<18 years) listed for pLT in Italy between 2002-2018 were included (Era 1 [2002-2007]: centre-based allocation; Era 2 [2008-2014]: national allocation; Era 3 [2015-2018]: national allocation+mandatory-split policy). RESULTS A total of 1,424 patients (median age: 2.0 [IQR 1.0-9.0] years; median weight: 12.0 kg [IQR 7-27]) were listed for pLT. Median WL time was 2 days (IQR 1-5) for Status 1 and 44 days (IQR 15-120) for non-Status 1 patients; 1,302 children (91.4%) were transplanted (67.3% with split grafts), while 50 children (3.5%) dropped off the WL (2.5% death, 1.0% clinical deterioration). Predictive factors for receiving LT included Status 1 (hazard ratio [HR] 1.66, p = 0.001), Status 1B (HR 1.96, p = 0.016), Status 2A (HR 2.15, p = 0.024) and each 1-point increase in PELD/MELD score. Children with recipient's weight >25 kg, blood group O or awaiting pLT combined with other organs had less chance of being transplanted. ITT patient survival rates were 90.5% at 1 year and 87.5% at 5 years, remaining stable across eras. Risk factors for ITT survival were re-transplantation (HR 5.83, p <0.001), Status 1 (HR 2.28, p = 0.006), Status 1B (HR 2.90, p = 0.014), Status 2A (HR 9.12, p <0.001), recipient weight <6 kg (HR 4.53, p <0.001) and low-volume activity (HR 4.38, p = 0.001). CONCLUSIONS In Italy, continuous adaption of paediatric organ allocation policies via the introduction of national allocation, paediatric prioritisation rules and a mandatory-split policy have helped maximise the use of donors for paediatric candidates and to minimise WL mortality without compromising outcomes. IMPACT AND IMPLICATIONS Globally, paediatric liver transplant candidates still suffer from high mortality. Over recent decades, the continuous adaption of organ allocation policies in Italy has led to excellent outcomes for children awaiting liver transplantation. The mortality rate of paediatric liver transplant candidates has been minimised to almost zero, mainly using grafts from deceased donors. Paediatric prioritisation rules, national organ exchange organisation and a mandatory-split liver policy have resulted in a unique allocation model for paediatric liver transplant candidates and represent a landmark for the paediatric transplant community.
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Affiliation(s)
- Marco Spada
- Divison of Hepatobiliopancreatic Surgery, Liver and Kidney Transplantation, Research Unit of Clinical Hepatogastroenterology and Transplantation, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - Roberta Angelico
- HPB and Transplant Unit, Department of Surgical Sciences, University of Rome Tor Vergata, Rome, Italy
| | - Silvia Trapani
- Italian National Transplant Center, National Institute of Health, Rome, Italy
| | - Lucia Masiero
- Italian National Transplant Center, National Institute of Health, Rome, Italy
| | - Francesca Puoti
- Italian National Transplant Center, National Institute of Health, Rome, Italy
| | - Michele Colledan
- Department of Organ Failure and Transplantation - ASST Papa Giovanni XXIII, Bergamo, Italy; Università Milano-Bicocca, Milan, Italy
| | - Davide Cintorino
- Department of Pediatrics for the Study of Abdominal Diseases and Abdominal Transplantation, ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), IRCCS -UPMC (University of Pittsburgh Medical Center), Palermo, Italy
| | - Renato Romagnoli
- General Surgery 2U, Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy
| | - Umberto Cillo
- Hepatobiliary Surgery and Liver Transplantation Unit, University of Padova, Padova, Italy
| | - Massimo Cardillo
- Italian National Transplant Center, National Institute of Health, Rome, Italy
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4
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Ferrarese A, Bucci M, Zanetto A, Senzolo M, Germani G, Gambato M, Russo FP, Burra P. Prognostic models in end stage liver disease. Best Pract Res Clin Gastroenterol 2023; 67:101866. [PMID: 38103926 DOI: 10.1016/j.bpg.2023.101866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 08/13/2023] [Accepted: 08/18/2023] [Indexed: 12/19/2023]
Abstract
Cirrhosis is a major cause of death worldwide, and is associated with significant health care costs. Even if milestones have been recently reached in understanding and managing end-stage liver disease (ESLD), the disease course remains somewhat difficult to prognosticate. These difficulties have already been acknowledged already in the past, when scores instead of single parameters have been proposed as valuable tools for short-term prognosis. These standard scores, like Child Turcotte Pugh (CTP) and model for end-stage liver disease (MELD) score, relying on biochemical and clinical parameters, are still widely used in clinical practice to predict short- and medium-term prognosis. The MELD score, which remains an accurate, easy-to-use, objective predictive score, has received significant modifications over time, in order to improve its performance especially in the liver transplant (LT) setting, where it is widely used as prioritization tool. Although many attempts to improve prognostic accuracy have failed because of lack of replicability or poor benefit with the comparator (often the MELD score or its variants), few scores have been recently proposed and validated especially for subgroups of patients with ESLD, as those with acute-on-chronic liver failure. Artificial intelligence will probably help hepatologists in the near future to fill the current gaps in predicting disease course and long-term prognosis of such patients.
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Affiliation(s)
- A Ferrarese
- Gastroenterology and Multivisceral Transplant Unit, Padua University Hospital, 2, Giustiniani Street, 35122, Padua, Italy
| | - M Bucci
- Gastroenterology and Multivisceral Transplant Unit, Padua University Hospital, 2, Giustiniani Street, 35122, Padua, Italy
| | - A Zanetto
- Gastroenterology and Multivisceral Transplant Unit, Padua University Hospital, 2, Giustiniani Street, 35122, Padua, Italy
| | - M Senzolo
- Gastroenterology and Multivisceral Transplant Unit, Padua University Hospital, 2, Giustiniani Street, 35122, Padua, Italy
| | - G Germani
- Gastroenterology and Multivisceral Transplant Unit, Padua University Hospital, 2, Giustiniani Street, 35122, Padua, Italy
| | - M Gambato
- Gastroenterology and Multivisceral Transplant Unit, Padua University Hospital, 2, Giustiniani Street, 35122, Padua, Italy
| | - F P Russo
- Gastroenterology and Multivisceral Transplant Unit, Padua University Hospital, 2, Giustiniani Street, 35122, Padua, Italy
| | - P Burra
- Gastroenterology and Multivisceral Transplant Unit, Padua University Hospital, 2, Giustiniani Street, 35122, Padua, Italy.
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Rodriguez-Davalos MI, Lopez-Verdugo F, Kasahara M, Muiesan P, Reddy MS, Flores-Huidobro Martinez A, Xia Q, Hong JC, Niemann CU, Seda-Neto J, Miloh TA, Yi NJ, Mazariegos GV, Ng VL, Esquivel CO, Lerut J, Rela M. International Liver Transplantation Society Global Census: First Look at Pediatric Liver Transplantation Activity Around the World. Transplantation 2023; 107:2087-2097. [PMID: 37750781 DOI: 10.1097/tp.0000000000004644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND Over 16 000 children under the age of 15 died worldwide in 2017 because of liver disease. Pediatric liver transplantation (PLT) is currently the standard of care for these patients. The aim of this study is to describe global PLT activity and identify variations between regions. METHODS A survey was conducted from May 2018 to August 2019 to determine the current state of PLT. Transplant centers were categorized into quintile categories according to the year they performed their first PLT. Countries were classified according to gross national income per capita. RESULTS One hundred eight programs from 38 countries were included (68% response rate). 10 619 PLTs were performed within the last 5 y. High-income countries performed 4992 (46.4%) PLT, followed by upper-middle- (4704 [44·3%]) and lower-middle (993 [9·4%])-income countries. The most frequently used type of grafts worldwide are living donor grafts. A higher proportion of lower-middle-income countries (68·7%) performed ≥25 living donor liver transplants over the last 5 y compared to high-income countries (36%; P = 0.019). A greater proportion of programs from high-income countries have performed ≥25 whole liver transplants (52.4% versus 6.2%; P = 0.001) and ≥25 split/reduced liver transplants (53.2% versus 6.2%; P < 0.001) compared to lower-middle-income countries. CONCLUSIONS This study represents, to our knowledge, the most geographically comprehensive report on PLT activity and a first step toward global collaboration and data sharing for the greater good of children with liver disease; it is imperative that these centers share the lead in PLT.
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Affiliation(s)
- Manuel I Rodriguez-Davalos
- Liver Transplant Unit, Intermountain Primary Children's Hospital and the Center for Global Surgery, University of Utah, Salt Lake City, UT
| | - Fidel Lopez-Verdugo
- Liver Transplant Unit, Intermountain Primary Children's Hospital and the Center for Global Surgery, University of Utah, Salt Lake City, UT
- School of Medicine, Tecnologico de Monterrey, Mexico City, Mexico
| | - Mureo Kasahara
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Paolo Muiesan
- Liver Unit, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, United Kingdom
| | - Mettu S Reddy
- The Institute of Liver Disease and Transplantation, Dr. Rela Institute and Medical Centre, and Bharath Institute of Higher Education and Research, Chennai, India
| | - Angel Flores-Huidobro Martinez
- Liver Transplant Unit, Intermountain Primary Children's Hospital and the Center for Global Surgery, University of Utah, Salt Lake City, UT
- School of Medicine, Universidad Anahuac, Mexico City, Mexico
| | - Qiang Xia
- Department of Liver Surgery and Liver Transplantation, Renji Hospital, Shanghai, People's Republic of China
| | - Johnny C Hong
- Division of Transplant Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Claus U Niemann
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA
- Department of Surgery, University of California San Francisco, San Francisco, CA
| | - Joao Seda-Neto
- Department of Hepatology and Liver Transplantation, Hospital Sirio-Libanes, Sao Paulo, Brazil
| | - Tamir A Miloh
- Miami Transplant Institute, University of Miami, Miami, FL
| | - Nam-Joon Yi
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - George V Mazariegos
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Vicky L Ng
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, and Transplant and Regenerative Medicine Center, The Hospital for Sick Children (SickKids), University of Toronto, Toronto, Canada
| | - Carlos O Esquivel
- Department of Abdominal Transplantation, Stanford University Medical Center, Palo Alto, CA
| | - Jan Lerut
- Institute for Experimental and Clinical Research, Université Catholique Louvain, Brussels, Belgium
| | - Mohamed Rela
- The Institute of Liver Disease and Transplantation, Dr. Rela Institute and Medical Centre, and Bharath Institute of Higher Education and Research, Chennai, India
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
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6
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Rasmussen SK, Lemoine CP, Superina R, Sayed B, Goldaracena N, Soltys KA, Griesemer A, Dick A, Angelis M, Chin LT, Florman S, Ganoza A, Lyer K, Kang SM, Magliocca J, Squires J, Eisenberg E, Bray D, Tunno J, Reyes JD, Mazariegos GV. State of pediatric liver transplantation in the United States and achieving zero wait list mortality with ideal outcomes: A statement from the Starzl Network for Excellence in Pediatric Transplant Surgeon's Working Group. Pediatr Transplant 2023; 27 Suppl 1:e14283. [PMID: 36468324 DOI: 10.1111/petr.14283] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 03/14/2022] [Accepted: 03/22/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Liver transplant is a life-saving therapy that can restore quality life for several pediatric liver diseases. However, it is not available to all children who need one. Expertise in medical and surgical management is heterogeneous, and allocation policies are not optimally serving children. Technical variant grafts from both living and deceased donors are underutilized. METHODS Several national efforts in pediatric liver transplant to improve access to and outcomes from liver transplant for children have been instituted and include adjustments to allocation policies, UNOS-sponsored collaborative improvement projects, and the emergence of national learning networks to study ongoing challenges in the field the Surgical Working group of the Starzl Network for Excellence in Pediatric Transplantation (SNEPT) discusses key issues and proposes potential solutions to eliminate the persistent wait list mortality that pediatric patients face. RESULTS A discussion of the factors impacting pediatric patients' access to liver transplant is undertaken, along with a proposal of several measures to ensure equitable access to life-saving liver transplant. CONCLUSIONS Pediatric liver transplant wait list mortality can and should be eliminated. Several measures, including collaborative efforts among centers, could be leveraged to acheive this goal.
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Affiliation(s)
- Sara K Rasmussen
- Department of Surgery, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA
| | - Caroline P Lemoine
- Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Riccardo Superina
- Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Blayne Sayed
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | - Kyle A Soltys
- UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Adam Griesemer
- Department of Surgery, Columbia University, New York, New York, USA
| | - Andre Dick
- Department of Surgery, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA
| | | | - L Thomas Chin
- Advent Health Transplant Institute, Orlando, Florida, USA
| | - Sander Florman
- Mt Sinai Recanati/Miller Transplantation Institute, New York, New York, USA
| | - Armando Ganoza
- UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kishore Lyer
- Mt Sinai Recanati/Miller Transplantation Institute, New York, New York, USA
| | - Sang-Mo Kang
- Mt Sinai Recanati/Miller Transplantation Institute, New York, New York, USA
| | - Joseph Magliocca
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - James Squires
- UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Elizabeth Eisenberg
- Department of Surgery, Emory University, Atlanta, Georgia, USA.,Patient and Family Voice Committee, Starzl Network, Pittsburgh, Pennsylvania, USA
| | - David Bray
- Department of Surgery, Emory University, Atlanta, Georgia, USA.,Patient and Family Voice Committee, Starzl Network, Pittsburgh, Pennsylvania, USA
| | - John Tunno
- Department of Surgery, Emory University, Atlanta, Georgia, USA
| | - Jorge D Reyes
- Department of Surgery, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA
| | - George V Mazariegos
- UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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7
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Hernández Benabe S, Batsis I, Dipchand AI, Marks SD, McCulloch MI, Hsu EK. Allocation to pediatric recipients around the world: An IPTA global survey of current pediatric solid organ transplantation deceased donation allocation practices. Pediatr Transplant 2023; 27 Suppl 1:e14317. [PMID: 36468320 DOI: 10.1111/petr.14317] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 04/25/2022] [Accepted: 04/29/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND There has not been a comprehensive global survey of pediatric-deceased donor allocation practices across all organs since the advent of deceased donor transplantation at the end of the 20th century. As an international community that is responsible for transplanting children, we set out to survey the existing landscape of allocation. We aimed to summarize current practices and provide a snapshot overview of deceased donor allocation practices to children across the world. METHODS The International Registry in Organ Donation and Transplantation (IRODAT, www.irodat.org) was utilized to generate a list of all countries in the world, divided by continent, that performed transplantation. We reviewed the published literature, published allocation policy, individual website references and associated links to publicly available listed allocation policies. Following this, we utilized tools of communication, relationships, and international fellowship to confirm deceased donation pediatric centers and survey pediatric allocation practices for liver, kidney, heart, and lung across the world. We summarize pediatric allocation practices by organ when available using source documents, and personal communication when no source documents were available. RESULTS The majority of countries had either formal or informal policies directed toward minimizing organ distribution disparity among pediatric patients. CONCLUSION Children have long-term life to gain from organ donation yet continue to die while awaiting transplantation. We summarize global strategies that have been employed to provide meaningful and sustained benefit to children on the waitlist.
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Affiliation(s)
| | | | | | - Stephen D Marks
- NIHR Great Ormond Street Hospital Biomedical Research Centre, University College London Great Ormond Street Institute of Child Health, London, UK
| | | | - Evelyn K Hsu
- University of Washington School of Medicine, Seattle, Washington, USA
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8
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Ettenger R, Venick RS, Gritsch HA, Alejos JC, Weng PL, Srivastava R, Pearl M. Deceased donor organ allocation in pediatric transplantation: A historical narrative. Pediatr Transplant 2023; 27 Suppl 1:e14248. [PMID: 36468338 DOI: 10.1111/petr.14248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 01/05/2022] [Accepted: 01/06/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Since the earliest clinical successes in solid organ transplantation, the proper method of organ allocation for children has been a contentious subject. Over the past 30-35 years, the medical and social establishments of various countries have favored some degree of preference for children on the respective waiting lists. However, the specific policies to accomplish this have varied widely and changed frequently between organ type and country. METHODS Organ allocation policies over time were examined. This review traces the reasons behind and the measures/principles put in place to promote early deceased donor transplantation in children. RESULTS Preferred allocation in children has been approached in a variety of ways and with varying degrees of commitment in different solid organ transplant disciplines and national medical systems. CONCLUSION The success of policies to advantage children has varied significantly by both organ and medical system. Further work is needed to optimize allocation strategies for pediatric candidates.
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Affiliation(s)
- Robert Ettenger
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Robert S Venick
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Hans A Gritsch
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Juan C Alejos
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Patricia L Weng
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Rachana Srivastava
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Meghan Pearl
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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9
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Dou XJ, Wang QP, Liu WH, Weng YQ, Sun Y, Yu WL. Effect of cardiac output - guided hemodynamic management on acute lung injury in pediatric living donor liver transplantation. World J Gastrointest Surg 2022; 14:1037-1048. [PMID: 36185553 PMCID: PMC9521467 DOI: 10.4240/wjgs.v14.i9.1037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 05/25/2022] [Accepted: 08/18/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Acute lung injury (ALI) after liver transplantation (LT) may lead to acute respiratory distress syndrome, which is associated with adverse postoperative outcomes, such as prolonged hospital stay, high morbidity, and mortality. Therefore, it is vital to maintain hemodynamic stability and optimize fluid management. However, few studies have reported cardiac output-guided (CO-G) management in pediatric LT.
AIM To investigate the effect of CO-G hemodynamic management on early postoperative ALI and hemodynamic stability during pediatric living donor LT.
METHODS A total of 130 pediatric patients scheduled for elective living donor LT were enrolled as study participants and were assigned to the control group (65 cases) and CO-G group (65 cases). In the CO-G group, CO was considered the target for hemodynamic management. In the control group, hemodynamic management was based on usual perioperative care guided by central venous pressure, continuous invasive arterial pressure, urinary volume, etc. The primary outcome was early postoperative ALI. Secondary outcomes included other early postoperative pulmonary complications, readmission to the intense care unit (ICU) for pulmonary complications, ICU stay, hospital stay, and in-hospital mortality.
RESULTS The incidence of early postoperative ALI was 27.7% in the CO-G group, which was significantly lower than that in the control group (44.6%) (P < 0.05). During the surgery, the incidence of postreperfusion syndrome was lower in the CO-G group (P < 0.05). The level of intraoperative positive fluid transfusions was lower and the rate of dobutamine use before portal vein opening was higher, while the usage and dosage of epinephrine during portal vein opening and vasoactive inotropic score after portal vein opening were lower in the CO-G group (P < 0.05). Compared to the control group, serum inflammatory factors (interleukin-6 and tumor necrosis factor-α), cardiac troponin I, and N-terminal pro-brain natriuretic peptide were lower in the CO-G group after the operation (P < 0.05).
CONCLUSION CO-G hemodynamic management in pediatric living-donor LT decreases the incidence of early postoperative ALI due to hemodynamic stability through optimized fluid management and appropriate administration of vasopressors and inotropes.
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Affiliation(s)
- Xiao-Jing Dou
- Department of Anesthesiology, Tianjin First Central Hospital, Tianjin 300192, China
| | - Qing-Ping Wang
- Department of Anesthesiology, Tianjin First Central Hospital, Tianjin 300192, China
| | - Wei-Hua Liu
- Department of Anesthesiology, Tianjin First Central Hospital, Tianjin 300192, China
| | - Yi-Qi Weng
- Department of Anesthesiology, Tianjin First Central Hospital, Tianjin 300192, China
| | - Ying Sun
- Department of Anesthesiology, Tianjin First Central Hospital, Tianjin 300192, China
| | - Wen-Li Yu
- Department of Anesthesiology, Tianjin First Central Hospital, Tianjin 300192, China
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10
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Variability of Care and Access to Transplantation for Children with Biliary Atresia Who Need a Liver Replacement. J Clin Med 2022; 11:jcm11082142. [PMID: 35456234 PMCID: PMC9032543 DOI: 10.3390/jcm11082142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 02/24/2022] [Accepted: 03/09/2022] [Indexed: 02/04/2023] Open
Abstract
Background & Aims: Biliary atresia (BA) is the commonest single etiology indication for liver replacement in children. As timely access to liver transplantation (LT) remains challenging for small BA children (with prolonged waiting time being associated with clinical deterioration leading to both preventable pre- and post-transplant morbidity and mortality), the care pathway of BA children in need of LT was analyzed—from diagnosis to LT—with particular attention to referral patterns, timing of referral, waiting list dynamics and need for medical assistance before LT. Methods: International multicentric retrospective study. Intent-to-transplant study analyzing BA children who had indication for LT early in life (aged < 3 years at the time of assessment), over the last 5 years (2016−2020). Clinical and laboratory data of 219 BA children were collected from 8 transplant centers (6 in Europe and 2 in USA). Results: 39 patients underwent primary transplants. Children who underwent Kasai in a specialist -but not transplant- center were older at time of referral and at transplant. At assessment for LT, the vast majority of children already were experiencing complication of cirrhosis, and the majority of children needed medical assistance (nutritional support, hospitalization, transfusion of albumin or blood) while waiting for transplantation. Severe worsening of the clinical condition led to the need for requesting a priority status (i.e., Peld Score exception or similar) for timely graft allocation for 76 children, overall (35%). Conclusions: As LT currently results in BA patient survival exceeding 95% in many expert LT centers, the paradigm for BA management optimization and survival have currently shifted to the pre-LT management. The creation of networks dedicated to the timely referral to a pediatric transplant center and possibly centralization of care should be considered, in combination with implementing all different graft type surgeries in specialist centers (including split and living donor LTs) to achieve timely LT in this vulnerable population.
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11
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Barbetta A, Butler C, Barhouma S, Hogen R, Rocque B, Goldbeck C, Schilperoort H, Meeberg G, Shapiro J, Kwon YK, Kohli R, Emamaullee J. Living Donor Versus Deceased Donor Pediatric Liver Transplantation: A Systematic Review and Meta-analysis. Transplant Direct 2021; 7:e767. [PMID: 34557584 PMCID: PMC8454909 DOI: 10.1097/txd.0000000000001219] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 07/21/2021] [Accepted: 07/22/2021] [Indexed: 12/19/2022] Open
Abstract
Reduced-size deceased donors and living donor liver transplantation (LDLT) can address the organ shortage for pediatric liver transplant candidates, but concerns regarding technical challenges and the risk of complications using these grafts have been raised. The aim of this study was to compare outcomes for pediatric LDLT and deceased donor liver transplantation (DDLT) via systematic review. METHODS A systematic literature search was performed to identify studies reporting outcomes of pediatric (<18 y) LDLT and DDLT published between 2005 and 2019. A meta-analysis was conducted to examine peri- and postoperative outcomes using fixed- and random-effects models. RESULTS Overall, 2518 abstracts were screened, and 10 studies met criteria for inclusion. In total, 1622 LDLT and 6326 DDLT pediatric patients from 4 continents were examined. LDLT resulted in superior patient survival when compared with DDLT at 1, 3, and 5 y post-LT (1-y hazard ratio: 0.58, 95% confidence interval [CI] 0.47-0.73, P < 0.0001). Similarly, LDLT resulted in superior graft survival at all time points post-LT when compared with DDLT (1-y hazard ratio: 0.56 [95% CI 0.46-0.68], P < 0.0001]. The OR for vascular complications was 0.73 (95% CI 0.39-1.39) and 1.31 (95% CI 0.92-1.86) for biliary complications in LDLT compared with DDLT, whereas LDLT was associated with lower rates of rejection (OR: 0.66 [95% CI 0.45-0.96], P = 0.03). CONCLUSIONS This meta-analysis demonstrates that LDLT may offer many advantages when compared with DDLT in children and suggests that LDLT should continue to be expanded to optimize outcomes for pediatric LT candidates.
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Affiliation(s)
- Arianna Barbetta
- Department of Surgery, University of Southern California, Los Angeles, CA
| | - Chanté Butler
- Department of Surgery, University of Southern California, Los Angeles, CA
| | - Sarah Barhouma
- Department of Surgery, University of Southern California, Los Angeles, CA
| | - Rachel Hogen
- Department of Surgery, University of Southern California, Los Angeles, CA
| | - Brittany Rocque
- Department of Surgery, University of Southern California, Los Angeles, CA
| | - Cameron Goldbeck
- Department of Surgery, University of Southern California, Los Angeles, CA
| | - Hannah Schilperoort
- Wilson Dental Library, USC Libraries, University of Southern California, Los Angeles, CA
| | - Glenda Meeberg
- Department of Surgery, University of Alberta, Edmonton, Canada
| | - James Shapiro
- Department of Surgery, University of Alberta, Edmonton, Canada
| | - Yong K. Kwon
- Department of Surgery, University of Southern California, Los Angeles, CA
| | - Rohit Kohli
- Department of Pediatrics, University of Southern California, Los Angeles, CA
- Division of Gastroenterology, Hepatology and Nutrition, Children’s Hospital Los Angeles, Los Angeles, CA
| | - Juliet Emamaullee
- Department of Surgery, University of Southern California, Los Angeles, CA
- Division of Abdominal Transplantation, Children’s Hospital Los Angeles, Los Angeles, CA
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12
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Bruckmann EK, Beretta M, Demopolous D, Brannigan L, Bouter C, Maher H, Etheredge HR, Fabian J, Haeri Mazanderani A, Britz R, Loveland J, Botha JF. Minding the gap-Providing quality transplant care for South African children with acute liver failure. Pediatr Transplant 2020; 24:e13827. [PMID: 32871038 DOI: 10.1111/petr.13827] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 06/26/2020] [Accepted: 07/26/2020] [Indexed: 11/28/2022]
Abstract
Pediatric ALF is rare but life-threatening and may require urgent transplantation. In low and middle-income countries, access to transplantation is limited, deceased organ donation rates are low, and data on outcomes scarce. The Wits Donald Gordon Medical Centre, in Johannesburg, is one of only two centers in South Africa that perform pediatric liver transplant. We describe the etiology, clinical presentation, and outcomes of children undergoing liver transplant for ALF at our center over the past 14 years. We performed a retrospective chart review of all children undergoing liver transplantation for ALF from November 2005 to September 2019. Recipient data included demographics, clinical and biochemical characteristics pretransplant, post-operative complications, and survival. We conducted descriptive data analysis and used the Kaplan-Meier method for survival analysis. We performed 182 primary pediatric liver transplants. Of these, 27 (15%) were for ALF, mostly from acute hepatitis A infection (11/27;41%). Just over half of the grafts were from living donors (15/27;56%), and five grafts (5/27;19%) were ABO-incompatible. The most frequent post-transplant complications were biliary leaks (9/27;33%). There were two cases of hepatic artery thrombosis (2/27;7%), one of whom required re-transplantation. Unadjusted patient and graft survival at one and 3 years were the same, at 81% (95% CI 61%-92%) and 78% (95% CI 57%-89%), respectively. At WDGMC, our outcomes for children who undergo liver transplantation for ALF are excellent. We found workable solutions that effectively addressed our pervasive organ shortages without compromising patient outcomes.
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Affiliation(s)
- Eduard K Bruckmann
- Faculty of Health Sciences, Wits Donald Gordon Medical Centre, University of the Witwatersrand, Johannesburg, South Africa.,Faculty of Health Sciences, Department of Pediatric Intensive Care, University of the Witwatersrand, Johannesburg, South Africa
| | - Marisa Beretta
- Faculty of Health Sciences, Wits Donald Gordon Medical Centre, University of the Witwatersrand, Johannesburg, South Africa
| | - Despina Demopolous
- Faculty of Health Sciences, Wits Donald Gordon Medical Centre, University of the Witwatersrand, Johannesburg, South Africa
| | - Lliam Brannigan
- Faculty of Health Sciences, Wits Donald Gordon Medical Centre, University of the Witwatersrand, Johannesburg, South Africa
| | - Carolyn Bouter
- Faculty of Health Sciences, Wits Donald Gordon Medical Centre, University of the Witwatersrand, Johannesburg, South Africa
| | - Heather Maher
- Faculty of Health Sciences, Wits Donald Gordon Medical Centre, University of the Witwatersrand, Johannesburg, South Africa
| | - Harriet R Etheredge
- Faculty of Health Sciences, Wits Donald Gordon Medical Centre, University of the Witwatersrand, Johannesburg, South Africa.,Faculty of Health Sciences, Department of Internal Medicine, University of the Witwatersrand, Parktown, South Africa
| | - June Fabian
- Faculty of Health Sciences, Wits Donald Gordon Medical Centre, University of the Witwatersrand, Johannesburg, South Africa
| | - Ahmad Haeri Mazanderani
- National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
| | - Russel Britz
- Faculty of Health Sciences, Wits Donald Gordon Medical Centre, University of the Witwatersrand, Johannesburg, South Africa
| | - Jerome Loveland
- Faculty of Health Sciences, Wits Donald Gordon Medical Centre, University of the Witwatersrand, Johannesburg, South Africa.,Faculty of Health Sciences, Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Jean F Botha
- Faculty of Health Sciences, Wits Donald Gordon Medical Centre, University of the Witwatersrand, Johannesburg, South Africa.,Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Parktown, South Africa
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13
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Qin T, Fu J, Verkade HJ. The role of the gut microbiome in graft fibrosis after pediatric liver transplantation. Hum Genet 2020; 140:709-724. [PMID: 32920649 PMCID: PMC8052232 DOI: 10.1007/s00439-020-02221-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 08/29/2020] [Indexed: 12/18/2022]
Abstract
Liver transplantation (LT) is a life-saving option for children with end-stage liver disease. However, about 50% of patients develop graft fibrosis in 1 year after LT, with normal liver function. Graft fibrosis may progress to cirrhosis, resulting in graft dysfunction and ultimately the need for re-transplantation. Previous studies have identified various risk factors for the post-LT fibrogenesis, however, to date, neither of the factors seems to fully explain the cause of graft fibrosis. Recently, evidence has accumulated on the important role of the gut microbiome in outcomes after solid organ transplantation. As an altered microbiome is present in pediatric patients with end-stage liver diseases, we hypothesize that the persisting alterations in microbial composition or function contribute to the development of graft fibrosis, for example by bacteria translocation due to increased intestinal permeability, imbalanced bile acids metabolism, and/or decreased production of short-chain fatty acids (SCFAs). Subsequently, an immune response can be activated in the graft, together with the stimulation of fibrogenesis. Here we review current knowledge about the potential mechanisms by which alterations in microbial composition or function may lead to graft fibrosis in pediatric LT and we provide prospective views on the efficacy of gut microbiome manipulation as a therapeutic target to alleviate the graft fibrosis and to improve long-term survival after LT.
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Affiliation(s)
- Tian Qin
- Pediatric Gastroenterology/Hepatology, Section of Nutrition and Metabolism, Research Laboratory of Pediatrics, Department of Pediatrics, Beatrix Children's Hospital/University Medical Center Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Jingyuan Fu
- Pediatric Gastroenterology/Hepatology, Section of Nutrition and Metabolism, Research Laboratory of Pediatrics, Department of Pediatrics, Beatrix Children's Hospital/University Medical Center Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands.,Department of Genetics, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Henkjan J Verkade
- Pediatric Gastroenterology/Hepatology, Section of Nutrition and Metabolism, Research Laboratory of Pediatrics, Department of Pediatrics, Beatrix Children's Hospital/University Medical Center Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands.
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14
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Ng VL, Mazariegos GV, Kelly B, Horslen S, McDiarmid SV, Magee JC, Loomes KM, Fischer RT, Sundaram SS, Lai JC, Te HS, Bucuvalas JC. Barriers to ideal outcomes after pediatric liver transplantation. Pediatr Transplant 2019; 23:e13537. [PMID: 31343109 DOI: 10.1111/petr.13537] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 06/03/2019] [Accepted: 06/11/2019] [Indexed: 12/13/2022]
Abstract
Long-term survival for children who undergo LT is now the rule rather than the exception. However, a focus on the outcome of patient or graft survival rates alone provides an incomplete and limited view of life for patients who undergo LT as an infant, child, or teen. The paradigm has now appropriately shifted to opportunities focused on our overarching goals of "surviving and thriving" with long-term allograft health, freedom of complications from long-term immunosuppression, self-reported well-being, and global functional health. Experts within the liver transplant community highlight clinical gaps and potential barriers at each of the pretransplant, intra-operative, early-, medium-, and long-term post-transplant stages toward these broader mandates. Strategies including clinical research, innovation, and quality improvement targeting both traditional as well as PRO are outlined and, if successfully leveraged and conducted, would improve outcomes for recipients of pediatric LT.
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Affiliation(s)
- Vicky Lee Ng
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Transplant and Regenerative Medicine Center, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - George V Mazariegos
- Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - Beau Kelly
- Division of Surgery, DCI Donor Services, Sacramento, California
| | - Simon Horslen
- Department of Pediatrics, University of Washington, Seattle, Washington
| | - Sue V McDiarmid
- David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - John C Magee
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Kathleen M Loomes
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Ryan T Fischer
- Division of Gastroenterology, Hepatology and Nutrition, Children's Mercy Hospital, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Shikha S Sundaram
- Pediatrics, Gastroenterology, Hepatology and Nutrition, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Jennifer C Lai
- Division of Gastroenterology/Hepatology, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Helen S Te
- Adult Liver Transplant Program, University of Chicago Medicine, Chicago, Illinois
| | - John C Bucuvalas
- Mount Sinai Kravis Childrens Hospital and Recanati/Miller Transplant Institute, New York City, New York
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