Emergency liver transplantation in neonates with acute liver failure: long-term follow-up. Transplantation. 2008;86:932-936. [PMID: 18852658 DOI: 10.1097/tp.0b013e318186d64a]

Aetiology, Characteristics and Outcomes of Neonatal Liver Failure: lessons learned over the last 3 decades

OBJECTIVE

To evaluate trends in etiology and outcomes of neonatal liver failure (NLF) over 30 years retrospectively at a single institution.

STUDY DESIGN

Inclusion criteria for this retrospective cohort study were babies presenting at a chronological age of ≤ 28 days between 1991 and 2020 with prothrombin time (PT) ≥ 20 seconds and biochemical liver injury. Demographics, etiology, laboratory investigations, need for extrahepatic organ support, acute kidney injury (AKI), and intervention with liver transplant (LT) were recorded. Survival outcomes were measured as discharge from the hospital alive with native liver or LT. The study period was stratified into three 10-year blocks. Trends were analyzed for hospital admissions, etiology, and survival outcomes.

RESULTS

126 babies met the NLF criteria. Admissions to the hospital increased from 21 in 1991-2000 to 65 in 2011-2020. An increasing trend in infectious and metabolic causes, while a decreasing trend in indeterminate etiology, was noted. Survival with native liver improved from 23.8% in 1991-2000 to 55.4% in 2011-20 (p=0.021), and mortality reduced from 52.4 % to 35.4% during the same periods (p=0.213). Twenty-three (18.2 %) neonates received LT. Post-LT survival outcomes were 100% for gestational alloimmune liver disease (GALD), 66.6 % in the indeterminate group, and 25% for herpes simplex virus (HSV). Specific etiologies (GALD, OR=0.07 [0-0.77, p=0.048]), presence of acute kidney injury (OR= 6.22 [1.45, 29.38, p=0.015]) and need for inotropes (OR=6.22 [1.45, 29.38, p=0.028}) influenced mortality in multivariable logistic regression analysis.

CONCLUSION

In the last 30 years, advances in diagnosis, treatment, and increasing experience with LT have improved survival in NLF.

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.

Rescue case of low birth weight infant with acute hepatic failure

We report a case involving a rescued low birth weight infant (LBWI) with acute liver failure. Case: The patient was 1594 g and 32^3/7 gestational wk at birth. At the age of 11 d, she developed acute liver failure due to gestational alloimmune liver disease. Exchange transfusion and high-dose gamma globulin therapy were initiated, and body weight increased with enteral nutrition. Exchange transfusion was performed a total of 33 times prior to living donor liver transplantation (LDLT). Her liver dysfunction could not be treated by medications alone. At 55 d old and a body weight of 2946 g, she underwent LDLT using an S2 monosegment graft from her mother. Three years have passed with no reports of intellectual disability or liver dysfunction. LBWIs with acute liver failure may be rescued by LDLT after body weight has increased to over 2500 g.

Outcomes in infants listed for liver transplantation: A retrospective cohort study using the United Network for Organ Sharing database

LT in neonates and young infants can be challenging due to a variety of factors. To describe the waitlist mortality rates and outcomes of patients listed and transplanted as infants identified from the UNOS database. Infants listed for LT between January 1985 and September 2010 were identified from the UNOS database. Mortality on the waitlist as well as outcomes post-LT was compared between infants aged ≤60 days (Group 1), 61-179 days (Group 2), and 180-364 days (Group 3). Of 6763 infants listed for LT (Group 1 n = 496, Group 2 n = 2404, Group 3 n = 3863), mean age at listing was 196 ± 87 days (Group 1, 29 ± 16 days; Group 2, 132 ± 32 days; Group 3, 257 ± 52 days). Waitlist mortality was highest in Group 1 (Group 1 vs. 3 HR 3.01, 95% CI 2.19-4.15, Group 2 vs. Group 3 HR 0.82, 95% CI 0.66-1.03). One- and five-yr graft survival was 59.6% and 42% (Group 1), 66% and 45% (Group 2), and 66.8% and 41% (Group 3) (one-yr survival p = 0.20; five-yr survival p = 0.19). Infants listed for LT at age ≤60 days had greater waitlist mortality risk than older infants. Infants undergoing LT at age ≤60 days had similar rates of patient and graft survival to older infants.

Dorsal approach plus branch patch technique is the preferred method for liver transplanting small babies with monosegmental grafts

PURPOSE

When living donor liver transplantation (LDLT) is performed on small infant patients, the incidence of hepatic artery complications (HACs) is high. Here, we present a retrospective analysis that focuses on our surgical procedure for hepatic arterial reconstruction and the outcomes of monosegmental LDLT.

METHODS

Of the 275 patients who underwent LDLT between May 2001 and December 2015, 13 patients (4.7 %) underwent monosegmental LDLT. Hepatic artery reconstruction was performed under a microscope. The size discrepancy between the graft and the recipient's abdominal cavity was defined as the graft to recipient distance ratio (GRDR) between the left hepatic vein and the portal vein (PV) bifurcation on a preoperative computed tomography scan. HACs were defined as hepatic arterial hypoperfusion.

RESULTS

Recipient hepatic arteries were selected for the branch patch technique in five cases (38.5 %), and the diameter was 2.2 ± 0.6 mm. The anastomotic approaches selected were the dorsal position of the PV in seven cases (53.8 %) and the ventral position in six, and the GRDRs were 2.8 ± 0.4 and 1.9 ± 0.5, respectively (p = 0.012). The incidence rate of HACs caused by external factors, such as compression or inflammation around the anastomotic site, was significantly higher in monosegmental than in non-monosegmental graft recipients (15.4 vs. 1.1 %, p < 0.001).

CONCLUSION

Although monosegmental graft recipients experienced HACs caused by external factors around the anastomotic field, hepatic arterial reconstruction could be safely performed. Important components of successful hepatic arterial reconstructions include the employment of the branch patch technique and the selection of the dorsal approach.

Neonatal hemochromatosis: management, outcome, and prevention

Neonatal hemochromatosis (NH) is a rare disorder but the most common cause of acute liver failure in neonates. NH is characterized by severe hepatic injury and iron overload and is associated with high perinatal mortality and morbidity rates. NH is often preceded by oligohydramnios and intrauterine growth restriction, suggesting an important impact of NH during fetal life. Stillbirth and prematurity are not uncommon. During the last decade, major discoveries on the etiology of NH have radically changed the management and outcome of this disease. NH is now regarded as an alloimmune disease and is, as such, often referred to as gestational alloimmune liver disease. Antenatal treatment with intravenous immunoglobulins starting at 14 weeks' gestation has been shown to prevent the development of NH in subsequent pregnancies. Postnatal treatment, previously based on the use of anti-oxidants and chelation therapy, has now successfully been replaced by exchange transfusions and intravenous immunoglobulins substitution. This review summarizes the latest discoveries on the etiology of NH and the new recommendations concerning its management and prevention.

Pediatric liver transplantation: where do we stand? Where we are going to?

Pediatric liver transplantation (LT) is one of the most successful solid organ transplants with long-term survival more than 80%. Many aspects have contributed to improve survival, especially advancements in pre-, peri- and post-transplant management. The development of new surgical techniques, such as split-LT and the introduction of living related LT, has extended LT to small infants. Progress in the last 30 years has also been characterized by the introduction of calcineurin inhibitors. One problem remains the lack of donors. Donation after cardiac death offers a new possibility to increase the pool of potential donors. In children with acute liver failure, increasing interest has centered on the possibility of providing temporary liver support based on extracorporeal devices or hepatocyte transplantation. Similarly, hepatocyte transplantation offers new perspective in children with metabolic failure. As long-term survival increases, attention has now focused on the quality of life achieved by children undergoing LT.

Characterization and outcomes of young infants with acute liver failure

OBJECTIVE

To characterize infants aged ≤ 90 days enrolled in an international, multicenter, prospective registry of children aged < 18 years with acute liver failure (ALF).

STUDY DESIGN

The Pediatric Acute Liver Failure (PALF) Study Group collects prospective data on children from birth to 18 years. We analyzed data from infants aged ≤ 90 days enrolled in the PALF Study before May 18, 2009.

RESULTS

A total of 148 infants were identified in the PALF registry (median age, 18 days). Common etiologies of ALF were indeterminate (38%), neonatal hemochromatosis (13.6%), and herpes simplex virus (12.8%). Spontaneous survival occurred in 60% of the infants, 16% underwent liver transplantation, and 24% died without undergoing liver trsansplantation. Infants with indeterminate ALF were more likely to undergo liver transplantation than those with viral-induced ALF (P = .0002). The cumulative incidence of death without liver transplantation was higher in infants with viral ALF (64%) compared with those with neonatal hemochromatosis (16%) or indeterminate ALF (14%) (P = .0007).

CONCLUSION

ALF in young infants presents unique diagnostic considerations. Spontaneous survival is better than previously thought. Liver transplantation provides an additional option for care.

Paediatric liver transplantation for metabolic disorders. Part 2: Metabolic disorders with liver lesions

Liver based metabolic disorders account for 10 to 15% of the indications for paediatric liver transplantation. In the last three decades, important progress has been made in the understanding of these diseases, and new therapies have emerged. Concomitantly, medical and surgical innovations have lead to improved results of paediatric liver transplantation, patient survival nowadays exceeding 80% 10 year after surgery with close to normal quality of life in most survivors. This review is a practical update on medical therapy, indications and results of liver transplantation, and potential future therapies, for the main liver based metabolic disorders in which paediatric liver transplantation may be considered. Part 1 focuses on metabolic based liver disorders without liver lesions, and part 2 on metabolic liver diseases with liver lesions.

Living donor liver transplantation for neonates using segment 2 monosubsegment graft

The prognosis of liver transplantation for neonates with fulminant hepatic failure (FHF) continues to be extremely poor, especially in patients whose body weight is less than 3 kg. To address this problem, we have developed a safe living donor liver transplantation (LDLT) modality for neonates. We performed LDLTs with segment 2 monosubsegment (S2) grafts for three neonatal FHF. The recipient age and body weight at LDLT were 13-27 days, 2.59-2.84 kg, respectively. S2 or reduced S2 grafts (93-98 g) obtained from their fathers were implanted using temporary portacaval shunt. The recipient portal vein was reconstructed at a more distal site, such as the umbilical portion, to have the graft liver move freely during hepatic artery (HA) reconstruction. The recipient operation time and bleeding were 11 h 58 min-15 h 27 min and 200-395 mL, respectively. The graft-to-recipient weight ratio was 3.3-3.8% and primary abdominal wall closure was possible in all cases. Although hepatic artery thrombosis occurred in one case, all cases survived with normal growth. Emergency LDLT with S2 grafts weighing less than 100 g can save neonates with FHF whose body weight is less than 3 kg. This LDLT modality using S2 grafts could become a new option for neonates and very small infants requiring LT.

Liver transplantation in children: update 2010

Pediatric liver transplant recipients represent an important target population for primary care health professionals as well as transplant practitioners. With improving patient and graft survival, new concerns now face health care professionals caring for the transplant community, namely the long-term complications of immunosuppressive therapy and the potential for withdrawal of immunosuppression, transplant recipients' quality of life, and the persistent shortage of donor organs leading to morbidity and mortality on the waiting list. These issues require constant collaboration between pediatricians, transplant hepatologists, transplant surgeons, nurses, dieticians, social workers, psychologists, and other supporting services.

Pig liver xenotransplantation as a bridge to allotransplantation: which patients might benefit?

Acute liver failure is a potentially devastating clinical syndrome that, without liver transplantation (Tx), is associated with high mortality. Rapid deterioration in clinical status and a shortage of deceased human organs prohibits liver Tx in many patients. Bridging to liver Tx has been attempted by various approaches, for example, bioartificial liver support, extracorporeal pig liver perfusion, and hepatocyte Tx, but none of these approaches has convincingly improved patient survival. The orthotopic Tx of a genetically engineered pig liver could theoretically provide successful bridging. Immediate availability, perfect metabolic condition, adequate size-match and hepatocyte mass, and freedom from potentially pathogenic microorganisms could be assured. The advantages and disadvantages of bridging by pig liver Tx compared with other approaches are discussed. The selection of patients for an initial clinical trial of pig liver Tx would be similar to that of various prior trials in patients experiencing rapid and severe deterioration in liver function. The ability to give truly informed consent for a pig bridging procedure at the time of listing for liver Tx renders the patient with acute-on-chronic liver failure or primary allograft failure is a preferable candidate for this procedure than a patient who is admitted urgently with acute (fulminant) liver failure in whom consent may not be possible. Although several barriers to successful pig organ xenoTx remain, for example, coagulation dysfunction between pig and primate, if these can be resolved by further genetic engineering of the organ-source pigs, a pig liver may prove life saving to patients dying rapidly of liver failure.

Neonates with severe infantile hepatic hemangioendothelioma: limitations of liver transplantation

IHHE as the most common vascular tumor of the liver in infancy can present with acute postnatal liver and congestive heart failure. LTx may be a lifesaving option, but can be complicated by extrahepatic involvement and bleeding complications, especially in neonates. Here we discuss the benefit of LTx in cases of acute postnatal deterioration and massive extent of the hepatic tumor. Three infants with IHHE were transplanted at our institution between 2005 and 2007. Two were neonates with acute postnatal decompensation and progressive liver and heart failure within days. Treatment with steroids and chemotherapy was ineffective; resection surgery and interventional treatment were not considered appropriate. LTx was performed at the age of 7 and 24 days, respectively. An additional infant with a bilobar tumor that evolved more slowly was transplanted on day-of-life 56. Patients 1 and 2 had to be resuscitated during the LTx procedure because of massive bleeding and both died during the procedure. Patient 3 had a complicated post-operative course but is doing well one-yr post-LTx. Neonates with extended hepatic and extrahepatic involvement of IHHE should be evaluated carefully prior to LTx. Whenever possible, alternative interventional treatment options should be considered.