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Forna L, Bozomitu L, Lupu VV, Lupu A, Trandafir LM, Adam Raileanu A, Cojocariu C, Anton C, Girleanu I, Muzica CM. Pediatric Perspectives on Liver Cirrhosis: Unravelling Clinical Patterns and Therapeutic Challenges. J Clin Med 2024; 13:4275. [PMID: 39064318 PMCID: PMC11278264 DOI: 10.3390/jcm13144275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2024] [Revised: 07/01/2024] [Accepted: 07/19/2024] [Indexed: 07/28/2024] Open
Abstract
Background: Liver cirrhosis presents significant challenges in the pediatric population due to a complex interplay of etiological factors, clinical manifestations, and limited therapeutic options. The leading contributors to cirrhosis among pediatric patients are chronic cholestasis, metabolic disorders present from birth, and long-term hepatitis. Materials and method: Our narrative review aimed to synthesize literature data on the etiology, clinical picture, diagnostic techniques, optimal management of complications, and timely transplantation. Results: The epidemiology of liver cirrhosis in pediatric patients is evolving. The introduction of a universal vaccination and effective long-term viral suppression in viral hepatitis have significantly decreased complications rates. Liver transplantation programs worldwide have also improved the management of cirrhosis complications. Conclusions: Early diagnosis, comprehensive management strategies, and advancements in treatment modalities are critical for improving outcomes. Understanding these differences is crucial in providing age-appropriate care and support for those affected by cirrhosis.
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Affiliation(s)
- Lorenza Forna
- Pediatrics—“Sf. Maria” Clinical Emergency Children’s Hospital, 700309 Iași, Romania; (L.F.); (V.V.L.); (A.L.); (L.M.T.); (A.A.R.)
- Faculty of General Medicine, University of Medicine and Pharmacy “Gr. T. Popa”, 700115 Iași, Romania; (C.C.); (C.A.); (I.G.); (C.M.M.)
| | - Laura Bozomitu
- Pediatrics—“Sf. Maria” Clinical Emergency Children’s Hospital, 700309 Iași, Romania; (L.F.); (V.V.L.); (A.L.); (L.M.T.); (A.A.R.)
- Faculty of General Medicine, University of Medicine and Pharmacy “Gr. T. Popa”, 700115 Iași, Romania; (C.C.); (C.A.); (I.G.); (C.M.M.)
| | - Vasile Valeriu Lupu
- Pediatrics—“Sf. Maria” Clinical Emergency Children’s Hospital, 700309 Iași, Romania; (L.F.); (V.V.L.); (A.L.); (L.M.T.); (A.A.R.)
- Faculty of General Medicine, University of Medicine and Pharmacy “Gr. T. Popa”, 700115 Iași, Romania; (C.C.); (C.A.); (I.G.); (C.M.M.)
| | - Ancuta Lupu
- Pediatrics—“Sf. Maria” Clinical Emergency Children’s Hospital, 700309 Iași, Romania; (L.F.); (V.V.L.); (A.L.); (L.M.T.); (A.A.R.)
- Faculty of General Medicine, University of Medicine and Pharmacy “Gr. T. Popa”, 700115 Iași, Romania; (C.C.); (C.A.); (I.G.); (C.M.M.)
| | - Laura Mihaela Trandafir
- Pediatrics—“Sf. Maria” Clinical Emergency Children’s Hospital, 700309 Iași, Romania; (L.F.); (V.V.L.); (A.L.); (L.M.T.); (A.A.R.)
- Faculty of General Medicine, University of Medicine and Pharmacy “Gr. T. Popa”, 700115 Iași, Romania; (C.C.); (C.A.); (I.G.); (C.M.M.)
| | - Anca Adam Raileanu
- Pediatrics—“Sf. Maria” Clinical Emergency Children’s Hospital, 700309 Iași, Romania; (L.F.); (V.V.L.); (A.L.); (L.M.T.); (A.A.R.)
- Faculty of General Medicine, University of Medicine and Pharmacy “Gr. T. Popa”, 700115 Iași, Romania; (C.C.); (C.A.); (I.G.); (C.M.M.)
| | - Camelia Cojocariu
- Faculty of General Medicine, University of Medicine and Pharmacy “Gr. T. Popa”, 700115 Iași, Romania; (C.C.); (C.A.); (I.G.); (C.M.M.)
- Department of Clinical Gastroenterology, “Sf. Spiridon” Clinical Emergency Hospital, 700111 Iași, Romania
| | - Carmen Anton
- Faculty of General Medicine, University of Medicine and Pharmacy “Gr. T. Popa”, 700115 Iași, Romania; (C.C.); (C.A.); (I.G.); (C.M.M.)
- Department of Clinical Gastroenterology, “Sf. Spiridon” Clinical Emergency Hospital, 700111 Iași, Romania
| | - Irina Girleanu
- Faculty of General Medicine, University of Medicine and Pharmacy “Gr. T. Popa”, 700115 Iași, Romania; (C.C.); (C.A.); (I.G.); (C.M.M.)
- Department of Clinical Gastroenterology, “Sf. Spiridon” Clinical Emergency Hospital, 700111 Iași, Romania
| | - Cristina Maria Muzica
- Faculty of General Medicine, University of Medicine and Pharmacy “Gr. T. Popa”, 700115 Iași, Romania; (C.C.); (C.A.); (I.G.); (C.M.M.)
- Department of Clinical Gastroenterology, “Sf. Spiridon” Clinical Emergency Hospital, 700111 Iași, Romania
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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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Wu Y, Jing Y, Li T, Che L, Sheng M, Jia L, Li H, Yu W, Weng Y. Impact of patent foramen ovale on short-term outcomes in children with biliary atresia undergoing living donor liver transplantation: a retrospective cohort study. BMC Anesthesiol 2023; 23:315. [PMID: 37715177 PMCID: PMC10503016 DOI: 10.1186/s12871-023-02268-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 09/04/2023] [Indexed: 09/17/2023] Open
Abstract
OBJECTIVE To investigate the impact of patent foramen ovale (PFO) on the short-term outcomes of living donor liver transplantation (LDLT) in children with biliary atresia. METHODS With the approval of the hospital ethics committee, 304 children with biliary atresia who underwent LDLT in our center from January 2020 to December 2021 were enrolled. According to the results of echocardiography before the operation, the subjects were divided into the PFO group (n = 73) and the NoPFO group (n = 231). The baseline characteristics; intraoperative recipient-related data and donor-related data; incidence of postreperfusion syndrome (PRS); postoperative mechanical ventilation time; ICU stay duration; postoperative hospital stay duration; liver function index; incidences of postoperative complications including acute renal injury (AKI), graft dysfunction, hepatic artery thrombosis (HAT) and portal vein thrombosis (PVT); and one-year survival rate were compared between the two groups. RESULTS The median age in the PFO group was 6 months and that in the NoPFO group was 9 months (P < 0.001), and the median height (65 cm) and weight (6.5 kg) in the PFO group were significantly lower than those in the NoPFO group (68 cm, 8.0 kg) (P < 0.001). The preoperative total bilirubin level (247 vs. 202 umol/L, P = 0.007) and pediatric end-stage liver disease (PELD) score (21 vs. 16, P = 0.001) in the PFO group were higher than those in the NoPFO group. There were no significant differences in the intraoperative PRS incidence (46.6% vs. 42.4%, P = 0.533 ), postoperative mechanical ventilation time (184 vs. 220 min, P = 0.533), ICU stay duration (3.0 vs. 2.5 d, P = 0.267), postoperative hospital stay duration (22 vs. 21 d, P = 0.138), AKI incidence (19.2% vs. 24.7%, P = 0.333), graft dysfunction incidence (11.0% vs. 12.6%, P = 0.716), HAT incidence (5.5% vs. 4.8%, P = 0.762), PVT incidence (2.7% vs. 2.2%, P = 0.675) or one-year survival rate (94.5% vs. 95.7%, P = 0.929) between the two groups. CONCLUSION The presence of PFO has no negative impact on short-term outcomes in children with biliary atresia after LDLT.
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Affiliation(s)
- Yuli Wu
- Department of Anesthesiology, Tianjin First Central Hospital, 300192, Tianjin, China
| | - Yongle Jing
- Department of Cardiology, Tianjin First Central Hospital, 300192, Tianjin, China
| | - Tianying Li
- School of Medicine, Nankai University, 300071, Tianjin, China
| | - Lu Che
- Department of Anesthesiology, Tianjin First Central Hospital, 300192, Tianjin, China
| | - Mingwei Sheng
- Department of Anesthesiology, Tianjin First Central Hospital, 300192, Tianjin, China
| | - Lili Jia
- Department of Anesthesiology, Tianjin First Central Hospital, 300192, Tianjin, China
| | - Hongxia Li
- Department of Anesthesiology, Tianjin First Central Hospital, 300192, Tianjin, China
| | - Wenli Yu
- Department of Anesthesiology, Tianjin First Central Hospital, 300192, Tianjin, China.
| | - Yiqi Weng
- Department of Anesthesiology, Tianjin First Central Hospital, 300192, Tianjin, China.
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McElroy LM, Martin AE, Feldman AG, Ng VL, Kato T, Reichman T, Valentino PL, Anand R, Anderson SG, Sudan DL. An appraisal of technical variant grafts compared to whole liver grafts in pediatric liver transplant recipients: Multicenter analysis from the SPLIT registry. Pediatr Transplant 2023; 27:e14415. [PMID: 36303260 PMCID: PMC10184704 DOI: 10.1111/petr.14415] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 08/08/2022] [Accepted: 08/10/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Shortages of liver allografts for children awaiting transplantation have led to high LT waitlist mortality. Prior studies have shown that usage of TVG can reduce waiting time and waitlist mortality, but their use is not universal. We sought to compare patient and graft survival between WLG and TVG and to identify potential associated risk factors in a contemporary pediatric LT cohort. METHODS We performed a retrospective analysis of patient survival, graft survival, and biliary and vascular complications for LT recipients <18 years old entered into the Society of Pediatric Liver Transplantation prospective multicenter database. RESULTS Of 1839 LT recipients, 1029 received a WLG and 810 received a TVG from either a LD or a DD. There was no difference in patient survival or graft survival by graft type. Three-year patient survival and graft survival were 96%, 93%, and 96%, and 95%, 89%, and 92% for TVG-LD, TVG-DD, and WLG, respectively. Biliary complications were more frequent in TVG. Hepatic artery thrombosis was more frequent in WLG. Multivariate analysis revealed primary diagnosis was the only significant predictor of patient survival. Predictors for graft survival included time-dependent development of biliary and vascular complications. CONCLUSIONS There were no significant differences in patient and graft survival based on graft types in this North American multi-center pediatric cohort. Widespread routine use of TVG should be strongly encouraged to decrease mortality on the waitlist for pediatric LT candidates.
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Affiliation(s)
- Lisa M McElroy
- Division of Abdominal Transplant Surgery, Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Abigail E Martin
- Division of Solid Organ Transplantation, Department of Surgery, Nemours Children's Hospital Delaware, Wilmington, Delaware, USA
| | - Amy G Feldman
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Digestive Health Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Vicky L Ng
- Division of Gastroenterology, Hepatology and Nutrition, Transplant and Regenerative Medicine Center, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Tomoaki Kato
- Division of Abdominal Organ Transplantation, Department of Surgery, New York Presbyterian-Morgan Stanley Children's Hospital, Columbia University, New York, New York, USA
| | - Trevor Reichman
- Multi Organ Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Pamela L Valentino
- Division of Gastroenterology and Hepatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
| | | | | | - Debra L Sudan
- Division of Abdominal Transplant Surgery, Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
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Martínez-Rodrigo JJ, Boukhoubza A, Enguix DP, García-Marcos R, Vila-Carbó JJ, Domenech A, Nebot CS, Solana J, Marti-Bonmatí L. Feasibility and outcomes of transjugular intrahepatic portosystemic shunts in infants. Pediatr Radiol 2022; 53:953-962. [PMID: 36580102 DOI: 10.1007/s00247-022-05575-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 12/03/2022] [Accepted: 12/14/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Experience with transjugular intrahepatic portosystemic shunts (TIPS) in the pediatric population, especially in infants, is limited. OBJECTIVE To evaluate the feasibility, efficacy and safety of TIPS placement in infants. MATERIALS AND METHODS This retrospective non-comparative observational cohort study analyzed all pediatric patients < 12 months of age treated with TIPS while waiting for liver transplant between October 2018 and April 2021. The sample consisted of 10 infants with chronic liver disease. All had refractory ascites and decreased portal vein size. Their mean age ± standard deviation was 5 ± 1 months and their mean weight was 5.4 ± 1.0 kg. We calculated the pediatric end-stage liver disease score and portosystemic gradients before and after TIPS placement. We used ultrasound to check for complications and to assess the presence of ascites. We used paired-sample t-test for the mean comparison of paired variables. RESULTS Ten TIPS procedures were performed that were technically and hemodynamically successful except for one, in which an extrahepatic portal puncture required surgical repair. Ascites resolved in three infants and was reduced in six. The portal vein size remained stable after TIPS placement. Four infants had early stent thrombosis and two had late stent thrombosis treated with angioplasty or covered stents. CONCLUSION TIPS placement in infants is a feasible, safe and effective procedure.
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Affiliation(s)
- José J Martínez-Rodrigo
- Department of Radiology, Hospital Universitario y Politécnico La Fe, Avda. de Fernando Abril Martorell, 106, 46026, Valencia, Spain.
| | - Ali Boukhoubza
- Department of Radiology, Hospital Universitario y Politécnico La Fe, Avda. de Fernando Abril Martorell, 106, 46026, Valencia, Spain
| | - Daniel Pérez Enguix
- Department of Radiology, Hospital Universitario y Politécnico La Fe, Avda. de Fernando Abril Martorell, 106, 46026, Valencia, Spain
| | - Raúl García-Marcos
- Department of Radiology, Hospital Universitario y Politécnico La Fe, Avda. de Fernando Abril Martorell, 106, 46026, Valencia, Spain
| | - Juan J Vila-Carbó
- Department of Pediatric Surgery, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Anna Domenech
- Department of Pediatric Surgery, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Cinta Sangüesa Nebot
- Department of Radiology, Hospital Universitario y Politécnico La Fe, Avda. de Fernando Abril Martorell, 106, 46026, Valencia, Spain
| | - Jimena Solana
- Department of Radiology, Hospital Universitario y Politécnico La Fe, Avda. de Fernando Abril Martorell, 106, 46026, Valencia, Spain
| | - Luis Marti-Bonmatí
- Department of Radiology, Hospital Universitario y Politécnico La Fe, Avda. de Fernando Abril Martorell, 106, 46026, Valencia, Spain
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Taylor SA, Venkat V, Arnon R, Gopalareddy VV, Rosenthal P, Anderson SG, Anand R, Daniel JF. Organ-Specific Comorbidities Are Associated With Distinct Complications After Liver Transplantation for Biliary Atresia. Liver Transpl 2022; 28:855-866. [PMID: 34821466 DOI: 10.1002/lt.26376] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/22/2021] [Accepted: 11/12/2021] [Indexed: 01/24/2023]
Abstract
Although transplant outcomes for biliary atresia (BA) have improved, there are few data to predict the risk of specific posttransplant complications. We therefore defined the impact of comorbidities in BA on posttransplant outcomes. Patients enrolled in the Society of Pediatric Liver Transplantation registry from 2011 to 2019 (n = 1034) were grouped by comorbidities of >1.0% incidence: any supplemental feeding, dialysis, other abdominal surgery (not Kasai portoenterostomy [KPE]), hepatopulmonary syndrome, and cardiac disease requiring intervention. Demographic and outcome data were compared using the Kruskal-Wallis, chi-square, and log-rank tests. Cox proportional hazards models and binary logistic regression were performed for modeling. Patients with BA with comorbidities comprised 77% (n = 799) of our cohort and had evidence of greater medical acuity, including higher calculated Pediatric End-Stage Liver Disease scores and hospitalizations in the intensive care unit before transplant (P < 0.001 for both) versus those without comorbidities. After transplant, patients with BA with comorbidities had more graft loss (P = 0.02), longer initial hospitalization and intubation (P < 0.001 for both), and increased rates of reoperation (P = 0.001) and culture-proven infection (P < 0.001) within 30 days after transplant. Only patients with BA with comorbidities on supplemental feed had increased rates of patient death (P = 0.02). Multivariate analysis identified lower z weight and higher creatinine as risk factors for graft and patient loss in patients with BA with comorbidities. Prior KPE was protective against culture-proven infection and vascular complications within 30 and 90 days, respectively. Patients with BA with comorbidities have evidence of higher medical acuity at transplant and reduced graft survival; however, they overall did not experience greater incidence of patient death. Our data provide organ-system-specific data to risk-stratify patients with BA and posttransplant outcomes.
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Affiliation(s)
- Sarah A Taylor
- Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Veena Venkat
- Department of Pediatrics, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Ronen Arnon
- Department of Pediatrics, Mount Sinai School of Medicine, New York, NY
| | - Vani V Gopalareddy
- Department of Pediatrics, Levine Children's Hospital at Atrium Health, Charlotte, NC
| | - Philip Rosenthal
- Department of Pediatrics and Surgery, University of California San Francisco, San Francisco, CA
| | | | | | - James F Daniel
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO
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Boster JM, Feldman AG, Mack CL, Sokol RJ, Sundaram SS. Malnutrition in Biliary Atresia: Assessment, Management, and Outcomes. Liver Transpl 2022; 28:483-492. [PMID: 34669243 PMCID: PMC8857023 DOI: 10.1002/lt.26339] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 10/08/2021] [Accepted: 10/11/2021] [Indexed: 01/05/2023]
Abstract
Children with biliary atresia (BA), particularly infants, are at high risk for malnutrition attributed to a multitude of factors, including poor oral intake and intolerance of enteral feeding, fat malabsorption, abnormal nutrient metabolism, and increased caloric demand. Malnutrition and sarcopenia negatively impact outcomes in BA, leading to higher pretransplant and posttransplant morbidity and mortality. This review summarizes factors contributing to nutritional deficiencies in BA and offers an organized approach to the assessment and management of malnutrition in this vulnerable population.
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Affiliation(s)
- Julia M Boster
- Department of Pediatrics, Pediatric Liver Center, Digestive Health Institute and Section of Pediatric Gastroenterology, Hepatology & Nutrition, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | - Amy G Feldman
- Department of Pediatrics, Pediatric Liver Center, Digestive Health Institute and Section of Pediatric Gastroenterology, Hepatology & Nutrition, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | - Cara L Mack
- Department of Pediatrics, Pediatric Liver Center, Digestive Health Institute and Section of Pediatric Gastroenterology, Hepatology & Nutrition, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ronald J Sokol
- Department of Pediatrics, Pediatric Liver Center, Digestive Health Institute and Section of Pediatric Gastroenterology, Hepatology & Nutrition, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | - Shikha S Sundaram
- Department of Pediatrics, Pediatric Liver Center, Digestive Health Institute and Section of Pediatric Gastroenterology, Hepatology & Nutrition, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
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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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9
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Takeda M, Sakamoto S, Uchida H, Shimizu S, Yanagi Y, Fukuda A, Nosaka S, Kasahara M. Impact of sarcopenia in infants with liver transplantation for biliary atresia. Pediatr Transplant 2021; 25:e13950. [PMID: 33326674 DOI: 10.1111/petr.13950] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 11/13/2020] [Accepted: 12/01/2020] [Indexed: 12/11/2022]
Abstract
While sarcopenia is an important predictor of LT outcomes in adults, few studies have examined the association of sarcopenia with LT outcomes in pediatric patients. We investigated the clinical influence of sarcopenia on the post-transplant outcomes in infants with BA. To define sarcopenia in infants, the cross-sectional area of the tPMA in 93 healthy control infants was measured by computed tomography. Sarcopenia was defined as a tPMA lower than two standard deviations below the mean of healthy control infants. Eighty-nine infants with BA with a median age at LT of 7.6 months old were enrolled. The clinical characteristics and outcomes of LT were verified in the sarcopenia group (n = 21) and non-sarcopenia group (n = 68). The sarcopenia group had a significantly longer operation time and greater blood loss during LT than the non-sarcopenia group (P = .03 and 0.02). The incidence of portal vein stenosis and post-operative bloodstream infection was also significantly higher in the sarcopenia group than in the non-sarcopenia group (23.8% vs 4.4%, P = .02 and 28.6% vs 10.3%, P = .04, respectively). The total length of hospital stay did not differ significantly. The 1-year patient and graft survival rates tended to be lower in the sarcopenia group than in the non-sarcopenia group (90.5% vs 98.5%, P = .07 and 85.7% vs 97.1%, P = .05, respectively). Sarcopenia in infants with BA may be associated with the patient survival and serve as an effective marker for post-operative outcomes of LT.
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Affiliation(s)
- Masahiro Takeda
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Seisuke Sakamoto
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Hajime Uchida
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Seiichi Shimizu
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Yusuke Yanagi
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Akinari Fukuda
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Shunsuke Nosaka
- Department of Radiology, National Center for Child Health and Development, Tokyo, Japan
| | - Mureo Kasahara
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
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10
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Perito ER, Squires JE, Bray D, Bucuvalas J, Krise-Confair C, Eisenberg E, Gonzalez-Peralta RP, Gupta N, Hsu EK, Kosmach-Park B, Lobritto S, Logan B, Mohammad S, Ng VL, Pillari T, Rasmussen S, Shemesh E, Soltys K, Szolna J, Superina R, Tunno J, Mazariegos GV. A Learning Health System for Pediatric Liver Transplant: The Starzl Network for Excellence in Pediatric Transplantation. J Pediatr Gastroenterol Nutr 2021; 72:417-424. [PMID: 33560758 DOI: 10.1097/mpg.0000000000002974] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE Learning health systems (LHS) integrate research, improvement, management, and patient care, such that every child receives "the right care at the right time...every time," that is, evidence-based, personalized medicine. Here, we report our efforts to establish a sustainable, productive, multicenter LHS focused on pediatric liver transplantation. METHODS The Starzl Network for Excellence in Pediatric Transplantation (SNEPT) is the first multicenter effort by pediatric liver transplant families and providers to develop shared priorities and a shared agenda for innovation in clinical care. This report outlines SNEPT's structure, accomplishments, and challenges as an LHS. RESULTS We prioritized 4 initial projects: immunosuppression, perioperative anticoagulation, quality of life, and transition of care. We shared center protocols/management to identify areas of practice variability between centers. We prioritized actionable items that address barriers to providing "the right care at the right time" to every pediatric liver transplant recipient: facilitating transparency of practice variation and the connection of practices to patient outcomes, harnessing existing datasets to reduce the burden of tracking outcomes, incorporating patient-reported outcomes into outcome metrics, and accelerating the implementation of knowledge into clinical practice. This has allowed us to strengthen collaborative relationships, design quality improvement projects, and collect pilot data for each of our priority projects. CONCLUSIONS The field of pediatric liver transplantation can be advanced through application of LHS principles. Going forward, SNEPT will continue to unite patient advocacy, big data, technology, and transplant thought leaders to deliver the best care, while developing new, scalable solutions to pediatric transplantation's most challenging problems.
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Affiliation(s)
- Emily R Perito
- University of California San Francisco, Benioff Children's Hospital, San Francisco, CA
| | - James E Squires
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - David Bray
- Patient and Family Voice. Starzl Network for Excellence in Pediatric Transplantation
| | - John Bucuvalas
- Recanati Miller Transplant Institute, Icahn School of Medicine at Mount Sinai, Mount Sinai Kravis Children's Hospital, New York, NY
| | - Cassandra Krise-Confair
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Elizabeth Eisenberg
- Patient and Family Voice. Starzl Network for Excellence in Pediatric Transplantation
| | | | - Nitika Gupta
- Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA
| | - Evelyn K Hsu
- University of Washington School of Medicine, Department of Pediatrics, Division of Gastroenterology and Hepatology, Seattle Children's Hospital, Seattle, WA
| | - Beverly Kosmach-Park
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Steven Lobritto
- Columbia University Medical Center, Children's Hospital of New York, New York, NY
| | - Beth Logan
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Saeed Mohammad
- Northwestern University Feinberg School of Medicine, Lurie Children's Hospital, Chicago, IL
| | - Vicky L Ng
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Eyal Shemesh
- Recanati Miller Transplant Institute, Icahn School of Medicine at Mount Sinai, Mount Sinai Kravis Children's Hospital, New York, NY
| | - Kyle Soltys
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Jonathan Szolna
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Riccardo Superina
- Northwestern University Feinberg School of Medicine, Lurie Children's Hospital, Chicago, IL
| | - John Tunno
- Patient and Family Voice. Starzl Network for Excellence in Pediatric Transplantation
| | - George V Mazariegos
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
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11
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Hsu E, Schladt DP, Wey A, Perito ER, Israni AK. Improving the predictive ability of the pediatric end-stage liver disease score for young children awaiting liver transplant. Am J Transplant 2021; 21:222-228. [PMID: 32306489 DOI: 10.1111/ajt.15925] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 03/05/2020] [Accepted: 04/05/2020] [Indexed: 01/25/2023]
Abstract
The current pediatric end-stage liver disease (PELD) score underestimates pediatric waitlist mortality. Children frequently require PELD exception points to achieve appropriate priority ranking. We developed a new PELD score using serum sodium, creatinine, and updated original PELD components to more accurately rank children and equalize children's mortality risk with the age-standardized mortality rate of adults. We included children aged younger than 12 years with chronic liver disease, listed for deceased donor livers January 1, 2005-December 31, 2017. Pediatric candidates (n = 5111) were followed from listing to the earliest of waitlist mortality (death or removal from the list due to being too sick to undergo transplant, n = 339) or 180 days. We incorporated linear splines for the current components of PELD and added sodium and creatinine to the equation. The updated PELD-Na-Cr had a cross-validated AUC ROC of 0.854, vs 0.799 for the original PELD. PELD-Na-Cr required 9.44 additional points to equalize children's mortality risk with the age-standardized mortality rate of adults. PELD-Na-Cr better ordered the sickest children and should better prioritize children relative to adults. As a result, PELD-Na-Cr could increase pediatric transplant rates and reduce pediatric liver transplant waitlist mortality.
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Affiliation(s)
- Evelyn Hsu
- Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Hospital Center for Clinical and Translational Research, Seattle, Washington, USA
| | - David P Schladt
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | - Andrew Wey
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | - Emily R Perito
- University of California San Francisco School of Medicine, Benioff Children's Hospital, San Francisco, California, USA
| | - Ajay K Israni
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA.,Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota, USA
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12
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Kassam AF, Goddard GR, Johnston ME, Cortez AR, Trout AT, Jenkins TM, Miethke AG, Campbell KM, Bezerra JA, Balistreri WF, Nathan JD, Alonso MH, Tiao GM, Bondoc AJ. Natural Course of Pediatric Portal Hypertension. Hepatol Commun 2020; 4:1346-1352. [PMID: 32923837 PMCID: PMC7471417 DOI: 10.1002/hep4.1560] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/09/2020] [Accepted: 05/31/2020] [Indexed: 12/16/2022] Open
Abstract
The etiology of portal hypertension (pHTN) in children differs from that of adults and may require different management strategies. We set out to review the etiology, management, and natural history of pHTN at a pediatric liver center. From 2008 to 2018, 151 children and adolescents with pHTN were identified at a free‐standing children’s hospital. Patients were stratified by etiology of pHTN (intrahepatic disease [IH], defined as cholestatic disease and fibrotic or hepatocellular disease; extrahepatic disease [EH], defined as hepatic vein obstruction and prehepatic pHTN). Patients with EH were more likely to undergo an esophagoduodenscopy for a suspected gastrointestinal bleed (77% vs. 41%; P < 0.01). Surgical interventions differed based on etiology (P < 0.01), with IH more likely resulting in a transplant only (65%) and EH more likely to result in a shunt only (43%); 30% of patients with IH and 47% of patients with EH did not undergo an intervention for pHTN. Kaplan‐Meier analysis revealed a significant increase in mortality in the group that received no intervention compared to shunt, transplant, or both and lower mortality in patients with prehepatic pHTN compared to other etiologies (P < 0.01 each). Multivariate analysis revealed increased odds of mortality in patients with refractory ascites (odds ratio [OR], 4.34; 95% confidence interval [CI], 1.00, 18.88; P = 0.05) and growth failure (OR, 13.49; 95% CI, 3.07, 58.99; P < 0.01). Conclusion: In this single institution study, patients with prehepatic pHTN had better survival and those who received no intervention had higher mortality than those who received an intervention. Early referral to specialized centers with experience managing these complex disease processes may allow for improved risk stratification and early intervention to improve outcomes.
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Affiliation(s)
- Al-Faraaz Kassam
- Division of Pediatric General and Thoracic Surgery Cincinnati Children's Hospital Medical Center Cincinnati OH.,Department of Surgery University of Cincinnati Cincinnati OH
| | - Gillian R Goddard
- Division of Pediatric General and Thoracic Surgery Cincinnati Children's Hospital Medical Center Cincinnati OH
| | - Michael E Johnston
- Division of Pediatric General and Thoracic Surgery Cincinnati Children's Hospital Medical Center Cincinnati OH.,Department of Surgery University of Cincinnati Cincinnati OH
| | | | - Andrew T Trout
- Department of Radiology Cincinnati Children's Hospital Medical Center Cincinnati OH.,Department of Radiology University of Cincinnati College of Medicine Cincinnati OH
| | - Todd M Jenkins
- Division of Pediatric General and Thoracic Surgery Cincinnati Children's Hospital Medical Center Cincinnati OH
| | - Alexander G Miethke
- Division of Gastroenterology, Hepatology, and Nutrition Cincinnati Children's Hospital Medical Center Cincinnati OH
| | - Kathleen M Campbell
- Division of Gastroenterology, Hepatology, and Nutrition Cincinnati Children's Hospital Medical Center Cincinnati OH
| | - Jorge A Bezerra
- Division of Gastroenterology, Hepatology, and Nutrition Cincinnati Children's Hospital Medical Center Cincinnati OH
| | - William F Balistreri
- Division of Gastroenterology, Hepatology, and Nutrition Cincinnati Children's Hospital Medical Center Cincinnati OH
| | - Jaimie D Nathan
- Division of Pediatric General and Thoracic Surgery Cincinnati Children's Hospital Medical Center Cincinnati OH
| | - Maria H Alonso
- Division of Pediatric General and Thoracic Surgery Cincinnati Children's Hospital Medical Center Cincinnati OH
| | - Gregory M Tiao
- Division of Pediatric General and Thoracic Surgery Cincinnati Children's Hospital Medical Center Cincinnati OH
| | - Alexander J Bondoc
- Division of Pediatric General and Thoracic Surgery Cincinnati Children's Hospital Medical Center Cincinnati OH
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