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Rokop ZP, Mangus RS, Tolliver K, Jarasvaraparn C, Molleston J, Mihaylov P, Kubal C. Comparative analysis of whole vs. split liver transplantation in infants. Pediatr Transplant 2023; 27:e14564. [PMID: 37424507 DOI: 10.1111/petr.14564] [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: 02/10/2023] [Revised: 04/26/2023] [Accepted: 06/27/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND Liver transplantation (LT) in infants can be challenging due to their small size and small vasculature. Although both whole LT (WLT) and split LT (SLT) have been described in infants, the head-to-head comparison of these techniques in this population is sparse. METHODS We retrospectively analyzed the records of all patients with age ≤1 year at Indiana University between 2016 and 2022. All SLT were left lateral segment grafts split in situ. RESULTS A total of 24 infants were transplanted, with 11 SLT and 13 WLT. The median follow-up time was 52.1 months. Donor and recipient characteristics were comparable except for donor age (19 years vs. 2 years; p < .01) and weight (64 kg vs. 14.2 kg; p < .01). Early allograft dysfunction, primary nonfunction, and hepatic artery thrombosis developed more frequently in the WLT group. There were no biliary complications. There were two early deaths (2 and 4 days) in the WLT group. One-year graft survival (100% vs. 77%; p = .10) and patient survival (100% vs. 85%; p = .18) were numerically higher in the SLT group. CONCLUSIONS SLT with LLS offers a safe and viable option for liver transplantation in infants and is associated with a trend toward superior outcomes. SLT should be considered as a strategy to reduce waitlist times for infants in the absence of small, deceased donors for WLT.
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Affiliation(s)
- Zachary P Rokop
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Richard S Mangus
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Kyla Tolliver
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Chaowapong Jarasvaraparn
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jean Molleston
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Plamen Mihaylov
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Chandrashekhar Kubal
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Hukkinen M, Wong M, Demir Z, Salem RH, Debray D, Renolleau S, Sissaoui S, Lacaille F, Girard M, Oualha M, Querciagrossa S, Fabre M, Lozach C, Clement R, Lasne D, Borgel D, Capito C, Chardot C. Antithrombin supplementation for prevention of vascular thrombosis after pediatric liver transplantation. J Pediatr Surg 2022; 57:666-675. [PMID: 35871859 DOI: 10.1016/j.jpedsurg.2022.06.008] [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: 11/30/2021] [Revised: 05/23/2022] [Accepted: 06/12/2022] [Indexed: 11/27/2022]
Abstract
AIMS After liver transplantation (LT), synthesis of coagulation factors by the graft recovers faster for pro thrombotic than anti thrombotic factors, resulting in a potential pro thrombotic imbalance. We studied the thrombotic and hemorrhagic complications in our pediatric LT series, providing supplementation of fresh frozen plasma (FFP) and/or antithrombin (AT) in the prophylactic antithrombotic regimen. METHODS This was a retrospective observational single center study. All isolated pediatric LTs performed between 1/11/2009 and 31/12/2019 (n = 181) were included. Postoperatively, in addition to low molecular weight heparin, 22 patients (12%) received FFP (10 ml/kg twice daily for 10 days), 27 patients (15%) were given FFP (reduced duration) and AT (50-100 IU/kg/day if AT activity remained <70%), and 132 (73%) received AT only. Complications, outcome, and coagulation profiles in postoperative days 0-10 were analyzed. RESULTS In all three treatment groups, AT activity normalized by day 4 while prothrombin remained <70% of normal until day 9. Hepatic artery thrombosis (HAT), portal vein thrombosis (PVT), and hemorrhagic complications occurred in 2.8%, 3.3%, and 3.9% of LTs. One- and 5-year patient and graft survival were 88% (±2.4% Standard Error) and 84% (±2.5%), and 86% (±2.6%) and 84% (±2.7%), respectively, without difference between groups. HAT were associated with low AT on days 0 and 1, and PVT with low AT on day 0. CONCLUSIONS Low antithrombin activity after LT was associated with postoperative thromboses. FFP and/or AT supplementation allowed early normalization of AT activity, while thrombotic or hemorrhagic complications were rare, suggesting efficient and safe management of post-LT coagulopathy.
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Affiliation(s)
- Maria Hukkinen
- Pediatric Surgery Unit, Hôpital Universitaire Necker-Enfants Malades, 149 rue de Sèvres, Paris 75015, France
| | - Michela Wong
- Pediatric Surgery Unit, Hôpital Universitaire Necker-Enfants Malades, 149 rue de Sèvres, Paris 75015, France
| | - Zeynep Demir
- Pediatric Hepatology Unit, Hôpital Universitaire Necker-Enfants Malades, 149 rue de Sèvres, Paris 75015, France
| | - Radhia Hadj Salem
- Pediatric Hepatology Unit, Hôpital Universitaire Necker-Enfants Malades, 149 rue de Sèvres, Paris 75015, France
| | - Dominique Debray
- Pediatric Hepatology Unit, Hôpital Universitaire Necker-Enfants Malades, 149 rue de Sèvres, Paris 75015, France; Université Paris Cité, 85 Bd Saint Germain, Paris 75006, France
| | - Sylvain Renolleau
- Pediatric Intensive Care Unit, Hôpital Universitaire Necker-Enfants Malades, 149 rue de Sèvres, Paris 75015, France; Université Paris Cité, 85 Bd Saint Germain, Paris 75006, France
| | - Samira Sissaoui
- Pediatric Hepatology Unit, Hôpital Universitaire Necker-Enfants Malades, 149 rue de Sèvres, Paris 75015, France
| | - Florence Lacaille
- Pediatric Hepatology Unit, Hôpital Universitaire Necker-Enfants Malades, 149 rue de Sèvres, Paris 75015, France
| | - Muriel Girard
- Pediatric Hepatology Unit, Hôpital Universitaire Necker-Enfants Malades, 149 rue de Sèvres, Paris 75015, France; Université Paris Cité, 85 Bd Saint Germain, Paris 75006, France
| | - Mehdi Oualha
- Pediatric Intensive Care Unit, Hôpital Universitaire Necker-Enfants Malades, 149 rue de Sèvres, Paris 75015, France; Université Paris Cité, 85 Bd Saint Germain, Paris 75006, France
| | - Stefania Querciagrossa
- Pediatric Anesthesiology Department, Hôpital Universitaire Necker-Enfants Malades, 149 rue de Sèvres, Paris 75015, France
| | - Monique Fabre
- Pathology Department, Hôpital Universitaire Necker-Enfants Malades, 149 rue de Sèvres, Paris 75015, France
| | - Cecile Lozach
- Radiology Department, Hôpital Universitaire Necker-Enfants Malades, 149 rue de Sèvres, Paris 75015, France
| | - Rozenn Clement
- Pharmacy, Hôpital Universitaire Necker-Enfants Malades, 149 rue de Sèvres, Paris 75015, France
| | - Dominique Lasne
- Université Paris Cité, 85 Bd Saint Germain, Paris 75006, France; Biological Hematology Laboratories, Hôpital Universitaire Necker-Enfants Malades, 149 rue de Sèvres, Paris 75015, France
| | - Delphine Borgel
- Université Paris Cité, 85 Bd Saint Germain, Paris 75006, France; Biological Hematology Laboratories, Hôpital Universitaire Necker-Enfants Malades, 149 rue de Sèvres, Paris 75015, France
| | - Carmen Capito
- Pediatric Surgery Unit, Hôpital Universitaire Necker-Enfants Malades, 149 rue de Sèvres, Paris 75015, France; Université Paris Cité, 85 Bd Saint Germain, Paris 75006, France.
| | - Christophe Chardot
- Pediatric Surgery Unit, Hôpital Universitaire Necker-Enfants Malades, 149 rue de Sèvres, Paris 75015, France; Université Paris Cité, 85 Bd Saint Germain, Paris 75006, France
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Lemoine CP, Brandt KA, Mohammad S, Bhat R, Superina R. Early thrombotic and hemorrhagic complications associated with a risk-adjusted postoperative anticoagulation protocol after pediatric liver transplantation. Pediatr Blood Cancer 2022; 69:e29898. [PMID: 35906750 DOI: 10.1002/pbc.29898] [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: 01/12/2022] [Revised: 05/28/2022] [Accepted: 06/30/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Systemic anticoagulation after pediatric liver transplantation (pLT) is believed to reduce the incidence of vascular thrombosis, but it may also cause an increase in hemorrhagic complications. PROCEDURE A 5-year retrospective review of pLT done at our institution was performed (2014-2018). The occurrence of early hemorrhagic and thrombotic complications was compared when using low-dose or high-dose anticoagulation after transplant (p < .05 considered significant). RESULTS Sixty-nine patients received 73 transplants during the study period. Median age at transplant was 2.3 years (40 days to 18.5 years). Low-dose anticoagulation was utilized in 71% cases. Additionally, six patients were converted from low-dose to high-dose anticoagulation because of a thrombotic event or concerns for suboptimal vascular inflow. Postoperative anticoagulation was discontinued in 18 occurrences due to bleeding (low dose 19%, high dose 47% vs. low dose to high dose 17%, p = .085). Surgical take back for bleeding occurred in 17 occasions (low dose 13.5%, high dose 53% vs. low dose to high dose 33%, p = .005). The overall incidence of hepatic artery thrombosis (HAT) and portal vein thrombosis were each 5.5%, respectively. While patient survival was not statistically different between groups, graft survival was significantly lower in the high-dose group (low dose 93%, high dose 73% vs. low dose to high dose 100%, p = .046). However, graft losses from HAT were similar between groups (low dose 2%, high dose 7% vs. low dose to high dose 0%, p = .56). CONCLUSION The use of a standardized risk-adjusted anticoagulation protocol after pLT is associated with a low occurrence of thrombotic and hemorrhagic complications. High-dose anticoagulation leads to more bleeding, but those risks outweigh the risks of possible graft loss.
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Affiliation(s)
- Caroline P Lemoine
- Division of Transplant and Advanced Hepatobiliary Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Katherine A Brandt
- Division of Transplant and Advanced Hepatobiliary Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Saeed Mohammad
- Division of Gastroenterology, Hepatology, and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Rukhmi Bhat
- Division of Hematology, Oncology and Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Riccardo Superina
- Division of Transplant and Advanced Hepatobiliary Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
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Maue DK, Mangus RS, Lutfi R, Hobson MJ, Rao GS, Nitu ME, Abu-Sultaneh S. Practice variation in the immediate postoperative care of pediatric liver transplant patients: Framework for a national consensus. Pediatr Transplant 2021; 25:e13976. [PMID: 33502816 DOI: 10.1111/petr.13976] [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: 05/20/2020] [Revised: 07/20/2020] [Accepted: 08/24/2020] [Indexed: 11/27/2022]
Abstract
Advancements in critical care management have led to improvement in pediatric LT outcomes. However, there are no specific guidelines for many aspects of immediate post-LT care. This survey examines practice variations in the immediate postoperative care of pediatric LT patients at a large number of active US centers. This study is a cross-sectional survey of medical directors at PALISI-affiliated PICU in the United States. Centers performing pediatric LT were analyzed. Study measures included PICU practices regarding staffing, composition of the multidisciplinary team, early post-LT graft and patient monitoring, and anticoagulation. Of the thirty-five responding centers, twenty-five had a LT program which accounted for one-half of all US pediatric LTs. For analysis, centers were categorized by volume: high (7), medium (11), and low (7). The majority of PICU teams included an intensivist (80%) and hepatologist (84%). High-volume centers were less likely to have 24-hour in-house attending coverage (29%, compared to 64% (medium) and 100% (low)). High-volume centers were most likely to have pre-printed orders, but least likely to have written PICU management protocols. Most centers utilize routine daily liver ultrasound. Routine prophylactic anticoagulation, and the agent of choice, was variable. There is marked inconsistency in post-LT practice across PALISI centers in regards to team composition and immediate post-LT management. A national US consensus for post-LT PICU practices would facilitate outcomes research and would establish a platform for multicenter studies.
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Affiliation(s)
- Danielle K Maue
- Division of Critical Care, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Richard S Mangus
- Transplant Division, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Riad Lutfi
- Division of Critical Care, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Michael J Hobson
- Division of Critical Care, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Girish S Rao
- Division of Gastroenterology, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mara E Nitu
- Division of Critical Care, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Samer Abu-Sultaneh
- Division of Critical Care, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
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Jamil O, Fung J, Kelly D, Azzam R. Perioperative fatal pulmonary embolism in a pediatric liver transplant recipient. Pediatr Transplant 2021; 25:e14017. [PMID: 33772990 DOI: 10.1111/petr.14017] [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: 03/11/2021] [Accepted: 03/15/2021] [Indexed: 11/27/2022]
Abstract
Patients with cirrhotic liver disease are in a state of fluctuating hemostatic balance. Hepatic synthetic dysfunction is commonly complicated by coagulation disorders that constitute an important parameter of most prognostic scores. The dominant feature of this dysfunction is bleeding tendencies, but cirrhotic patients may also exhibit inappropriate clotting and pro-coagulation placing them at risk for thromboembolism. We present a case of perioperative fatal pulmonary embolism in an 8-year-old patient with biliary cirrhosis secondary to drug-induced vanishing bile duct syndrome undergoing a deceased donor liver transplant. The massive pulmonary embolism occurred intra-operatively after reperfusion of the donor liver. Despite the initiation of extracorporeal membrane oxygenation, the postoperative course was complicated by bleeding and the patient expired. This unique case highlights the need for venous thromboembolism prevention by screening and prophylaxis prior to liver transplant in at least a subpopulation of pediatric patients. While the risk of thrombosis postoperatively in pediatrics patients is well known, the preoperative risk is less frequently described and deserves attention and practice changing action.
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Affiliation(s)
- Omar Jamil
- Departments of Internal Medicine and Pediatrics, University of Chicago, Chicago, IL, USA
| | - John Fung
- Department of Surgery, Section of Transplant Surgery, University of Chicago, Chicago, IL, USA
| | - Dympna Kelly
- Department of Surgery, Section of Transplant Surgery, University of Chicago, Chicago, IL, USA
| | - Ruba Azzam
- Department of Pediatrics, Section of Pediatric Gastroenterology and Hepatology, University of Chicago, Chicago, IL, USA
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Namgoong JM, Hwang S, Kim DY, Ha TY, Song GW, Jung DH, Park GC, Kim KM, Oh SH. Whole liver deceased donor liver transplantation for pediatric recipients: single-center experience for 20 years. KOREAN JOURNAL OF TRANSPLANTATION 2020; 34:249-256. [PMID: 35770102 PMCID: PMC9186848 DOI: 10.4285/kjt.20.0036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 09/30/2020] [Accepted: 10/02/2020] [Indexed: 12/26/2022] Open
Abstract
Background We investigated the incidence and outcomes of pediatric deceased donor liver transplantation (DDLT) using whole liver grafts in a high-volume liver transplantation (LT) center. Methods The study was a retrospective single-center analysis of whole LT in pediatric recipients. The study period was set as 20 years between January 2000 and December 2019. We defined pediatric recipients and donors to be aged ≤18 years. Results During the study period, there were 98 cases of pediatric DDLT, and 34 patients (34.7%) received whole liver grafts. The age range of the deceased donors was 3 months to 56 years and that of pediatric recipients was 7 months to 17 years. Common primary diseases for LT were biliary atresia in 13, acute liver failure in four, Wilson disease in four, congenital portal vein agenesis in three, and genetic metabolic diseases in three. Pediatric-to-pediatric and adult-to-pediatric whole LTs were 22 (64.7%) and 12 (35.3%), respectively. A good correlation was noted between the donor and the recipient’s body weight, and the recipient’s body weight and allograft’s weight. Graft and overall patient survival rates were 91.2% and 91.2% at 1 year, 88.0% and 88.0% at 3 years, and 88.0% and 88.0% at 5 years, respectively. Conclusions The results of this study revealed that Korean Network for Organ Sharing (KONOS) regulations with donor-recipient body weight matching exhibited good performance. Considering the reciprocal trades of liver organs among pediatric and adult donors and recipients, it is necessary to establish a policy for pediatric donor liver grafts to pediatric recipients on a priority basis.
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Affiliation(s)
- Jung-Man Namgoong
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Shin Hwang
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dae-Yeon Kim
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae-Yong Ha
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gi-Won Song
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Hwan Jung
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gil-Chun Park
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyung Mo Kim
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seak Hee Oh
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Namgung JM, Hwang S, Ahn CS, Kim KH, Moon DB, Ha TY, Song GW, Jung DH, Park GC, Kim DY, Kim KM, Oh SH, Lee SG. Korea-nationwide incidence of pediatric deceased donors and single-institutional status of liver transplantation using pediatric donor liver grafts. KOREAN JOURNAL OF TRANSPLANTATION 2020; 34:178-184. [PMID: 35769067 PMCID: PMC9187037 DOI: 10.4285/kjt.2020.34.3.178] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 08/17/2020] [Accepted: 08/17/2020] [Indexed: 12/03/2022] Open
Abstract
Background The present study intended to investigate the allocation status of pediatric deceased donor liver allografts. We analyzed the incidence of pediatric deceased donors in the Korean Network for Organ Sharing (KONOS) database and single-institutional status of liver transplantation (LT) using pediatric donors. Methods We assessed the nationwide incidence of pediatric donors aged ≤15 years and conducted single-center analysis of LT using pediatric donors. Results Between 2010 and 2019, pediatric donors aged ≤15 years accounted for 171 out of 4,395 donors (3.9%) in the KONOS database and 31 out of 640 liver donors (4.8%) in Asan Medical Center (AMC) database. In AMC, 11 (35.5%) and 20 (64.5%) grafts were allocated to pediatric recipients aged ≤15 years and adult recipients aged ≥19 years, respectively. All nine livers from donors aged ≤5 years were implanted in pediatric recipients aged ≤5 years. From 21 donors aged ≥9 years, 16 whole liver grafts and four split extended right liver grafts were implanted in 20 adult recipients and two split left lateral section grafts were implanted in two pediatric recipients. Four split liver grafts were implanted in other institutions. The overall patient survival rates at 1, 3, and 5 years were 90.9%, 80.8%, and 80.8%, respectively in pediatric-to-pediatric LT group and 69.6%, 58.4%, and 58.4%, respectively in pediatric-to-adult LT group (P=0.21). Conclusions More than half of the pediatric donor livers were allocated to adult patients. Recipient criteria for allocation of liver allografts from pediatric donors need revision for children on pediatric LT waitlist.
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Affiliation(s)
- Jung-Man Namgung
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Shin Hwang
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chul-Soo Ahn
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ki-Hun Kim
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Deok-Bog Moon
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae-Yong Ha
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gi-Won Song
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Hwan Jung
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gil-Chun Park
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dea-Yeon Kim
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyung Mo Kim
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seak Hee Oh
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Gyu Lee
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Fortunato AC, Pinheiro RS, Nacif LS, Waisberg DR, Ducatti L, Rocha-Santos V, Galvao FHF, Haddad LBP, Abdala E, Song ATW, Terrabuio DRB, Bezerra ROF, Macedo RA, Martino RB, Andraus W, Carneiro-D'Albuquerque LA. Hepatic Artery Thrombosis in Liver Transplantation in Adult Recipients Using Pediatric Deceased Donors. Transplant Proc 2020; 52:1332-1335. [PMID: 32249054 DOI: 10.1016/j.transproceed.2020.02.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 02/06/2020] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Routinely, pediatric donor (PD) grafts are allocated to pediatric liver transplantation (LT) recipients; however, occasionally they can be allocated for adult recipients (ARs). Some authors reported decreased patient/graft survival and higher vascular complications, such as hepatic artery thrombosis (HAT), in LT in ARs using PDs. METHODS It is a retrospective study enrolling 1202 ARs undergoing LT using whole liver grafts during the period of January 2002 to April 2019. The patients were categorized according to donor age in 2 groups: PDs and adult donors (ADs). The variables were collected from the database including the graft to recipient weight ratio (GWRW) and the incidence of HAT and graft primary nonfunction (PNF). RESULTS The AD group had 1152 patients, and the PD group had 50 patients. PNF occurred in 68 (5.66%) patients, and the distribution between the 2 groups were similar: 65 (5.64%) in the AD group, and 3 (6%) in the PD group (P = .915). HAT was diagnosed in 30 (2.6%) patients in the AD group and in 6 (12%) patients in the PD group. HAT was significantly higher in the PD group (P = .001). In the PD group, the GWRWs among patients diagnosed with HAT were similar (P = .152). CONCLUSION HAT is higher in PDs, although it is a viable alternative with satisfactory results. Serial Doppler in the first week and early introduction of platelet antiaggregants and/or anticoagulants may be beneficial, albeit it is not clear if it could reduce the incidence of HAT.
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Affiliation(s)
- Allana C Fortunato
- Disciplina de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Rafael S Pinheiro
- Disciplina de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.
| | - Lucas S Nacif
- Disciplina de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Daniel R Waisberg
- Disciplina de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Liliana Ducatti
- Disciplina de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Vinicius Rocha-Santos
- Disciplina de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Flávio H F Galvao
- Disciplina de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Luciana B P Haddad
- Disciplina de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Edson Abdala
- Disciplina de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil; Departamento de Molestias Infecciosas e Parasitarias Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Alice T W Song
- Disciplina de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Débora R B Terrabuio
- Disciplina de Gastroenterologia Clínica e Hepatologia, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Regis O F Bezerra
- Departamento de Radiologia, Instituto do Cancer do Estado de São Paulo, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Rubens A Macedo
- Disciplina de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Rodrigo B Martino
- Disciplina de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Wellington Andraus
- Disciplina de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Luiz A Carneiro-D'Albuquerque
- Disciplina de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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9
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Flynn E, Huang JY, Hardikar W, Herd L, Hodgson A, Monagle P. Antithrombotic management and thrombosis rates in children post-liver transplantation: A case series and literature review. Pediatr Transplant 2019; 23:e13420. [PMID: 31012220 DOI: 10.1111/petr.13420] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 03/05/2019] [Accepted: 03/20/2019] [Indexed: 12/14/2022]
Abstract
Thrombosis is a major postoperative complication in pediatric liver transplantation. There is marked heterogeneity in prophylactic antithrombotic therapies used, without established guidelines. This review summarizes current worldwide incidence of thrombotic events and compares antithrombotic therapies in children post-liver transplant, with comparison to our institution's experience. Of the twenty-three articles with sufficient detail to compare antithrombotic regimens, the overall incidence of thrombosis ranged from 2.4% to 17.3%. Incidence of HAT ranged from 0% to 28.1%, of HVT from 0% to 4.7%, of PVT from 1.5% to 11.2%, and of IVC thrombosis from 0% to 2.8%. Re-transplantation due to thrombosis ranged from 0% to 4.8%. Prophylactic antithrombotic therapies varied between studies, and bleeding complications were infrequently reported. Since 2010, 96 children underwent 100 liver transplants at our institution with thrombosis incidence comparable to international literature (HAT 6%, PVT 5%, IVC 1%, and HVT 0%). Re-transplantation due to thrombosis occurred in 2% and major bleeding occurred in 10%. The prophylactic antithrombotic therapies used post-liver transplantation in children remain varied. Low rates of thrombosis have been reported with antiplatelet use both with and without anticoagulation. Standard definitions and consistent reporting of bleeding complications are required, in addition to thrombosis rates, so that true risk-benefit assessment of reported regimes can be understood.
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Affiliation(s)
- Elise Flynn
- Department of Clinical Hematology, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Joanna Y Huang
- Department of Clinical Hematology, Royal Children's Hospital, Parkville, Victoria, Australia.,Hematology Research Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
| | - Winita Hardikar
- Department of Clinical Hematology, Royal Children's Hospital, Parkville, Victoria, Australia.,Department of Pediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Lauren Herd
- Department of Clinical Hematology, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Alexandra Hodgson
- Department of Clinical Hematology, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Paul Monagle
- Department of Clinical Hematology, Royal Children's Hospital, Parkville, Victoria, Australia.,Hematology Research Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of Pediatrics, University of Melbourne, Parkville, Victoria, Australia
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10
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Calinescu AM, Karam O, Wilde JCH, Ansari M, McLin VA, Wildhaber BE. International survey on anticoagulation and antiplatelet strategies after pediatric liver transplantation. Pediatr Transplant 2019; 23:e13317. [PMID: 30393923 DOI: 10.1111/petr.13317] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Revised: 09/15/2018] [Accepted: 10/04/2018] [Indexed: 12/20/2022]
Abstract
In pediatric LT, anticoagulants and antiplatelet agents are regularly used to reduce the risk of vascular thrombosis. As evidence for optimal strategy is lacking, local practices vary greatly. The present survey aimed to compile an international overview of anticoagulation and antiplatelet strategies in pediatric LT. An online survey was sent to 98 pediatric LT centers in North and South America, Europe, Asia, and Australia. Twenty-four centers answered the survey. 20/24 (83%) use some sort of anticoagulation and antiplatelet therapy, yielding 20 different strategies. Perioperative vascular problems, size of the hepatic artery, and patient weight were the most frequent determinants of changes in anticoagulant and antiplatelet strategy. Early HAT rates were reported to be 5% or less in 79% of responding centers. Anticoagulation and antiplatelet strategies were not significantly associated with early HAT rates (P = 0.63), or with the number of pediatric LTs performed per year and center (P = 0.92). Internationally, there is a wide variety in anticoagulation and antiplatelet strategies after pediatric LT. Efforts must be made to design a prospective multicentric trial to identify the optimal antithrombotic strategy.
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Affiliation(s)
- Ana M Calinescu
- Division of Pediatric Surgery, University Center of Pediatric Surgery of Western Switzerland, Geneva University Hospitals, Geneva, Switzerland
| | - Oliver Karam
- Pediatric Intensive Care Unit, Geneva University Hospitals, Geneva, Switzerland.,Division of Pediatric Intensive Care Medicine, Children's Hospital of Richmond at VCU, Richmond, Virginia
| | - Jim C H Wilde
- Division of Pediatric Surgery, University Center of Pediatric Surgery of Western Switzerland, Geneva University Hospitals, Geneva, Switzerland
| | - Marc Ansari
- Division of Pediatrics, Unit of Pediatric Hematology, Geneva University Hospitals, Geneva, Switzerland
| | - Valerie A McLin
- Division of Pediatric Specialties, Unit of Pediatric Gastroenterology, Hepatology and Nutrition, Geneva University Hospitals, Geneva, Switzerland
| | - Barbara E Wildhaber
- Division of Pediatric Surgery, University Center of Pediatric Surgery of Western Switzerland, Geneva University Hospitals, Geneva, Switzerland
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11
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Nacoti M, Ruggeri GM, Colombo G, Bonanomi E, Lussana F. Thrombosis prophylaxis in pediatric liver transplantation: A systematic review. World J Hepatol 2018; 10:752-760. [PMID: 30386468 PMCID: PMC6206147 DOI: 10.4254/wjh.v10.i10.752] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 07/13/2018] [Accepted: 08/01/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To review current literature of thrombosis prophylaxis in pediatric liver transplantation (PLT) as thrombosis remains a critical complication.
METHODS Studies were identified by electronic search of MEDLINE, EMBASE and Cochrane Library (CENTRAL) databases until March 2018. The search was supplemented by manually reviewing the references of included studies and the references of the main published systematic reviews on thrombosis and PLT. We excluded from this review case report, small case series, commentaries, conference abstracts, papers which describing less than 10 pediatric liver transplants/year and articles published before 1990. Two reviewers performed study selection independently, with disagreements solved through discussion and by the opinion of a third reviewer when necessary.
RESULTS Nine retrospective studies were included in this review. The overall quality of studies was poor. A pooled analysis of results from studies was not possible due to the retrospective design and heterogeneity of included studies. We found an incidence of portal vein thrombosis (PVT) ranging from 2% to 10% in pediatric living donor liver transplantation (LDLT) and from 4% to 33% in pediatric deceased donor liver transplantation (DDLT). Hepatic artery thrombosis (HAT) was observed mostly in mixed LDLT and DDLT pediatric population with an incidence ranging from 0% to 29%. In most of the studies Doppler ultrasonography was used as a first line diagnostic screening for thrombosis. Four different surgical techniques for portal vein anastomosis were reported with similar efficacy in terms of PVT reduction. Reduced size liver transplant was associated with a low risk of both PVT (incidence 4%) and HAT (incidence 0%, P < 0.05). Similarly, aortic arterial anastomosis without graft interposition and microsurgical hepatic arterial reconstruction were associated with a significant reduced HAT incidence (6% and 0%, respectively). According to our inclusion and exclusion criteria, we did not find eligible studies that evaluated pharmacological prevention of thrombosis.
CONCLUSION Poor quality retrospective studies show the use of tailored surgical strategies might be useful to reduce HAT and PVT after PLT; prospective studies are urgently needed.
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Affiliation(s)
- Mirco Nacoti
- Department of Anesthesia and Intensive Care, Pediatric Intensive Care Unit, Papa Giovanni XXIII Hospital, Bergamo 24127, Italy
| | - Giulia Maria Ruggeri
- Department of Anesthesia and Intensive Care, Pediatric Intensive Care Unit, Papa Giovanni XXIII Hospital, Bergamo 24127, Italy
| | - Giovanna Colombo
- Department of Anesthesia and Intensive Care, Pediatric Intensive Care Unit, Papa Giovanni XXIII Hospital, Bergamo 24127, Italy
| | - Ezio Bonanomi
- Department of Anesthesia and Intensive Care, Pediatric Intensive Care Unit, Papa Giovanni XXIII Hospital, Bergamo 24127, Italy
| | - Federico Lussana
- Hematology and Bone Marrow Transplant Unit, Papa Giovanni XXIII Hospital, Bergamo 24127, Italy
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12
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Voulgarelis S, Vitola B, Lerret SM, Hong JC, Scott JP. Perioperative anticoagulation practices for pediatric liver transplantation. Pediatr Transplant 2018; 22:e13193. [PMID: 29663585 DOI: 10.1111/petr.13193] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/12/2018] [Indexed: 12/13/2022]
Abstract
Despite continued advancements in perioperative care for pediatric liver transplant (LT), graft-threatening vascular occlusion events including hepatic artery thrombosis (HAT) and portal vein thrombosis (PVT) remain a source of significant morbidity and mortality. Perioperative anticoagulation is commonly used for the prevention of HAT and PVT, but evidence-based guidelines are lacking. The goals of this survey were to determine the frequency of use of an anticoagulation protocol and to describe variation in anticoagulation practices among pediatric LT centers. The study consisted of an online survey distributed to members of SPLIT. The survey focused on institutional anticoagulation practices employed to reduce the incidence of graft and life-threatening vascular occlusion events. Responses were received from 31 of 39 SPLIT centers. All respondents report using anticoagulation after pediatric LT, and approximately 90% have institutional anticoagulation protocols. Subgroup analysis of high volume pediatric LT centers revealed similar variability in anticoagulation patterns. All participating SPLIT centers reported the use of post-transplant anticoagulation and nearly all use a protocol. However, there is marked variability in the type and dose of anticoagulation as well as the timing of initiation and duration of therapy across centers.
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Affiliation(s)
- Stylianos Voulgarelis
- Divisions of Pediatric and Adult Cardiac Anesthesiology, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Bernadette Vitola
- Division of Gastroenterology, Hepatology, and Nutrition, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Stacee M Lerret
- Division of Gastroenterology and Transplant Surgery, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Johnny C Hong
- Division of Transplant Surgery, Department of Surgery, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - John P Scott
- Divisions of Pediatric Anesthesiology and Pediatric Critical Care, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI, USA.,Pediatric Liver Transplant Anesthesia, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI, USA.,Pediatric Intensive Care Unit, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI, USA
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13
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Arni D, Wildhaber BE, McLin V, Rimensberger PC, Ansari M, Fontana P, Karam O. Effects of plasma transfusions on antithrombin levels after paediatric liver transplantation. Vox Sang 2018; 113:569-576. [PMID: 29761839 DOI: 10.1111/vox.12664] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Revised: 03/19/2018] [Accepted: 04/20/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVES Thrombotic complications affect 3-10% of patients after liver transplantation (LT), leading to potentially life-threatening complications. In the days following LT, antithrombin (AT) is decreased longer than pro-coagulant factors, thus favouring a pro-thrombotic profile. Plasma transfusions are given empirically in some centres to correct AT levels following LT. We assessed the effect of plasma transfusion on AT levels after paediatric LT. MATERIALS AND METHODS Prospective single-centre observational study in 20 consecutive paediatric LT recipients over a 24-month period. Plasma was administered twice daily (10 ml/kg/dose) according to an existing protocol. AT levels were measured once daily, immediately prior to and one hour after the morning plasma transfusion. Sample size was calculated based on a non-inferiority hypothesis. RESULTS The median age and weight were 11.6 years (IQR 2.8; 14.7) and 40 kg (IQR 12.75; 44.8), respectively. We collected 85-paired blood samples. The median AT level prior to plasma transfusion was 58%. The median difference in AT levels before and after plasma transfusion was 4.2% (P = 0.001). Changes in AT levels after plasma transfusion were not correlated with baseline AT levels (R = 0.19) or patient weight (R = 0.18). CONCLUSION Plasma transfusions only marginally increase AT levels in children after LT. Therefore, prophylactic plasma transfusions probably do not seem to confer an advantage in the routine management of paediatric LT patients. Randomized controlled trials are needed to identify the optimal anticoagulation strategy in this specific population.
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Affiliation(s)
- D Arni
- Pediatric Surgery, University Center of Pediatric Surgery of Western Switzerland, Geneva University Hospital, Geneva, Switzerland
| | - B E Wildhaber
- Pediatric Surgery, University Center of Pediatric Surgery of Western Switzerland, Geneva University Hospital, Geneva, Switzerland
- Swiss Center for Liver Disease in Children, Geneva University Hospital, Geneva, Switzerland
| | - V McLin
- Swiss Center for Liver Disease in Children, Geneva University Hospital, Geneva, Switzerland
- Pediatric Gastro-Enterology, Geneva University Hospital, Geneva, Switzerland
| | - P C Rimensberger
- Pediatric Critical Care Unit, Geneva University Hospital, Geneva, Switzerland
| | - M Ansari
- Pediatric Oncology and Hematology, Geneva University Hospital, Geneva, Switzerland
| | - P Fontana
- Angiology and Hemostasis, Geneva University Hospital, Geneva, Switzerland
| | - O Karam
- Pediatric Critical Care Unit, Geneva University Hospital, Geneva, Switzerland
- Division of Pediatric Critical Care Medicine, Children's Hospital of Richmond at VCU, Richmond, VA, USA
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14
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Borst AJ, Sudan DL, Wang LA, Neuss MJ, Rothman JA, Ortel TL. Bleeding and thrombotic complications of pediatric liver transplant. Pediatr Blood Cancer 2018; 65:e26955. [PMID: 29350493 PMCID: PMC5867241 DOI: 10.1002/pbc.26955] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 12/05/2017] [Accepted: 12/06/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Pediatric patients undergoing liver transplant are at significant risk for bleeding and thrombotic complications due to the complex nature of rebalanced hemostasis in patients with liver disease. METHODS/OBJECTIVES We reviewed records of 92 pediatric liver and multivisceral transplant cases at Duke University Medical Center between January 2009 and December 2015. The goal was to define the nature and incidence of bleeding and thrombotic complications in this cohort and define potential risk factors. RESULTS There were 24 major bleeding events in 19 transplants (incidence 20.7%) and 30 thrombotic events in 23 transplants (incidence 25%). Five of the 10 retransplantations were for vascular thrombotic complications. Thirty-day mortality was 4.9%, and three of these four deaths were due to vascular thrombosis. No bleeding events led to retransplantation or mortality. Prophylactic aspirin was associated with decreased risk of thrombosis without increased bleeding. Prophylactic heparin did not increase bleeding risk. Laboratory assays predicted events poorly, apparently failing to capture the nuanced and dynamic interplay between pro- and anticoagulant factors in the posttransplant patient. CONCLUSIONS Both bleeding and thrombosis are frequent in this population, but only thrombotic complications contributed to retransplantation and mortality. A standardized approach to coagulation testing and antithrombotic therapy may be useful in predicting and reducing adverse outcomes. Alternative approaches to monitoring hemostasis need to be prospectively investigated in this complex patient population.
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Affiliation(s)
- Alexandra J Borst
- Duke University Medical Center, Division of Pediatric Hematology-Oncology
- Vanderbilt University Medical Center, Division of Pediatric Hematology-Oncology
| | - Debra L Sudan
- Duke University Medical Center, Division of Abdominal Transplant Surgery
| | | | - Michael J Neuss
- Vanderbilt University Medical Center, Department of Medicine
| | - Jennifer A Rothman
- Duke University Medical Center, Division of Pediatric Hematology-Oncology
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15
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Zhang R, Zhu ZJ, Sun LY, Wei L, Qu W. Outcomes of Liver Transplantation Using Pediatric Deceased Donor Livers: A Single-Center Analysis of 102 Donors. Chin Med J (Engl) 2018; 131:677-683. [PMID: 29521290 PMCID: PMC5865313 DOI: 10.4103/0366-6999.226901] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The outcome of pediatric deceased donor liver transplantation (LT) has not been well studied, especially pediatric deceased donor livers used in adult transplantation. This study aimed to evaluate the efficacy of LT using pediatric deceased donor livers and compare the outcomes between pediatric-to-pediatric LT and pediatric-to-adult LT. METHODS A retrospective review of LT using pediatric deceased donor livers from June 2013 to August 2016 was performed. The patients were divided into the pediatric-to-pediatric LT group and pediatric-to-adult LT group based on the ages of the recipients. The survival and incidence of early vascular complications (VCs) were observed between the two groups. We also analyzed the risk factors of early VCs in pediatric LT and the effect of donor hypernatremia on the prognosis of recipients. RESULTS There were 102 cases of LT using pediatric deceased donor livers in our hospital from June 2013 to August 2016, 83 pediatric-to-pediatric LT (recipients' age ≤13 years) and 19 pediatric-to-adult LT (recipients' age ≥19 years). The ratio of early VC was similar in the two groups (19.3% vs. 10.6%, P = 0.514). Low body weight of recipient was an independent risk factor of early VC in pediatric LT (odds ratio: 0.856, 95% confidence interval: 0.752-0.975, P = 0.019). The 1-year cumulative survival rates of grafts and patients were 89.16% and 91.57% in pediatric-to-pediatric LT and 89.47% and 94.74% in pediatric-to-adult LT, respectively (all P > 0.05). In all cases, patients using donors with hypernatremia (serum sodium levels ≥150 mmol/L) had worse graft survival (χ2=4.330, P = 0.037). CONCLUSIONS Pediatric-to-pediatric LT group has similar graft and patient survival rates with those of pediatric-to-adult LT group. Low body weight of recipients is an independent risk factor of early VC in pediatric LT. Patients using donors with hypernatremia have worse graft survival.
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Affiliation(s)
- Rui Zhang
- Liver Transplantation Center, National Clinical Research Center for Digestive Disease, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
- Department of Hepatobiliary and Pancreatic Surgery, Shanxi Provincial People's Hospital, Taiyuan, Shanxi 030012, China
| | - Zhi-Jun Zhu
- Liver Transplantation Center, National Clinical Research Center for Digestive Disease, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Li-Ying Sun
- Liver Transplantation Center, National Clinical Research Center for Digestive Disease, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Lin Wei
- Liver Transplantation Center, National Clinical Research Center for Digestive Disease, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Wei Qu
- Liver Transplantation Center, National Clinical Research Center for Digestive Disease, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
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16
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Alobaidi R, Anton N, Cave D, Moez EK, Joffe AR. Predicting early outcomes of liver transplantation in young children: The EARLY study. World J Hepatol 2018; 10:62-72. [PMID: 29399279 PMCID: PMC5787685 DOI: 10.4254/wjh.v10.i1.62] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 12/20/2017] [Accepted: 12/29/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To determine potentially modifiable predictors of early outcomes after liver transplantation in children of age < 3 years.
METHODS This study was a retrospective chart review including all consecutive children of age less than 3-years-old having had a liver transplant done at the Western Canadian referral center from June 2005 to June 2015. Pre-specified potential predictor variables and primary and secondary outcomes were recorded using standard definitions and a case report form. Associations between potential predictor variables and outcomes were determined using univariate and multiple logistic [odds ratio (OR); 95%CI] or linear (effect size, ES; 95%CI) regressions.
RESULTS There were 65 children, of mean age 11.9 (SD 7.1) mo and weight 8.5 (2.1) kg, with biliary-atresia in 40 (62%), who had a living related donor [LRD; 29 (45%)], split/reduced [21 (32%)] or whole liver graft [15 (23%)]. Outcomes after liver transplant included: ventilator-days of 12.5 (14.1); pediatric intensive care unit mortality of 5 (8%); re-operation in 33 (51%), hepatic artery thrombosis (HAT) in 12 (19%), portal vein thrombosis (PVT) in 11 (17%), and any severe complication (HAT, PVT, bile leak, bowel perforation, intraabdominal infection, retransplant, or death) in 32 (49%) patients. Predictors of the prespecified primary outcomes on multiple regression were: (1) HAT: split/reduced (OR 0.06; 0.01, 0.76; P = 0.030) or LRD (OR 0.16; 0.03, 0.95; P = 0.044) vs whole liver graft; and (2) ventilator-days: surgeon (P < 0.05), lowest antithrombin (AT) postoperative day 2-5 (ES -0.24; -0.47, -0.02; P = 0.034), and split/reduced (ES -12.5; -21.8, -3.2; P = 0.009) vs whole-liver graft. Predictors of the pre-specified secondary outcomes on multiple regression were: (1) any thrombosis: LRD (OR 0.10; 0.01, 0.71; P = 0.021) or split/reduced (OR 0.10; 0.01, 0.85; P = 0.034) vs whole liver graft, and lowest AT postoperative day 2-5 (OR 0.93; 0.87, 0.99; P = 0.038); and (2) any severe complication: surgeon (P < 0.05), lowest AT postoperative day 2-5 (OR 0.92; 0.86-0.98; P = 0.016), and split/reduced (OR 0.06; 0.01, 0.78; P = 0.032) vs whole-liver graft.
CONCLUSION In young children, whole liver graft and surgeon was associated with more complications, and higher AT postoperative day 2-5 was associated with fewer complications early after liver transplantation.
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Affiliation(s)
- Rashid Alobaidi
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Alberta and Stollery Children’s Hospital, Edmonton, Alberta T6G 1C9, Canada
| | - Natalie Anton
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Alberta and Stollery Children’s Hospital, Edmonton, Alberta T6G 1C9, Canada
| | - Dominic Cave
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Alberta and Stollery Children’s Hospital, Edmonton, Alberta T6G 1C9, Canada
| | - Elham Khodayari Moez
- School of Public Health, University of Alberta, Edmonton, Alberta T6G 2B7, Canada
| | - Ari R Joffe
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Alberta and Stollery Children’s Hospital, Edmonton, Alberta T6G 1C9, Canada
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17
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Fukunaga N, Uryuhara K, Koyama T. Axillobifemoral Bypass for Aortitis Syndrome in a Living-Donor Liver Transplant Patient. Ann Vasc Dis 2016; 9:114-6. [PMID: 27375806 DOI: 10.3400/avd.cr.16-00016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 03/29/2016] [Indexed: 11/13/2022] Open
Abstract
A 64-year-old female patient with aortitis syndrome presented with progressive intermittent claudication for 6 months. Her medical history was notable for living-donor liver transplantation for primary biliary cirrhosis 4-years prior and chronic immunosuppressive therapy. Evaluation included normal laboratory examination, and contrast-enhanced computed tomography angiography which demonstrated severely calcified descending aorta with high-grade stenosis below the diaphragm. The patient was treated by axillobifemoral bypass using an 8-mm ringed expanded polytetrafluoroethylene graft under general anesthesia. Medical management included decreased preoperative doses of immunosuppressants and predonisolone, which were resumed after the operation, and chronic anticoagulation. There were no postoperative complications.
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Affiliation(s)
- Naoto Fukunaga
- Department of Cardiovascular Surgery and Surgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Kenji Uryuhara
- Department of Cardiovascular Surgery and Surgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Tadaaki Koyama
- Department of Cardiovascular Surgery and Surgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
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18
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Increased risk of vascular thrombosis in pediatric liver transplant recipients with thrombophilia. J Surg Res 2015; 199:671-5. [DOI: 10.1016/j.jss.2015.07.043] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2015] [Revised: 07/24/2015] [Accepted: 07/31/2015] [Indexed: 12/26/2022]
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19
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Abstract
Due to progressive advances in surgical techniques, immunosuppressive therapies, and supportive care, outcomes from both solid organ transplantation and hematopoietic stem cell transplantation continue to improve. Thrombosis remains a challenging management issue in this context, with implications for both graft survival and long-term quality of life. Unfortunately, there remains a general paucity of pediatric-specific data regarding thrombosis incidence, risk stratification, and the safety or efficacy of preventative strategies with which to guide treatment algorithms. This review summarizes the available evidence and rationale underlying the spectrum of current practices aimed at preventing thrombosis in the transplant recipient, with a particular focus on risk factors, pathophysiology, and described antithrombotic regimens.
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Affiliation(s)
- J D Robertson
- Haematology Service, Division of Medicine, Lady Cilento Children's Hospital, Brisbane, Qld, Australia
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20
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Mukerji AN, Karachristos A, Maloo M, Johnson D, Jain A. Do postliver transplant patients need thromboprophylactic anticoagulation? Clin Appl Thromb Hemost 2014; 20:673-7. [PMID: 24917126 DOI: 10.1177/1076029614538490] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Postoperative thromboprophylactic anticoagulation against Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) is standard of care with current evidence-based guidelines. However, majority of liver transplant (LT) patients have thrombocytopenia and/or prolonged INR before surgery. Studies or guidelines regarding role of prophylactic anticoagulation after LT are lacking. There is a need to balance the risk of thrombosis with significant hemorrhage, implying those needing transfusion or return to OR due to bleeding. We conclude that after LT, anticoagulation is not required routinely for DVT/PE prophylaxis. Rather, it is indicated in specific circumstances, chiefly for prophylaxis of hepatic artery thrombosis or portal vein thrombosis in cases with use of grafts, pediatric cases, small size vessels, Budd Chiari syndrome, amongst others.
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Affiliation(s)
- Amar Nath Mukerji
- Department of Surgery, Division of Abdominal Organ Transplant, Liver Transplant Program, Temple University Hospital, Philadelphia, PA, USA
| | - Andreas Karachristos
- Department of Surgery, Division of Abdominal Organ Transplant, Liver Transplant Program, Temple University Hospital, Philadelphia, PA, USA
| | - Manoj Maloo
- Department of Surgery, Division of Abdominal Organ Transplant, Liver Transplant Program, Temple University Hospital, Philadelphia, PA, USA
| | - David Johnson
- Department of Pharmacy, Temple University Hospital, Philadelphia, PA, USA
| | - Ashokkumar Jain
- Department of Surgery, Division of Abdominal Organ Transplant, Liver Transplant Program, Temple University Hospital, Philadelphia, PA, USA
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21
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Ponziani FR, Zocco MA, Senzolo M, Pompili M, Gasbarrini A, Avolio AW. Portal vein thrombosis and liver transplantation: implications for waiting list period, surgical approach, early and late follow-up. Transplant Rev (Orlando) 2014; 28:92-101. [PMID: 24582320 DOI: 10.1016/j.trre.2014.01.003] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Revised: 09/19/2013] [Accepted: 01/19/2014] [Indexed: 02/07/2023]
Abstract
Portal vein thrombosis (PVT) is a well-known and relatively common complication of liver cirrhosis. In the past, PVT was considered as a contraindication for liver transplantation (LT). To characterize prevalence, risk factors, perioperative management and outcome of PVT in the setting of LT, the English literature published between 1991 and 2011 was reviewed. Of 6807 articles, 280 were selected, and 39 experiences were analyzed in detail (methodology, type and duration of treatments, peri-operative management, strategy to avoid recurrence, strengths and weaknesses, Oxford evidence level, citations). 3/39 studies were prospective; 9/39 were based on prospectively recorded databases; no studies of 1, 2a, 3a level of evidence were present; 5/39 were recognized as level 2b, 23/39 as level 3b, and 8/39 as level 4. High complication rate has been reported with consequent effect on graft and patient survival. Overall, PVT presents today good results similar to those obtained in patients without PVT undergoing LT even if they require a higher transfusion number and a longer ICU/hospital stay. Reported cases were retrospectively stratified according to Yerdel classification. Grade 1-2 patients (76%) do well with eversion thromboendovenectomy, resection of damaged vein and porto-portal anastomosis. Results of patients with grade 3-4 (24%) are inferior, however data on outcome in this subsets are fragmented and do not allow a reliable analysis. Moreover, results obtained in grade 3-4 cases are better in transplant centers with large specific experience. The small number of reports suggests caution. The role of anticoagulant treatment is still debated. Although in cirrhotics with PVT LT remains a demanding procedure, PVT should not be considered a contraindication anymore.
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Affiliation(s)
- Francesca Romana Ponziani
- Department of Internal Medicine and Gastroenterology, Catholic University, Agostino Gemelli Hospital, Rome, Italy.
| | - Maria Assunta Zocco
- Department of Internal Medicine and Gastroenterology, Catholic University, Agostino Gemelli Hospital, Rome, Italy
| | - Marco Senzolo
- Department of surgical, Oncological, and Gastroenterological Sciences University hospital of Padua, Padua, Italy
| | - Maurizio Pompili
- Department of Internal Medicine, Catholic University, Agostino Gemelli Hospital, Rome, Italy
| | - Antonio Gasbarrini
- Department of Internal Medicine and Gastroenterology, Catholic University, Agostino Gemelli Hospital, Rome, Italy
| | - Alfonso Wolfango Avolio
- Department of Surgical Sciences, Division of General Surgery and Organs Transplantation, Catholic University, Agostino Gemelli Hospital, Rome, Italy
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Honda M, Yamamoto H, Hayashida S, Suda H, Ohya Y, Lee KJ, Takeichi T, Asonuma K, Inomata Y. Factors predicting persistent thrombocytopenia after living donor liver transplantation in pediatric patients. Pediatr Transplant 2011; 15:601-5. [PMID: 21790916 DOI: 10.1111/j.1399-3046.2011.01533.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Thrombocytopenia is common after LT for pediatric end-stage liver diseases. Seventy-six pediatric patients (≤15 yr old) who underwent LDLT were evaluated for the incidence and predictive factors of post-transplant thrombocytopenia (PLT <100, 000/mm(3) ). The prevalence of thrombocytopenia at two wk and at 12 months post-transplant was 22/76 (28.9%) and 11/62 (17.7%), respectively. Thrombocytopenia at two wk after LDLT was significantly associated with age at transplant, preoperative PLT, GRWR, acute rejection, and CMV infection in univariate analysis. Moreover, preoperative PLT, GRWR, and acute rejection had a strong correlation in multivariate analysis. Thrombocytopenia at 12 months after LDLT was associated only with preoperative PLT. We also demonstrated that vascular complications caused thrombocytopenia and that successful treatment recovered the PLT. These results showed that, in addition to considering the preoperative PLT, post-operative monitoring of platelets is very helpful for the early detection of adverse events related to the graft liver in pediatric liver transplant patients.
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Affiliation(s)
- Masaki Honda
- Department of Transplantation and Pediatric Surgery, Kumamoto University, Kumamoto, Japan
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23
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McLin VA, Rimensberger P, Belli DC, Wildhaber BE. Anticoagulation following pediatric liver transplantation reduces early thrombotic events. Pediatr Transplant 2011; 15:117-8. [PMID: 21159111 DOI: 10.1111/j.1399-3046.2010.01426.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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