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Byeman CJ, Harshman LA, Engen RM. Adult and late adolescent complications of pediatric solid organ transplantation. Pediatr Transplant 2024; 28:e14766. [PMID: 38682744 DOI: 10.1111/petr.14766] [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: 09/25/2023] [Revised: 03/29/2024] [Accepted: 04/08/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND There have been over 51 000 pediatric solid organ transplants since 1988 in the United States alone, leading to a growing population of long-term survivors who face complications of childhood organ failure and long-term immunosuppression. AIMS This is an educational review of existing literature. RESULTS Pediatric solid organ transplant recipients are at increased risk for risk for cardiovascular and kidney disease, skin cancers, and growth problems, though the severity of impact may vary by organ type. Pediatric recipients often are able to complete schooling, maintain a job, and form family and social networks in adulthood, though at somewhat lower rates than the general population, but face additional challenges related to neurocognitive deficits, mental health disorders, and discrimination. CONCLUSIONS Transplant centers and research programs should expand their focus to include long-term well-being. Increased collaboration between pediatric and adult transplant specialists will be necessary to better understand and manage long-term complications.
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Affiliation(s)
- Connor J Byeman
- University of Iowa Carver College of Medicine, Iowa, Iowa, USA
| | - Lyndsay A Harshman
- Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa, Iowa, USA
| | - Rachel M Engen
- University of Wisconsin Madison, Madison, Wisconsin, USA
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2
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Pornsiripratharn W, Treepongkaruna S, Tangkittithaworn P, Chitrapaz N, Lertudomphonwanit C, Getsuwan S, Tanpowpong P, Mahachoklertwattana P. Prevalence and Associated Factors of Vertebral Fractures in Children with Chronic Liver Disease with and without Liver Transplantation. Pediatr Gastroenterol Hepatol Nutr 2024; 27:158-167. [PMID: 38818276 PMCID: PMC11134177 DOI: 10.5223/pghn.2024.27.3.158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 02/17/2024] [Accepted: 03/27/2024] [Indexed: 06/01/2024] Open
Abstract
Purpose To evaluate the prevalence of vertebral fracture (VF) in children with chronic liver disease (CLD) with and without liver transplantation (LT) and to determine the associated factors. Methods A cross-sectional study was conducted. Patients aged 3-21 years with CLD both before and after LT were enrolled in the study. Lateral thoracolumbar spine radiographs were obtained and assessed for VF using Mäkitie's method. Clinical and biochemical data were collected. Results We enrolled 147 patients (80 females; median age 8.8 years [interquartile range 6.0-11.8]; 110 [74.8%] in the LT group and 37 [25.2%] in the non-LT group). VF was identified in 21 patients (14.3%): 17/110 (15.5%) in the LT group and 4/37 (10.8%) in the non-LT group (p=0.54). Back pain was noted in only three patients with VF. In the univariate analysis, a height z-score below -2.0 (p=0.010), pre-LT hepatopulmonary syndrome (p=0.014), elevated serum direct and total bilirubin levels (p=0.037 and p=0.049, respectively), and vitamin D deficiency at 1-year post-LT (p=0.048) were associated with VF in the LT group. In multivariate analysis, height z-score below -2.0 was the only significant associated factor (odds ratio, 5.94; 95% confidence interval, 1.49-23.76; p=0.012) for VF. All VFs in the non-LT group were reported in males. Conclusion In children with CLD, VF is common before and after LT. Most patients with VF are asymptomatic. Screening for VF should be considered in patients with a height z-score below -2.0 after LT.
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Affiliation(s)
- Wittayathorn Pornsiripratharn
- Division of Gastroenterology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Suporn Treepongkaruna
- Division of Gastroenterology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- Ramathibodi Excellence Center in Organ Transplantation, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Niyata Chitrapaz
- Department of Radiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chatmanee Lertudomphonwanit
- Division of Gastroenterology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- Ramathibodi Excellence Center in Organ Transplantation, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Songpon Getsuwan
- Division of Gastroenterology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- Ramathibodi Excellence Center in Organ Transplantation, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pornthep Tanpowpong
- Division of Gastroenterology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- Ramathibodi Excellence Center in Organ Transplantation, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pat Mahachoklertwattana
- Division of Endocrinology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Umemura K, Mita A, Ohno Y, Masuda Y, Yoshizawa K, Kubota K, Notake T, Hosoda K, Yasukawa K, Kamachi A, Goto T, Tomida H, Yamazaki S, Shimizu A, Soejima Y. Long-term Catch-up Growth and Risk Factors for Short Adult Height After Pediatric Liver Transplantation: A Retrospective Study. Transplantation 2024; 108:732-741. [PMID: 37691167 DOI: 10.1097/tp.0000000000004795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
BACKGROUND Children requiring liver transplantation generally have severe growth retardation. Recipients experience posttransplantation catch-up growth, although some show short adult heights. We aimed to determine decades-long catch-up growth trends and risk factors for short adult height following liver transplantation. METHODS We analyzed long-term height Z scores and risk factors for short adult height in a single-center retrospective cohort of 117 pediatric liver transplantation recipients who survived >5 y, with 75 of them reaching adult height. RESULTS Median age at transplantation was 1.3 y, and the most common primary diagnosis was biliary atresia (76.9%). Mean height Z scores pretransplantation and 1, 3, and 8 y after transplantation were -2.26, -1.59, -0.91, and -0.59, respectively. The data then plateaued until 20 y posttransplantation when mean adult height Z score became -0.88, with a median follow-up of 18.6 y. Nineteen recipients did not show any catch-up growth, and one quarter of recipients had short adult height (<5th percentile of the healthy population). Multivariate analysis identified old age (odds ratio, 1.22 by 1 y; P = 0.002), low height Z scores at transplantation (odds ratio, 0.46 by 1 point; P < 0.001), and posttransplantation hospital stay ≥60 d (odds ratio, 4.95; P = 0.015) as risk factors for short adult height. In contrast, prolonged steroid use after transplantation was not considered a significant risk factor. CONCLUSIONS Although tremendous posttransplantation catch-up growth was observed, final adult height remained inadequate. For healthy physical growth, liver transplantation should be performed as early as possible, before growth retardation becomes severe.
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Affiliation(s)
- Kentaro Umemura
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
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Trezeguet Renatti G, Riva N, Minetto J, Reijenstein H, Gole M, Meza V, Bosaleh A, Licciardone N, Aredes D, Lauferman L, Cervio G, Dip M, Schaiquevich P, Halac E, Imventarza O. Feasibility of steroid-free tacrolimus-basiliximab immunosuppression in pediatric liver transplantation and predictors for steroid requirement. Liver Transpl 2024; 30:61-71. [PMID: 37439661 DOI: 10.1097/lvt.0000000000000216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 07/06/2023] [Indexed: 07/14/2023]
Abstract
Avoidance of steroids in pediatric liver transplantation may reduce toxicity and morbidity. The aim of this study was to analyze the feasibility of a steroid-free tacrolimus-basiliximab immunosuppression scheme, the risk factors associated with steroid requirement, and safety parameters. Patients who underwent liver transplantation for biliary atresia between 2011 and 2019 were included and followed for 6 months after transplantation. Immunosuppression consisted of tacrolimus-based treatment with basiliximab induction. Steroid-free survival was estimated, and risk factors for steroid requirement were evaluated using multivariate Cox regression analysis. A total of 76 patients were included, of whom 42 (55.3%) required steroids (>14 d) due to biopsy-proven acute rejection (47.6%, n = 20), instability in liver function tests (35.7%, n = 15), tacrolimus-related adverse drug reactions (14.3%, n = 6), or other reasons (bronchospasm episode, n = 1). Steroid-free survival was 45.9% (95% CI, 35.9-58.8). Independent factors associated with steroid requirement included tortuosity in tacrolimus trough levels (≥1.76 vs. <1.76: HR 5.8, 95% CI, 2.6-12.7; p < 0.001) and mean tacrolimus trough levels (≥ 6.4 ng/mL vs. < 6.4 ng/mL: HR 0.4, 95% CI, 0.2-0.7; p = 0.002). The rate of bacterial and viral infections was comparable between patients with and without steroids, although in the former group, cytomegalovirus infection developed earlier ( p = 0.03). Patients receiving steroids had higher total cholesterol, LDL, and HDL levels ( p < 0.05) during follow-up, but no changes in the height Z-score were observed 1 year after transplantation. Basiliximab induction in combination with tacrolimus-based treatment avoided steroid requirements in 45% of the patients. Tacrolimus variability and trough levels below 6.4 ng/mL independently increased the risk of steroid requirement. Further efforts should be focused on personalizing immunosuppressive treatment.
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Affiliation(s)
- Guido Trezeguet Renatti
- Unit of Innovative Treatments, Hospital de Pediatría JP Garrahan, Buenos Aires, Argentina
- National Scientific and Technical Research Council, CONICET, Buenos Aires, Argentina
| | - Natalia Riva
- Unit of Innovative Treatments, Hospital de Pediatría JP Garrahan, Buenos Aires, Argentina
- National Scientific and Technical Research Council, CONICET, Buenos Aires, Argentina
| | - Julia Minetto
- Liver Transplant Unit, Hospital de Pediatría JP Garrahan, Buenos Aires, Argentina
| | - Hayellen Reijenstein
- Liver Transplant Unit, Hospital de Pediatría JP Garrahan, Buenos Aires, Argentina
| | - Maria Gole
- Liver Transplant Unit, Hospital de Pediatría JP Garrahan, Buenos Aires, Argentina
| | - Veronica Meza
- Liver Transplant Unit, Hospital de Pediatría JP Garrahan, Buenos Aires, Argentina
| | - Andrea Bosaleh
- Department of Pathology, Hospital de Pediatría JP Garrahan, Buenos Aires, Argentina
| | | | - Diego Aredes
- Liver Transplant Unit, Hospital de Pediatría JP Garrahan, Buenos Aires, Argentina
| | - Leandro Lauferman
- Liver Transplant Unit, Hospital de Pediatría JP Garrahan, Buenos Aires, Argentina
| | - Guillermo Cervio
- Liver Transplant Unit, Hospital de Pediatría JP Garrahan, Buenos Aires, Argentina
| | - Marcelo Dip
- Liver Transplant Unit, Hospital de Pediatría JP Garrahan, Buenos Aires, Argentina
| | - Paula Schaiquevich
- Unit of Innovative Treatments, Hospital de Pediatría JP Garrahan, Buenos Aires, Argentina
- National Scientific and Technical Research Council, CONICET, Buenos Aires, Argentina
| | - Esteban Halac
- Liver Transplant Unit, Hospital de Pediatría JP Garrahan, Buenos Aires, Argentina
| | - Oscar Imventarza
- Liver Transplant Unit, Hospital de Pediatría JP Garrahan, Buenos Aires, Argentina
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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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Leiskau C, Samuel S, Pfister ED, Junge N, Beneke J, Stupak J, Richter N, Vondran F, Schrem H, Baumann U. Low-dose steroids do make a difference: Independent risk factors for impaired linear growth after pediatric liver transplantation. Pediatr Transplant 2021; 25:e13989. [PMID: 33689189 DOI: 10.1111/petr.13989] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 01/14/2021] [Accepted: 01/31/2021] [Indexed: 01/31/2023]
Abstract
Growth failure persists after pediatric liver transplantation and impairs pediatric development and quality of life. Steroid dose minimization attempts to prevent growth impairment, yet long-term assessment in pediatric liver recipients is lacking. We identified risk factors for impaired linear growth after pediatric liver transplantation, with a special focus on low-dose steroid therapy. This is a single-center retrospective analysis of height development in pediatric liver recipients up to 5 years after transplantation. Risk factors for impaired linear growth (height Z-scores≤-2) at transplantation, after two (n = 347) and five years (n = 210) were identified by univariate and multivariate logistic regression. At transplantation, growth retardation was found in 52.2%, predominantly younger children. Height Z-scores improved from -2.23 to -1.40 (SE 0.11; 95%CI 0.74-1.16; p < .001) two years and -1.19 (SE 0.07;0.08-0.34; p = .017) five years post-transplant. Multivariate analysis showed previous growth impairment (OR=1.484; 95%-CI=1.107-1.988; p = .004), graft loss (49.006;2.232-1076; p = .006), and prolonged cold ischemic time (1.034;1.007-1.061; p = .011) as main long-term risk factors; steroid use was a significant predictor of 2-year but not 5-year growth impairment. In univariate analysis, impaired growth after 2 and 5 years was associated with continuous low-dose (2.5 mg/m2 BSA) steroid therapy (OR=3.323;1.578-6.996; p < .001/OR=8.352;1.089-64.07; p = .006)and graft loss (OR=2.513;1.395-4.525; p = .003/OR=3.378;1.815-7.576; p < .001). Furthermore, indication and era of transplantation affected growth. Our results show significant catch-up growth after pediatric liver transplantation, yet growth failure strongly affects particularly young liver recipients. The main influenceable long-term risk factor is pre-existing growth failure, emphasizing the importance of early aggressive nutritional therapy. Moreover, low-dose steroid therapy might impair growth and should therefore be critically questioned in long-term immunosuppression.
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Affiliation(s)
- Christoph Leiskau
- Division of Pediatric Gastroenterology, Hepatology and Liver Transplantation, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany.,Core Facility Quality Management & Health Technology Assessment in Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Saskia Samuel
- Division of Pediatric Gastroenterology, Hepatology and Liver Transplantation, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany.,Core Facility Quality Management & Health Technology Assessment in Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany.,Department of Internal Medicine, Military Hospital Hamburg, Germany
| | - Eva-Doreen Pfister
- Division of Pediatric Gastroenterology, Hepatology and Liver Transplantation, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Norman Junge
- Division of Pediatric Gastroenterology, Hepatology and Liver Transplantation, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Jan Beneke
- Core Facility Quality Management & Health Technology Assessment in Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Julia Stupak
- Core Facility Quality Management & Health Technology Assessment in Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Nicolas Richter
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Germany
| | - Florian Vondran
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Germany
| | - Harald Schrem
- Core Facility Quality Management & Health Technology Assessment in Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany.,Department of General, Visceral and Transplant Surgery, Hannover Medical School, Germany.,Division of Transplant Surgery, Department of Surgery, Medical University Graz, Austria
| | - Ulrich Baumann
- Division of Pediatric Gastroenterology, Hepatology and Liver Transplantation, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
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Slowik V, Lerret SM, Lobritto SJ, Voulgarelis S, Vitola BE. Variation in immunosuppression practices among pediatric liver transplant centers-Society of Pediatric Liver Transplantation survey results. Pediatr Transplant 2021; 25:e13873. [PMID: 33026158 DOI: 10.1111/petr.13873] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 07/28/2020] [Accepted: 09/11/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Variation in IS exists among pediatric liver transplant centers. While individual centers may publish their practice paradigms, current data on practices as a whole are lacking. This study sought to ascertain the IS protocols of pediatric liver transplant centers within the SPLIT to better understand variability and similarities among peer institutions. METHODS A 27-item questionnaire was developed within the SPLIT Quality Improvement and Clinical Care Committee. The survey collected data regarding center demographics, IS practices, and treatment of acute cellular rejection. RESULTS Twenty-eight (64%) SPLIT centers responded with 22 (79%) centers performing more than 10 transplants per year and 17 (61%) following more than 100 post-transplant recipients. All centers use a written protocol, and 25 (89%) have a dedicated transplant pharmacist/PharmD. Twenty-five (89%) centers use steroids for induction alone or in combination with thymoglobulin/interleukin-2 antibodies. All centers use tacrolimus for initial maintenance therapy. Most centers have specialized protocols for ABO-incompatible transplants, recipients with renal dysfunction, autoimmune liver diseases, and liver tumors. Treatment of rejection varied but was associated with escalation in IS. CONCLUSION IS practices among pediatric liver transplant centers are similar including the use of written protocols, pharmacy involvement, steroids for induction, tacrolimus as initial IS, tacrolimus reduction/delay for renal dysfunction, and escalation of IS with rejection severity. However, other IS practices show wide variability including treatment for ABO-incompatible grafts and presumed rejection. This study serves as a foundation to guide prospective research linking IS practice to outcomes to determine best practice.
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Affiliation(s)
- Voytek Slowik
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Children's Mercy Kansas City, University of Missouri - Kansas City School of Medicine, Kansas City, MO, USA
| | - Stacee M Lerret
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, WI, USA
| | - Steven J Lobritto
- Center for Liver Diseases and Transplantation, Department of Pediatrics and Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Stylianos Voulgarelis
- Division of Anesthesiology, Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, WI, USA
| | - Bernadette E Vitola
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, WI, USA
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Ranawaka R, Dayasiri K, Gamage M. Combined liver and kidney transplantation in children and long-term outcome. World J Transplant 2020; 10:283-290. [PMID: 33134116 PMCID: PMC7579435 DOI: 10.5500/wjt.v10.i10.283] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 09/17/2020] [Accepted: 09/25/2020] [Indexed: 02/06/2023] Open
Abstract
Combined liver-kidney transplantation (CLKT) is a rarely performed complex surgical procedure in children and involves transplantation of kidney and either whole or part of liver donated by the same individual (usually a cadaver) to the same recipient during a single surgical procedure. Most common indications for CLKT in children are autosomal recessive polycystic kidney disease and primary hyperoxaluria type 1. Atypical haemolytic uremic syndrome, methylmalonic academia, and conditions where liver and renal failure co-exists may be indications for CLKT. CLKT is often preferred over sequential liver-kidney transplantation due to immunoprotective effects of transplanted liver on renal allograft; however, liver survival has no significant impact. Since CLKT is a major surgical procedure which involves multiple and complex anastomosis surgeries, acute complications are not uncommon. Bleeding, thrombosis, haemodynamic instability, infections, acute cellular rejections, renal and liver dysfunction are acute complications. The long-term outlook is promising with over 80% 5-year survival rates among those children who survive the initial six-month postoperative period.
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Affiliation(s)
- Randula Ranawaka
- Department of Paediatrics, Faculty of Medicine, University of Colombo and Lady Ridgeway Hospital for Children, Colombo 0094, Sri Lanka
| | - Kavinda Dayasiri
- Department of Paediatrics, Base Hospital Mahaoya, Mahaoya 0094, Sri Lanka
| | - Manoji Gamage
- Department of Clinical Nutrition, Lady Ridgeway Hospital for Children, Colombo 0094, Sri Lanka
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9
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The current outcomes and future challenges in pediatric vascularized composite allotransplantation. Curr Opin Organ Transplant 2020; 25:576-583. [PMID: 33044345 DOI: 10.1097/mot.0000000000000809] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW We review the outcomes and future challenges associated with pediatric vascularized composite allotransplantation, including follow-up data from our bilateral pediatric hand-forearm transplantation. RECENT FINDINGS In 2015, the first heterologous pediatric upper extremity hand-forearm transplant was performed at the Children's Hospital of Philadelphia, and in 2019, the first pediatric neck reconstructive transplantation was performed in Poland. The 5-year follow-up of the pediatric upper extremity recipient demonstrates similar growth rates bilaterally, an increase in bone age parallel to chronologic age, and perhaps similar overall growth to nontransplant norms. The pediatric upper extremity recipient continues to make gains in functional independence. He excels academically and participates in various extracurricular activities. Future challenges unique to the pediatric population include ethical issues of informed consent, psychosocial implications, limited donor pool, posttransplant compliance issues, and greater life expectancy and therefore time to inherit the many complications of immunosuppression. SUMMARY Currently, we recommend pediatric vascularized composite allotransplantation (VCA) for bilateral upper extremity amputees, preferably on immunosuppression already, and those patients who would have the most potential gain not available through standard reconstructive techniques while being able to comply with postoperative immunosuppression protocols, surveillance, rehabilitation, and follow-up.
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10
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Ohnemus D, Neighbors K, Rychlik K, Venick RS, Bucuvalas JC, Sundaram SS, Ng VL, Andrews WS, Turmelle Y, Mazariegos GV, Sorensen LG, Alonso EM. Health-Related Quality of Life and Cognitive Functioning in Pediatric Liver Transplant Recipients. Liver Transpl 2020; 26:45-56. [PMID: 31509650 DOI: 10.1002/lt.25634] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 08/08/2019] [Indexed: 12/24/2022]
Abstract
The goal of this work was to examine the change in health-related quality of life (HRQOL) and cognitive functioning from early childhood to adolescence in pediatric liver transplantation (LT) recipients. Patients were recruited from 8 North American centers through the Studies of Pediatric Liver Transplantation consortium. A total of 79 participants, ages 11-18 years, previously tested at age 5-6 years in the Functional Outcomes Group study were identified as surviving most recent LT by 2 years and in stable medical follow-up. The Pediatric Quality of Life 4.0 Generic Core Scale, Pediatric Quality of Life Cognitive Function Scale, and PROMIS Pediatric Cognitive Function tool were distributed to families electronically. Data were analyzed using repeated measures and paired t tests. Predictive variables were analyzed using univariate regression analysis. Of the 69 families contacted, 65 (94.2%) parents and 61 (88.4%) children completed surveys. Median age of participants was 16.1 years (range, 12.9-18.0 years), 55.4% were female, 33.8% were nonwhite, and 84.0% of primary caregivers had received at least some college education. Median age at LT was 1.1 years (range, 0.1-4.8 years). The majority of participants (86.2%) were not hospitalized in the last year. According to parents, adolescents had worse HRQOL and cognitive functioning compared with healthy children in all domains. Adolescents reported HRQOL similar to healthy children in all domains except psychosocial, school, and cognitive functioning (P = 0.02; P < 0.001; P = 0.04). Participants showed no improvement in HRQOL or cognitive functioning over time. For cognitive and school functioning, 60.0% and 50.8% of parents reported "poor" functioning, respectively (>1 standard deviation below the healthy mean). Deficits in HRQOL seem to persist in adolescence. Over half of adolescent LT recipients appear to be at risk for poor school and cognitive functioning, likely reflecting attention and executive function deficits.
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Affiliation(s)
- Daniella Ohnemus
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Katie Neighbors
- Division of Gastroenterology, Hepatology and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Karen Rychlik
- Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Robert S Venick
- Department of Pediatrics, Division of Gastroenterology, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - John C Bucuvalas
- Jack and Lucy Clark Department of Pediatrics, Mount Sinai Kravis Children's Hospital Recanati/Miller Transplantation Institute, New York, NY
| | - Shikha S Sundaram
- Section of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics and the Digestive Health Institute, Children's Hospital of Colorado and University of Colorado School of Medicine, Aurora, CO
| | - Vicky L Ng
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Transplant and Regenerative Medicine Center, Toronto, Ontario, Canada
| | - Walter S Andrews
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO
| | - Yumi Turmelle
- Section of Hepatology, Department of Pediatrics, Washington University, St. Louis, MO
| | - George V Mazariegos
- Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Lisa G Sorensen
- Department of Child and Adolescent Psychiatry, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Estella M Alonso
- Division of Gastroenterology, Hepatology and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
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11
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Andacoglu OM, Himmler A, Geng X, Ahn J, Conlon E, Khan K, Yazigi N, Fishbein TM. Factors Associated With Growth After Deceased and Live Donor Pediatric Liver Transplantation. Transplant Proc 2019; 51:3059-3066. [PMID: 31711584 DOI: 10.1016/j.transproceed.2019.05.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 05/01/2019] [Accepted: 05/13/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND There are limited data on predictors of growth after pediatric liver transplantation. METHODS We reviewed the impact of graft type, ethnicity, and biliary complications (BC) on growth after pediatric liver transplantation (LT). We compared preoperative and 6-, 12-, and 24-month weight, height, and body mass index (BMI) percentiles between living donor (LD), deceased donor full-size (DD-full), and deceased donor split (DD-split) graft recipients. We also compared length of stay (LOS) between groups. RESULTS We had 98 patients (DD-split: 32; DD-full: 43, LD: 23). The Median Pediatric End-stage Liver Disease (PELD) scores, exception points, albumin, bilirubin, failure to thrive, and presence of ascites were similar among groups. The DD-full group had the lowest preoperative percentiles in all categories and exceeded these at 24 months. The DD-split group was at preoperative percentiles at 24 months. The LD group had parallel weight curves compared to the DD-full group and exceeded only the preoperative weight percentile at 24 months. Black patients had the lowest percentiles in all categories (P < .01). The BC group caught up weight and BMI percentile at 24 months but had persistent decrease in height percentiles. Patients without BC exceeded preoperative height percentiles. The longer LOS group had lower height and BMI percentiles at 24 months; however, there was no statistical difference. CONCLUSION DD-full and black patients seem to benefit the most from LT in terms of growth. BC seems to affect height percentiles. Patients with longer LOS had lower height and BMI percentiles (P>.05). Longer follow up and larger cohorts are necessary to improve the power of these findings.
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Affiliation(s)
- Oya M Andacoglu
- Georgetown University MedStar Transplant Institute, Washington, DC, United States.
| | - Amber Himmler
- Georgetown University Medical School, Washington, DC, United States
| | - Xue Geng
- Department of Biostatistics, Bioinformatics, and Biomathematics, Georgetown University, Washington, DC, United States
| | - Jaeil Ahn
- Department of Biostatistics, Bioinformatics, and Biomathematics, Georgetown University, Washington, DC, United States
| | - Elizabeth Conlon
- Georgetown University Medical School, Washington, DC, United States
| | - Khalid Khan
- Georgetown University MedStar Transplant Institute, Washington, DC, United States
| | - Nada Yazigi
- Georgetown University MedStar Transplant Institute, Washington, DC, United States
| | - Thomas M Fishbein
- Georgetown University MedStar Transplant Institute, Washington, DC, United States
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12
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Yamamoto H, Khorsandi SE, Cortes‐Cerisuelo M, Kawano Y, Dhawan A, McCall J, Vilca‐Melendez H, Rela M, Heaton N. Outcomes of Liver Transplantation in Small Infants. Liver Transpl 2019; 25:1561-1570. [PMID: 31379050 PMCID: PMC6856963 DOI: 10.1002/lt.25619] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 07/14/2019] [Indexed: 12/12/2022]
Abstract
Liver transplantation (LT) for small infants remains challenging because of the demands related to graft selection, surgical technique, and perioperative management. The aim of this study was to evaluate the short-term and longterm outcomes of LT regarding vascular/biliary complications, renal function, growth, and patient/graft survival in infants ≤3 months compared with those of an age between >3 and 6 months at a single transplant center. A total of 64 infants ≤6 months underwent LT and were divided into 2 groups according to age at LT: those of age ≤3 months (range, 6-118 days; XS group, n = 37) and those of age >3 to ≤6 months (range, 124-179 days; S group, n = 27) between 1989 and 2014. Acute liver failure was the main indication for LT in the XS group (n = 31, 84%) versus S (n = 7, 26%). The overall incidence of hepatic artery thrombosis and portal vein thrombosis/stricture were 5.4% and 10.8% in the XS group and 7.4% and 11.1% in the S group, respectively (not significant). The overall incidence of biliary stricture and leakage were 5.4% and 2.7% in the XS group and 3.7% and 3.7% in the S group, respectively (not significant). There was no significant difference between the 2 groups in terms of renal function. No significant difference was found between the 2 groups for each year after LT in terms of height and weight z score. The 1-, 5-, and 10-year patient survival rates were 70.3%, 70.3%, and 70.3% in the XS group compared with 92.6%, 88.9%, and 88.9% in the S group, respectively (not significant). In conclusion, LT for smaller infants has acceptable outcomes despite the challenges of surgical technique, including vascular reconstruction and graft preparation, and perioperative management.
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Affiliation(s)
- Hidekazu Yamamoto
- Liver Transplantation, Institute of Liver StudiesKing’s College HospitalLondonUnited Kingdom
| | - Shirin E. Khorsandi
- Liver Transplantation, Institute of Liver StudiesKing’s College HospitalLondonUnited Kingdom
| | - Miriam Cortes‐Cerisuelo
- Liver Transplantation, Institute of Liver StudiesKing’s College HospitalLondonUnited Kingdom
| | - Yoichi Kawano
- Liver Transplantation, Institute of Liver StudiesKing’s College HospitalLondonUnited Kingdom
| | - Anil Dhawan
- Liver Transplantation, Institute of Liver StudiesKing’s College HospitalLondonUnited Kingdom
| | - John McCall
- Liver Transplantation, Institute of Liver StudiesKing’s College HospitalLondonUnited Kingdom
| | - Hector Vilca‐Melendez
- Liver Transplantation, Institute of Liver StudiesKing’s College HospitalLondonUnited Kingdom
| | - Mohamed Rela
- Liver Transplantation, Institute of Liver StudiesKing’s College HospitalLondonUnited Kingdom
| | - Nigel Heaton
- Liver Transplantation, Institute of Liver StudiesKing’s College HospitalLondonUnited Kingdom
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13
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Alonso EM, Ye W, Hawthorne K, Venkat V, Loomes KM, Mack CL, Hertel PM, Karpen SJ, Kerkar N, Molleston JP, Murray KF, Romero R, Rosenthal P, Schwarz KB, Shneider BL, Suchy FJ, Turmelle YP, Wang KS, Sherker AH, Sokol RJ, Bezerra JA, Magee JC. Impact of Steroid Therapy on Early Growth in Infants with Biliary Atresia: The Multicenter Steroids in Biliary Atresia Randomized Trial. J Pediatr 2018; 202:179-185.e4. [PMID: 30244988 PMCID: PMC6365098 DOI: 10.1016/j.jpeds.2018.07.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 06/06/2018] [Accepted: 07/02/2018] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To investigate the impact of corticosteroid therapy on the growth of participants in the Steroids in Biliary Atresia Randomized Trial (START) conducted through the Childhood Liver Disease Research Network. The primary analysis in START indicated that steroids did not have a beneficial effect on drainage in a cohort of infants with biliary atresia. We hypothesized that steroids would have a detrimental effect on growth in these infants. STUDY DESIGN A total of 140 infants were enrolled in START, with 70 randomized to each treatment arm: steroid and placebo. Length, weight, and head circumference were obtained at baseline and follow-up visits to 24 months of age. RESULTS Patients treated with steroids had significantly lower length and head circumference z scores during the first 3 months post-hepatoportoenterostomy (HPE), and significantly lower weight until 12 months. Growth trajectories in the steroid and placebo arms differed significantly for length (P < .0001), weight (P = .009), and head circumference (P < .0001) with the largest impact noted for those with successful HPE. Growth trajectory for head circumference was significantly lower in patients treated with steroids irrespective of HPE status, but recovered during the second 6 months of life. CONCLUSIONS Steroid therapy following HPE in patients with biliary atresia is associated with impaired length, weight, and head circumference growth trajectories for at least 6 months post-HPE, especially impacting infants with successful bile drainage. TRIAL REGISTRATION ClinicalTrials.gov: NCT00294684.
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Affiliation(s)
- Estella M Alonso
- Division of Gastroenterology, Hepatology, and Nutrition, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL.
| | - Wen Ye
- Department of Biostatistics, University of Michigan, Ann Arbor, MI
| | | | - Veena Venkat
- Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Kathleen M Loomes
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Cara L Mack
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO
| | - Paula M Hertel
- Pediatric Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine, Houston, TX
| | - Saul J Karpen
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Emory University School of Medicine/Children's Healthcare of Atlanta, Atlanta, GA
| | - Nanda Kerkar
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital Los Angeles, University of Southern California, Los Angeles, CA; Division of Pediatric Gastroenterology, The Mount Sinai School of Medicine, New York, NY
| | - Jean P Molleston
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Indiana University School of Medicine, Rylie Hospital for Children, Indianapolis, IN
| | - Karen F Murray
- Division of Gastroenterology and Hepatology, Department of Pediatrics, University of Washington and Seattle Children's, Seattle, WA
| | - Rene Romero
- Pediatrics, Emory University School of Medicine/Children's Healthcare of Atlanta, Atlanta, GA
| | - Philip Rosenthal
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Francisco Benioff Children's Hospital, San Francisco, CA
| | | | - Benjamin L Shneider
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Frederick J Suchy
- Children's Hospital Research Institute, Children's Hospital Colorado, Aurora, CO
| | | | - Kasper S Wang
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital Los Angeles, University of Southern California, Los Angeles, CA
| | - Averell H Sherker
- Liver Diseases Research Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Ronald J Sokol
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO
| | - Jorge A Bezerra
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - John C Magee
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
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14
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Vascularized composite allotransplantation in children: what we can learn from solid organ transplantation. Curr Opin Organ Transplant 2018; 23:605-614. [DOI: 10.1097/mot.0000000000000576] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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15
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Abstract
OBJECTIVES The aim of the study was to describe long-term growth postpediatric liver transplantation and to conduct bivariate and multivariate analysis of factors that may predict post-transplantation growth in children who received a liver transplant from January 1999 to December 2008 at the Hospital for Sick Children. METHODS A retrospective cohort study was conducted with follow-up of up-to 10 years post-transplantation. Mean height and weight z scores and annual differences in mean z scores were plotted against time after transplantation. A 1-way analysis of variance was conducted. Multivariate and univariate Cox proportional hazards analyses were conducted to determine factors associated with reaching the 50th and 25th percentiles for height. RESULTS A total of 127 children met eligibility criteria. The mean height z score at time of transplantation was -2.21 which by the second year post-transplantation increased significantly to -0.66 (mean increase of 1.55 standard deviation units). There were no further significant increases in mean height z score from 2 years post-transplantation until the end of follow-up at year 10. In multivariate analysis, height at transplant was the most important predictor of linear growth post-transplantation. CONCLUSIONS Children who underwent liver transplantation had significant catch-up growth in the first 2 years post-transplantation followed by a plateau phase. Increased height z-score at transplantation is the most important predictor of long-term growth.
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16
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Feldman AG, Neighbors K, Mukherjee S, Rak M, Varni JW, Alonso EM. Impaired physical function following pediatric LT. Liver Transpl 2016; 22:495-504. [PMID: 26850789 PMCID: PMC5129748 DOI: 10.1002/lt.24406] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 01/14/2016] [Accepted: 01/19/2016] [Indexed: 01/13/2023]
Abstract
The purpose of this article is to investigate the spectrum of physical function of pediatric liver transplantation (LT) recipients 12-24 months after LT. Review data were collected through the functional outcomes group, an ancillary study of the Studies of Pediatric Liver Transplantation registry. Patients were eligible if they had survived LT by 12-24 months. Children ≥ 8 years and parents completed the Pediatric Quality of Life Inventory™ 4.0 generic core scales, which includes 8 questions assessing physical function. Scores were compared to a matched healthy child population (n = 1658) and between survivors with optimal versus nonoptimal health. A total of 263 patients were included. Median age at transplant and survey was 4.8 years (interquartile range [IQR], 1.3-11.4 years) and 5.9 years (IQR, 2.6-13.1 years), respectively. The mean physical functioning score on child and parent reports were 81.2 ± 17.3 and 77.1 ± 23.7, respectively. Compared to a matched healthy population, transplant survivors and their parents reported lower physical function scores (P < 0.001); 32.9% of patients and 35.0% of parents reported a physical function score <75, which is > 1 standard deviation below the mean of a healthy population. Physical functioning scores were significantly higher in survivors with optimal health than those with nonoptimal health (P < 0.01). There was a significant relationship between emotional functioning and physical functioning scores for LT recipients (r = 0.69; P < 0.001). In multivariate analysis, primary disease, height z score < -1.64 at longterm follow-up (LTF) visit, > 4 days of hospitalization since LTF visit, and not being listed as status 1 were predictors of poor physical function. In conclusion, pediatric LT recipients 1-2 years after LT and their parents report lower physical function than a healthy population. Findings suggest practitioners need to routinely assess physical function, and the development of rehabilitation programs may be important.
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Affiliation(s)
- Amy G. Feldman
- University of Colorado School of Medicine, and Digestive Health Institute, Children’s Hospital Colorado, Aurora, CO, USA; Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics
| | - Katie Neighbors
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA; Pediatrics
| | - Shubra Mukherjee
- Rehabilitation Institute of Chicago, Chicago, IL, USA; Pediatric and Adolescent Rehabilitation
| | - Melanie Rak
- Rehabilitation Institute of Chicago, Chicago, IL, USA; Pediatric and Adolescent Rehabilitation
| | - James W. Varni
- Texas A&M University, College Station, TX, USA; Pediatrics
| | - Estella M. Alonso
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA; Pediatrics
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17
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Mager D, Al-zaben AS, Robert C, Gilmour S, Yap J. Bone Mineral Density and Growth in Children Having Undergone Liver Transplantation With Corticosteroid-Free Immunosuppressive Protocol. JPEN J Parenter Enteral Nutr 2015; 41:632-640. [DOI: 10.1177/0148607115609524] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Diana Mager
- Department of Agriculture, Food, and Nutritional Sciences, University of Alberta, Edmonton, Canada
- Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Abeer Salman Al-zaben
- Department of Agriculture, Food, and Nutritional Sciences, University of Alberta, Edmonton, Canada
| | - Cheri Robert
- Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Susan Gilmour
- Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Jason Yap
- Department of Pediatrics, University of Alberta, Edmonton, Canada
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18
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Lee S, Kim JM, Choi GS, Kwon CHD, Choe YH, Joh JW, Lee SK. Sustained linear growth and preserved renal function in 10-year survivors of pediatric liver transplantation. Transpl Int 2015; 28:835-40. [DOI: 10.1111/tri.12550] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 07/29/2014] [Accepted: 02/20/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Sanghoon Lee
- Department of Surgery; Samsung Medical Center; Sungkyunkwan University School of Medicine; Seoul Korea
| | - Jong-Man Kim
- Department of Surgery; Samsung Medical Center; Sungkyunkwan University School of Medicine; Seoul Korea
| | - Gyu-Seong Choi
- Department of Surgery; Samsung Medical Center; Sungkyunkwan University School of Medicine; Seoul Korea
| | - Choon Hyuck D. Kwon
- Department of Surgery; Samsung Medical Center; Sungkyunkwan University School of Medicine; Seoul Korea
| | - Yon-Ho Choe
- Department of Pediatrics; Samsung Medical Center; Sungkyunkwan University School of Medicine; Seoul Korea
| | - Jae-Won Joh
- Department of Surgery; Samsung Medical Center; Sungkyunkwan University School of Medicine; Seoul Korea
| | - Suk-Koo Lee
- Department of Surgery; Samsung Medical Center; Sungkyunkwan University School of Medicine; Seoul Korea
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19
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Laster ML, Fine RN. Growth following solid organ transplantation in childhood. Pediatr Transplant 2014; 18:134-41. [PMID: 24438347 DOI: 10.1111/petr.12219] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/02/2013] [Indexed: 11/28/2022]
Abstract
One of the ultimate goals of successful transplantation in pediatric solid organ transplant recipients is the attainment of optimal final adult height. This manuscript will discuss the attainment of height following solid organ transplantation in pediatric recipients of kidney, liver, heart, lung, and small bowel transplantation. Age is a primary factor with younger recipients exhibiting the greatest immediate catch up growth. Graft function is a significant contributory factor with a reduction in glomerular filtration rate correlating with poor growth in kidney recipients and the need for re-transplantation with impaired growth in liver recipients. The known adverse impact of steroids on growth has led to modification of steroid dosage and even to steroid withdrawal and steroid avoidance. In kidney and liver recipients, this has been associated with the development on occasion of acute rejection episodes. In infant heart transplantation, avoidance of maintenance corticosteroid immunosuppression is associated with normal growth velocity in the majority of patients. With marked improvement in patient and graft survival rates in pediatric organ graft recipients, it is timely that the quality of life issues, such as normal adult height, receive paramount attention. In general, normal growth post-transplantation should be an achievable goal that results in normal adult height for many solid organ transplantation recipients.
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Affiliation(s)
- M L Laster
- LAC+USC Medical Center, Los Angeles, CA, USA
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20
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Asfaw M, Mingle J, Hendricks J, Pharis M, Nucci AM. Nutrition management after pediatric solid organ transplantation. Nutr Clin Pract 2014; 29:192-200. [PMID: 24523132 DOI: 10.1177/0884533614521242] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Survival rates for pediatric transplant recipients and organ grafts have increased due to improvements in surgical techniques and with immunosuppressant treatment therapies. Interdisciplinary management after pediatric organ transplantation is essential to assist not only with the complex medical issues and complications that can result from immunosuppressant therapy but also with the achievement of normal growth and development. Impaired growth is a complication frequently experienced by pediatric transplant patients. The presence or absence of impaired growth is affected by the length of illness prior to transplant, graft function, the use of corticosteroids, and the development of infectious complications after surgery. A review of posttransplant nutrition assessment, nutrition requirements, and nutrition goals is provided. In addition, a case series of experiences with nutrition management of pediatric solid organ transplant recipients is described.
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Affiliation(s)
- Meheret Asfaw
- Anita M. Nucci, Department of Nutrition, Georgia State University, PO Box 3995, Atlanta, GA 30302-3995, USA.
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21
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Abstract
One of the ultimate goals of successful solid organ transplantation in pediatric recipients is attaining an optimal final adult height. This manuscript will discuss growth following transplantation in pediatric recipients of kidney, liver, heart, lung or small bowel transplants. Remarkably similar factors impact growth in all of these recipients. Age is a primary factor, with younger recipients exhibiting the greatest immediate catch-up growth. Graft function is a significant contributing factor, with a reduced glomerular filtration rate correlating with poor growth in kidney recipients and the need for re-transplantation with impaired growth in liver recipients. The known adverse impact of steroids on growth has led to modification of the steroid dose and even steroid withdrawal and avoidance. In kidney and liver recipients, this strategy has been associated with the development of acute rejection. In infant heart transplantation, avoiding maintenance corticosteroid immunosuppression is associated with normal growth velocity in the majority of patients. With marked improvements in patient and graft survival rates in pediatric organ recipients, quality of life issues, such as normal adult height, should now receive paramount attention. In general, normal growth following solid organ transplantation should be an achievable goal that results in normal adult height.
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Affiliation(s)
- Richard N Fine
- Division of Pediatric Nephrology, Department of Pediatrics, Stony Brook University, Stony Brook, NY, United States
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22
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Abstract
Solid organ transplantation has transformed the lives of many children and adults by providing treatment for patients with organ failure who would have otherwise succumbed to their disease. The first successful transplant in 1954 was a kidney transplant between identical twins, which circumvented the problem of rejection from MHC incompatibility. Further progress in solid organ transplantation was enabled by the discovery of immunosuppressive agents such as corticosteroids and azathioprine in the 1950s and ciclosporin in 1970. Today, solid organ transplantation is a conventional treatment with improved patient and allograft survival rates. However, the challenge that lies ahead is to extend allograft survival time while simultaneously reducing the side effects of immunosuppression. This is particularly important for children who have irreversible organ failure and may require multiple transplants. Pediatric transplant teams also need to improve patient quality of life at a time of physical, emotional and psychosocial development. This review will elaborate on the long-term outcomes of children after kidney, liver, heart, lung and intestinal transplantation. As mortality rates after transplantation have declined, there has emerged an increased focus on reducing longer-term morbidity with improved outcomes in optimizing cardiovascular risk, renal impairment, growth and quality of life. Data were obtained from a review of the literature and particularly from national registries and databases such as the North American Pediatric Renal Trials and Collaborative Studies for the kidney, SPLIT for liver, International Society for Heart and Lung Transplantation and UNOS for intestinal transplantation.
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Affiliation(s)
- Jon Jin Kim
- Department of Pediatric Nephrology, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, England, United Kingdom
| | - Stephen D Marks
- Department of Pediatric Nephrology, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, England, United Kingdom
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23
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Mohammad S, Grimberg A, Rand E, Anand R, Yin W, Alonso EM. Long-term linear growth and puberty in pediatric liver transplant recipients. J Pediatr 2013; 163:1354-60.e1-7. [PMID: 23916225 PMCID: PMC4155930 DOI: 10.1016/j.jpeds.2013.06.039] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Revised: 04/29/2013] [Accepted: 06/19/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To explore linear growth, puberty, and predictors of linear growth impairment among pubertal liver transplant recipients. STUDY DESIGN Review of data collected prospectively through the Studies of Pediatric Liver Transplantation registry. Thirty-one variables were tested as risk factors for linear growth impairment, and factors significant at P < .1 were included in a logistic regression model. Risk factor analysis was limited to 512 patients who had complete demographic and medical data. RESULTS A total of 892 patients surviving their first liver transplant by >1 year, with ≥ 1 height recorded, who were between 8 and 18 years old between the years 2005 and 2009 were included. Median follow-up was 70.2 ± 38.6 months, mean age was 12.9 ± 3.3 years, and mean height z-score (zH) was -0.5 ± 1.4 SD. Twenty percent had linear growth impairment at last follow-up. Of 353 subjects with Tanner stage data, 39% of girls and 42% of boys ages 16-18 years were not yet Tanner 5. Growth impairment rates were higher among boys than girls (30% vs 7%, P < .05) at Tanner stage 4, and occurred in 8/72 (11%) of Tanner 5 subjects. Among patients with parental height data, zH were lower than calculated mid-parental zH (P < .005). Independent predictors of growth impairment included linear growth impairment at transplant (OR 11.53, P ≤ .0001), re-transplantation (OR 4.37, P = .001), non-white race (P = .0026), and primary diagnosis other than biliary atresia (P = .0105). CONCLUSIONS Linear growth impairment and delayed puberty are common in pubertal liver transplant recipients, with pre-transplant growth impairment identified as a potentially modifiable risk factor. Catch-up growth by the end of puberty may be incomplete.
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Affiliation(s)
- Saeed Mohammad
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL.
| | - Adda Grimberg
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Elizabeth Rand
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | | | | | - Estella M. Alonso
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL
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24
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Robertson CMT, Dinu IA, Joffe AR, Alton GY, Yap JYK, Asthana S, Acton BV, Sauve RS, Martin SR, Kneteman NM, Gilmour SM. Neurocognitive outcomes at kindergarten entry after liver transplantation at <3 yr of age. Pediatr Transplant 2013; 17:621-30. [PMID: 23961979 DOI: 10.1111/petr.12134] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/11/2013] [Indexed: 12/22/2022]
Abstract
This prospective inception cohort study determines kindergarten-entry neurocognitive abilities and explores their predictors following liver transplantation at age <3 yr. Of 52 children transplanted (1999-2008), 33 (89.2%) of 37 eligible survivors had psychological assessment at age 54.7 (8.4) months: 21 with biliary atresia, seven chronic cholestasis, and five acute liver failure. Neurocognitive scores (mean [s.d.], 100 [15]) as tested by a pediatric-experienced psychologist did not differ in relation to age group at transplant (≤12 months and >12 months): FSIQ, 93.9 (17.1); verbal (VIQ), 95.3 (16.5); performance (PIQ), 94.3 (18.1); and VMI, 90.5 (15.9), with >70% having scores ≥85, average or above. Adverse predictors from the pretransplant, transplant, and post-transplant (30 days) periods using univariate linear regressions for FSIQ were post-transplant use of inotropes, p = 0.029; longer transplant warm ischemia time, p = 0.035; and post-transplant highest serum creatinine, (p = 0.04). For PIQ, they were pretransplant encephalopathy, p = 0.027; post-transplant highest serum creatinine, p = 0.034; and post-transplant inotrope use, p = 0.037. For VMI, they were number of post-transplant infections, p = 0.019; post-transplant highest serum creatinine, p = 0.025; and lower family socioeconomic index, p = 0.039. Changes in care addressing modifiable predictors, including reducing acute post-transplant illness, pretransplant encephalopathy, transplant warm ischemia times, and preserving renal function, may improve neurocognitive outcomes.
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Affiliation(s)
- Charlene M T Robertson
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada; Pediatric Rehabilitation Outcomes Unit, Glenrose Rehabilitation Hospital, Edmonton, AB, Canada
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25
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Kelly DA. Will retransplantation be the norm for pediatric recipients with ambitions for grandparenthood? Liver Transpl 2013; 19 Suppl 2:S31-4. [PMID: 24115599 DOI: 10.1002/lt.23748] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Accepted: 09/05/2013] [Indexed: 02/07/2023]
Affiliation(s)
- Deirdre A Kelly
- Liver Unit, Birmingham Children's Hospital NHS Trust, Birmingham, United Kingdom
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Devictor D, Tissieres P. Pediatric liver transplantation: where do we stand? Where we are going to? Expert Rev Gastroenterol Hepatol 2013; 7:629-41. [PMID: 24070154 DOI: 10.1586/17474124.2013.832486] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Pediatric liver transplantation (LT) is one of the most successful solid organ transplants with long-term survival more than 80%. Many aspects have contributed to improve survival, especially advancements in pre-, peri- and post-transplant management. The development of new surgical techniques, such as split-LT and the introduction of living related LT, has extended LT to small infants. Progress in the last 30 years has also been characterized by the introduction of calcineurin inhibitors. One problem remains the lack of donors. Donation after cardiac death offers a new possibility to increase the pool of potential donors. In children with acute liver failure, increasing interest has centered on the possibility of providing temporary liver support based on extracorporeal devices or hepatocyte transplantation. Similarly, hepatocyte transplantation offers new perspective in children with metabolic failure. As long-term survival increases, attention has now focused on the quality of life achieved by children undergoing LT.
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Affiliation(s)
- Denis Devictor
- Department of Pediatrics, Neonatal and Pediatric Intensive Care Unit, APHP-Bicêtre Hospital, Paris 11-Sud University, 94275 Le Kremlin-Bicêtre, France
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Kelly DA, Bucuvalas JC, Alonso EM, Karpen SJ, Allen U, Green M, Farmer D, Shemesh E, McDonald RA. Long-term medical management of the pediatric patient after liver transplantation: 2013 practice guideline by the American Association for the Study of Liver Diseases and the American Society of Transplantation. Liver Transpl 2013; 19:798-825. [PMID: 23836431 DOI: 10.1002/lt.23697] [Citation(s) in RCA: 118] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Accepted: 06/15/2013] [Indexed: 12/15/2022]
Affiliation(s)
- Deirdre A Kelly
- Liver Unit, Birmingham Children's Hospital, National Health Service Trust, Birmingham, United Kingdom.
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Ee LC, Beale K, Fawcett J, Cleghorn GJ. Long-term growth and anthropometry after childhood liver transplantation. J Pediatr 2013; 163:537-42. [PMID: 23485029 DOI: 10.1016/j.jpeds.2013.01.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2012] [Revised: 12/17/2012] [Accepted: 01/09/2013] [Indexed: 10/27/2022]
Abstract
OBJECTIVES To describe longitudinal height, weight, and body mass index changes up to 15 years after childhood liver transplantation. STUDY DESIGN Retrospective chart review of patients who underwent liver transplant from 1985-2004 was performed. Subjects were age <18 years at transplant, survived ≥5 years, with at least 2 recorded measurements, of which one was ≥5 years post-transplant. Measurements were recorded pre-transplant, 1, 5, 10, and 15 years later. RESULTS Height and weight data were available in 98 and 104 patients, respectively; 47% were age <2 years at transplant; 58% were Australian, and the rest were from Japan. Height recovery continued for at least 10 years to reach the 26th percentile (Z-score -0.67) 15 years after transplant. Australians had better growth recovery and attained 47th percentile (Z-score -0.06) at 15 years. Weight recovery was most marked in the first year and continued for 15 years even in well-nourished children. Growth impaired and malnourished children at transplant exhibited the best growth, but remained significantly shorter and lighter even 15 years later. No effect of sex or age at transplant was noted on height or weight recovery. Post-transplant factors significantly impact growth recovery and likely caused the dichotomous growth recovery between Australian and Japanese children; 9% (9/98) of patients were overweight on body mass index calculations at 10-15 years but none were obese. CONCLUSIONS After liver transplant, children can expect ongoing height and weight recovery for at least 10-15 years. Growth impairment at transplant and post-transplant care significantly impact long-term growth recovery.
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Affiliation(s)
- Looi Cheng Ee
- Queensland Liver Transplant Service, Royal Children's Hospital, Brisbane, Australia
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Park KT, Bensen R, Lu B, Nanda P, Esquivel C, Cox K. Geographical rural status and health outcomes in pediatric liver transplantation: an analysis of 6 years of national United Network of Organ Sharing Data. J Pediatr 2013; 162:313-8.e1. [PMID: 22914224 DOI: 10.1016/j.jpeds.2012.07.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2012] [Revised: 06/11/2012] [Accepted: 07/10/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To determine whether children in rural areas have worse health than children in urban areas after liver transplantation (LT). STUDY DESIGN We used urban influence codes published by the US Department of Agriculture to categorize 3307 pediatric patients undergoing LT in the United Network of Organ Sharing database between 2004 and 2009 as urban or rural. Allograft rejection, patient death, and graft failure were used as primary outcome measures of post-LT health. Pediatric end-stage liver disease/model of end-stage liver disease scores >20 was used to measure worse pre-LT health. RESULTS In a multivariate analysis, we found greater rates of allograft rejection within 6 months of LT (OR 1.27; 95% CI 1.05-1.53) and a lower occurrence of posttransplantation lymphoproliferative disorder (OR 0.64; 95% CI 0.41-0.99) in patients in rural areas. The difference in allograft rejection was eliminated at 1 year of LT (OR 1.18; 95% CI 0.98-1.42). Rural location did not impact other outcome measures. CONCLUSION We conclude that rural location makes a negative impact on patient health within the first 6 months of LT by increasing the risk for allograft rejection, although patients in rural areas may have lower rates of developing posttransplantation lymphoproliferative disorder. Long-term adverse health effects were not seen.
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Affiliation(s)
- K T Park
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Lucile Packard Children's Hospital at Stanford, Palo Alto, CA 94304, USA.
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Abstract
1. After liver transplantation (LT), the majority of children now grow into adulthood, with 10-year patient survival rates of 74% to 84% and graft survival rates of 62% to 72% according to United Network for Organ Sharing data. 2. Graft and patient survival rates decrease for patients undergoing transplantation between the ages of 12 and 17 years, and this raises the importance of dedicated adolescent care and appropriate transitioning to adult services. 3. Complications associated with long-term immunosuppression, including renal complications, infections, malignancies, and cardiovascular complications, are well described, and the risk factors are defined. 4. Biomarkers for measuring clinical immunosuppression and the concept of tolerance-inducing regimens are exciting, but further assessment is needed in large, prospective, multicenter studies. 5. As long-term medical complications are better managed, we need to focus on understanding the challenges for pediatric LT patients with respect to quality of life and health status.
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Affiliation(s)
- Marianne Samyn
- King’s College Hospital, Denmark Hill, London, United Kingdom.
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Perito ER, Lau A, Rhee S, Roberts JP, Rosenthal P. Posttransplant metabolic syndrome in children and adolescents after liver transplantation: a systematic review. Liver Transpl 2012; 18:1009-28. [PMID: 22641460 PMCID: PMC3429630 DOI: 10.1002/lt.23478] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
During long-term follow-up, 18% to 67% of pediatric liver transplant recipients are overweight or obese, with rates varying by age and pretransplant weight status. A similar prevalence of posttransplant obesity has been seen in adults. Adults also develop posttransplant metabolic syndrome and, consequently, cardiovascular disease at rates that exceed the rates in age- and sex-matched populations. Posttransplant metabolic syndrome has never been studied in pediatric liver transplant recipients, and this population is growing as transplant outcomes continue to improve. Here we systematically review the literature for each component of metabolic syndrome-obesity, hypertension, dyslipidemia, and glucose intolerance-in pediatric liver transplant recipients. Their rates of obesity are similar to the rates in children in the general U.S. population. However, hypertension, dyslipidemia, and diabetes are more common than would be expected in transplant recipients according to age, sex, and obesity severity. Immunosuppressive medications are major contributors. The limitations of previous studies, including heterogeneous methods of diagnosis, follow-up times, and immunosuppressive regimens, hinder the analysis of risk factors. Importantly, no studies have reported graft or patient outcomes associated with components of metabolic syndrome after pediatric liver transplantation. However, if the trends in children are similar to the trends seen in adults, these conditions may lead to significant long-term morbidity. Further research on the prevalence, causes, and consequences of posttransplant metabolic syndrome in pediatric liver transplant recipients is needed and will ultimately help to improve long-term outcomes.
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Affiliation(s)
| | - Audrey Lau
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics
| | - Sue Rhee
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics
| | - John P. Roberts
- Division of Transplant Surgery, Department of Surgery University of California, San Francisco
| | - Philip Rosenthal
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics
,Division of Transplant Surgery, Department of Surgery University of California, San Francisco
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Ng VL, Alonso EM, Bucuvalas JC, Cohen G, Limbers CA, Varni JW, Mazariegos G, Magee J, McDiarmid SV, Anand R. Health status of children alive 10 years after pediatric liver transplantation performed in the US and Canada: report of the studies of pediatric liver transplantation experience. J Pediatr 2012; 160:820-6.e3. [PMID: 22192813 PMCID: PMC4144332 DOI: 10.1016/j.jpeds.2011.10.038] [Citation(s) in RCA: 185] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Revised: 08/12/2011] [Accepted: 10/27/2011] [Indexed: 12/23/2022]
Abstract
OBJECTIVES To determine clinical and health-related quality of life outcomes, and to derive an "ideal" composite profile of children alive 10 years after pediatric liver transplantation (LT) performed in the US and Canada. STUDY DESIGN This was a multicenter cross-sectional analysis characterizing patients enrolled in the Studies of Pediatric Liver Transplantation database registry who have survived >10 years from LT. RESULTS A total of 167 10-year survivors were identified, all of whom received daily immunosuppression therapy. Comorbidities associated with the post-LT course included post-transplantation lymphoproliferative disease (in 5% of patients), renal dysfunction (9%), and impaired linear growth (23%). Health-related quality of life, as assessed by the PedsQL 4.0 Generic Core Scales, revealed lower patient self-reported total scale scores for 10-year survivors compared with matched healthy children (77.2±12.9 vs 84.9±11.7; P<.001). At 10 years post-LT, only 32% of patients achieved an ideal profile of a first allograft stable on immunosuppression monotherapy, normal growth, and absence of common immunosuppression-induced sequelae. CONCLUSION Success after pediatric LT has moved beyond patient survival. Availability of an ideal composite profile at follow-up provides opportunities for patients, families, and healthcare providers to identify broader sets of outcomes at earlier stages, ultimately contributing to improved outcomes after pediatric LT.
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Affiliation(s)
- Vicky L. Ng
- SickKids Transplant Center, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Estella M. Alonso
- Siragusa Transplant Center, Children’s Memorial Hospital and Northwestern University Feinberg School of Medicine, Chicago, IL
| | - John C. Bucuvalas
- Pediatric Liver Care Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | | | | | - James W. Varni
- Departments of Pediatrics and Landscape Architecture and Urban Planning, Texas A&M University, College Station, TX
| | - George Mazariegos
- Hillman Center for Pediatric Transplantation, Children’s Hospital of Pittsburgh and Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - John Magee
- Division of Transplantation, University of Michigan Health System, Ann Arbor, MI
| | - Susan V. McDiarmid
- Dumont–University of California Los Angeles Liver Transplant Center, UCLA School of Medicine and Mattel Children’s Hospital, Los Angeles, CA
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Endocrine and bone metabolic complications in chronic liver disease and after liver transplantation in children. J Pediatr Gastroenterol Nutr 2012; 54:313-21. [PMID: 22064631 DOI: 10.1097/mpg.0b013e31823e9412] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
With improved survival of orthotopic liver transplantation (OLT) in children, prevention and treatment of pre- and posttransplant complications have become a major focus of care. End-stage liver failure can cause endocrine complications such as growth failure and hepatic osteodystrophy, and, like other chronic illnesses, also pubertal delay, relative adrenal insufficiency, and the sick euthyroid syndrome. Drug-induced diabetes mellitus post-OLT affects approximately 10% of children. Growth failure is found in 60% of children assessed for OLT. Despite optimisation of nutrition, rarely can further stunting of growth before OLT be prevented. Catch-up growth is usually observed after steroid weaning from 18 months post-OLT. Whether growth hormone treatment would benefit the 20% of children who fail to catch up in height requires testing in randomised controlled trials. Hepatic osteodystrophy in children comprises vitamin D deficiency rickets, low bone mass, and fractures caused by malnutrition and malabsorption. Vitamin D deficiency requires aggressive treatment with ergocalciferol (D2) or cholecalciferol (D3). The active vitamin D metabolites alphacalcidol or calcitriol increase gut calcium absorption but do not replace vitamin D stores. Prevalence of fractures is increased both before OLT (10%-28% of children) and after OLT (12%-38%). Most fractures are vertebral, are associated with low spine bone mineral density, and frequently occur asymptomatically, but they may also cause chronic pain. Fracture prediction in these children is limited. OLT in children is also associated with a greater risk of developing avascular bone necrosis (4%) and scoliosis (13%-38%). This article reviews the literature on endocrine and skeletal complications of liver disease and presents preventive screening recommendations and therapeutic strategies.
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Abstract
Liver transplantation is the standard of care for children with life-threatening liver disease. Survival rates posttransplantation are rising with current 1-year and 5-year rates being greater than 90% and 85%, respectively. Numerous factors contribute to posttransplant outcomes of graft and patient survival, including improved surgical techniques, immunosuppressive regimens, and posttransplant management. The present review aims to discuss predictors of long-term outcomes of pediatric transplant recipients and identify potential risk factors.
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Dhawan A. Immunosuppression in pediatric liver transplantation: are little people different? Liver Transpl 2011; 17 Suppl 3:S13-9. [PMID: 21850684 DOI: 10.1002/lt.22422] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
1. Children differ from adults in the pharmacokinetics and dynamics of most immunosuppressive agents. 2. A lack of clinical trials continues to be an issue for newer agents. 3. On the basis of clinical case series, mycophenolate mofetil and sirolimus are increasingly being used as renal-sparing agents. 4. In comparison with adults, the recurrence of both viral hepatitis and hepatocellular carcinoma is less of an issue in children. 5. Particular attention should be paid to complete age-appropriate immunization to avoid vaccine-preventable diseases. 6. Paying special attention to adherence and the transition to adult services is essential for minimizing graft loss.
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Affiliation(s)
- Anil Dhawan
- Paediatric Liver, GI, and Nutrition Centre, King's College Hospital, London, United Kingdom.
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Abstract
LaR Pediatric solid-organ transplantation is an increasingly successful treatment for organ failure. Five- and 10-yr patient survival rates have dramatically improved over the last couple of decades, and currently, over 80% of pediatric patients survive into adolescence and young adulthood. Waiting list mortality has been a concern for liver, heart, and intestinal transplantation, illustrating the importance of transplant as a life-saving therapy. Unfortunately, the success of pediatric transplantation comes at the cost of long-term or late complications that arise as a result of allograft rejection or injury, immunosuppression-related morbidity, or both. As transplant recipients enter adolescence treatment, non-adherence becomes a significant issue, and the medical and psychosocial impacts transition to adulthood not only with regard to healthcare but also in terms of functional outcomes, economic potential, and overall QoL. This review addresses the clinical and psychosocial challenges encountered by pediatric transplant recipients in the current era. A better understanding of pediatric transplant outcomes and adult morbidity and mortality requires further ongoing assessment.
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Affiliation(s)
- Christopher LaRosa
- Division of Nephrology, Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA 19104, USA
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Sorensen L, Neighbors K, Martz K, Zelko F, Bucuvalas J, Alonso E. Cognitive and academic outcomes after pediatric liver transplantation: Functional Outcomes Group (FOG) results. Am J Transplant 2011; 11:303-11. [PMID: 21272236 PMCID: PMC3075835 DOI: 10.1111/j.1600-6143.2010.03363.x] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
This multicenter study examined prevalence of cognitive and academic delays in children following liver transplant (LT). One hundred and forty-four patients ages 5-7 and 2 years post-LT were recruited through the SPLIT consortium and administered the Wechsler Preschool and Primary Scale of Intelligence, 3rd Edition (WPPSI-III), the Bracken Basic Concept Scale, Revised (BBCS-R), and the Wide Range Achievement Test, 4th edition (WRAT-4). Parents and teachers completed the Behavior Rating Inventory of Executive Function (BRIEF). Participants performed significantly below test norms on intelligence quotient (IQ) and achievement measures (Mean WPPSI-III Full Scale IQ = 94.7 ± 13.5; WRAT-4 Reading = 92.7 ± 17.2; WRAT-4 Math = 93.1 ± 15.4; p < 0001). Twenty-six percent of patients (14% expected) had 'mild to moderate' IQ delays (Full Scale IQ = 71-85) and 4% (2% expected) had 'serious' delays (Full Scale IQ ≤ 70; p < 0.0001). Reading and/or math scores were weaker than IQ in 25%, suggesting learning disability, compared to 7% expected by CDC statistics (p < 0.0001). Executive deficits were noted on the BRIEF, especially by teacher report (Global Executive Composite = 58; p < 0.001). Results suggest a higher prevalence of cognitive and academic delays and learning problems in pediatric LT recipients compared to the normal population.
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Affiliation(s)
- L.G. Sorensen
- Child & Adolescent Psychiatry, Children's Memorial Hospital, Chicago, IL
| | - K. Neighbors
- Pediatrics, Children's Memorial Hospital, Chicago, IL
| | - K. Martz
- The EMMES Corporation, Rockville, MD
| | - F. Zelko
- Child & Adolescent Psychiatry, Children's Memorial Hospital, Chicago, IL
| | - J.C. Bucuvalas
- Pediatric Liver Care Center, Cincinnati Children’s Hospital, Cincinnati, OH
| | - E.M. Alonso
- Pediatrics, Children's Memorial Hospital, Chicago, IL
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Campbell K, Ng V, Martin S, Magee J, Goebel J, Anand R, Martz K, Bucuvalas J. Glomerular filtration rate following pediatric liver transplantation--the SPLIT experience. Am J Transplant 2010; 10:2673-82. [PMID: 21114644 DOI: 10.1111/j.1600-6143.2010.03316.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Impaired kidney function is a well-recognized complication following liver transplantation (LT). Studies of this complication in children have been limited by small numbers and insensitive outcome measures. Our aim was to define the prevalence of, and identify risk factors for, post-LT kidney dysfunction in a multicenter pediatric cohort using measured glomerular filtration rate (mGFR). We conducted a cross-sectional study of 397 patients enrolled in the Studies in Pediatric Liver Transplantation (SPLIT) registry, using mGFR < 90 mL/min/1.73 m(2) as the primary outcome measure. Median age at LT was 2.2 years. Primary diagnoses were biliary atresia (44.6%), fulminant liver failure (9.8%), metabolic liver disease (16.4%), chronic cholestatic liver disease (13.1%), cryptogenic cirrhosis (4.3%) and other (11.8%). At a mean of 5.2 years post-LT, 17.6% of patients had a mGFR < 90 mL/min/1.73 m(2) . In univariate analysis, factors associated with this outcome were transplant center, age at LT, primary diagnosis, calculated GFR (cGFR) at LT and 12 months post-LT, primary immunosuppression, early post-LT kidney complications, age at mGFR, height and weight Z-scores at 12 months post-LT. In multivariate analysis, independent variables associated with a mGFR <90 mL/min/1.73 m(2) were primary immunosuppression, age at LT, cGFR at LT and height Z-score at 12 months post-LT.
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Affiliation(s)
- K Campbell
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
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Abstract
Pediatric liver transplant recipients represent an important target population for primary care health professionals as well as transplant practitioners. With improving patient and graft survival, new concerns now face health care professionals caring for the transplant community, namely the long-term complications of immunosuppressive therapy and the potential for withdrawal of immunosuppression, transplant recipients' quality of life, and the persistent shortage of donor organs leading to morbidity and mortality on the waiting list. These issues require constant collaboration between pediatricians, transplant hepatologists, transplant surgeons, nurses, dieticians, social workers, psychologists, and other supporting services.
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Affiliation(s)
- Binita M Kamath
- Department of Pediatrics, University of Toronto, Toronto, ON M5S 1A1, Canada.
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Most commonly asked questions from parents of pediatric transplant recipients. Pediatr Clin North Am 2010; 57:611-22, table of contents. [PMID: 20371055 DOI: 10.1016/j.pcl.2010.01.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Pediatric solid-organ transplant (SOT) recipients and their parents are often challenged to cope with new transplant regimens as well as common situations in the context of organ transplantation. Health care professionals will receive questions from parents and children regarding clinical transplant care as well as general pediatric concerns that seem unfamiliar to families now that their child has a transplant. The literature is limited in some areas of pediatric care after SOT, and there is little guidance for the health care practitioner. To help address gaps in the literature and provide guidance for health care professionals, this article reviews some of the most commonly asked questions regarding general care after SOT, parenting the child with a chronic illness, and growth and development. The answers provided stem from the literature in part but also the combined clinical experiences of transplant centers that over time have moved toward decreased limitations and full social integration.
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