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Yang N, Vittorio J, King LY. Pediatric liver transplant recipients are not just young adults: The importance of a structured health care transition program in adult transplant centers. Liver Transpl 2024; 30:945-959. [PMID: 38915180 DOI: 10.1097/lvt.0000000000000401] [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: 01/24/2024] [Accepted: 04/25/2024] [Indexed: 06/26/2024]
Abstract
Health care transition (HCT) is a vulnerable period that continues into adulthood, even after the transfer of care. Given the growing population of pediatric liver transplant recipients reaching young adulthood, the need for a standardized and multidisciplinary approach to transition that spans from pediatric to adult care is becoming more imperative. In this article, we review the unique challenges and barriers to successful HCT that adolescent and young adults (AYAs) who have undergone liver transplant face, highlight the gap in transition care in the adult setting, and present the Six Core Elements of Health Care Transition TM as a framework that can be used by adult providers to incorporate AYAs systematically and collaboratively into adult practice. Multidisciplinary HCT programs should be the standard of care for all AYAs with liver transplant, and while implementation is a necessary first step, ongoing efforts to increase awareness, funding, and research on HCTs into adulthood are needed.
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Affiliation(s)
- Nancy Yang
- Division of Gastroenterology, Department of Medicine, Duke University Health System, Durham, North Carolina, USA
| | - Jennifer Vittorio
- Department of Pediatrics, NYU Langone Health, New York, New York, USA
| | - Lindsay Y King
- Division of Gastroenterology, Department of Medicine, Duke University Health System, Durham, North Carolina, USA
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2
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Kehler T, Grothues D, Evert K, Wahlenmayer J, Knoppke B, Melter M. Elastography-The New Standard in the Assessment of Fibrosis After Pediatric Liver Transplantation? Pediatr Transplant 2024; 28:e14832. [PMID: 39075333 DOI: 10.1111/petr.14832] [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: 01/13/2024] [Revised: 06/21/2024] [Accepted: 07/12/2024] [Indexed: 07/31/2024]
Abstract
BACKGROUND The development of graft fibrosis after pediatric liver transplantation (PLT) remains a major concern as it can lead to graft failure and ultimately graft loss. Elastography is a non-invasive method to assess liver fibrosis, but its role in the posttransplant setting is unclear. The aim of our study was to evaluate shear wave elastography (SWE) in the assessment of liver fibrosis after PLT, including split-liver recipients. METHODS We retrospectively analyzed data from PLT recipients who underwent surveillance liver biopsy and concurrent 2D-SWE during the study period from April 2018 to July 2021. Spearman's correlation was used to compare histologic fibrosis stages with liver stiffness measurements (LSM) by 2D-SWE. AUROC analysis was performed to evaluate the performance. One sample t-test was used to compare results with reference values of healthy children. RESULTS 62 cases were included. 29% showed histologic fibrosis. LSM by 2D-SWE were feasible in all children regardless of age or graft type. There was a significant correlation between LSM and fibrosis stage for all three scoring systems used (Ishak, p = 0.003; METAVIR, p = 0.005; LAF Score, p = 0.003). Patients with a history of biliary complications had increased liver stiffness (p = 0.015). The AUROC of 2D-SWE for predicting significant liver graft fibrosis was 0.81. Liver stiffness after PLT without graft fibrosis was higher than in healthy subjects, but comparable to that in children with chronic liver disease without fibrosis. CONCLUSION 2D-SWE can reliably detect children with significant liver graft fibrosis, even in split-liver recipients. This study demonstrates the value of a non-invasive tool for fibrosis staging after PLT. 2D-SWE has the potential to improve long-term outcomes after PLT and to reduce the number of surveillance liver biopsies. But elastography is not a substitute for liver biopsy.
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Affiliation(s)
- Thomas Kehler
- University Children's Hospital Regensburg (KUNO), University Hospital Regensburg, Regensburg, Germany
| | - Dirk Grothues
- University Children's Hospital Regensburg (KUNO), University Hospital Regensburg, Regensburg, Germany
| | - Katja Evert
- Institute of Pathology, University Hospital Regensburg, Regensburg, Germany
| | - Janka Wahlenmayer
- University Children's Hospital Regensburg (KUNO), University Hospital Regensburg, Regensburg, Germany
| | - Birgit Knoppke
- University Children's Hospital Regensburg (KUNO), University Hospital Regensburg, Regensburg, Germany
| | - Michael Melter
- University Children's Hospital Regensburg (KUNO), University Hospital Regensburg, Regensburg, Germany
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3
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Bruns N, Hauschild J, Lainka E, Dohna-Schwake C. Surgical Site Infections After Pediatric Liver Transplantation-Impact of a Change in Perioperative Prophylactic Antibiotic Protocol. Pediatr Transplant 2024; 28:e14830. [PMID: 39030994 DOI: 10.1111/petr.14830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 06/21/2024] [Accepted: 07/08/2024] [Indexed: 07/22/2024]
Abstract
BACKGROUND In spite of improved survival rates after pediatric liver transplantation, infections remain major contributors to perioperative morbidity and mortality. This study aimed to understand the impact of type and duration of perioperative antibiotic prophylaxis (PAP) on the occurrence of surgical site infections (SSIs). METHODS In total, 125 patients who underwent liver transplantation between 2014 and 2020 were retrospectively included. Patients were categorized into two periods based on changes in the standard PAP regimen. Risk factors for SSIs were investigated, including the influence of PAP duration, antibiotic substances used, and abdominal patch placement using multivariable regression models. RESULTS SSIs occurred in 23 (19%) of 119 analyzed patients and were not impacted by changes in the PAP regimen. The placement of an abdominal patch was a relevant risk factor for SSIs (odds ratio 3.81; 95% confidence interval [CI] 1.15-12.68). Longer PAP duration reduced the occurrence of SSIs by up to 4.6 percentage points (95% CI 0.0-9.1) per day, with its effect diminishing with longer duration. The choice of antibiotic substances for PAP changed after implementation of the new protocol, with a decline in vancomycin usage from 14% to 3%. CONCLUSION The results of this study emphasize the need for evidence-based PAP regimens tailored to the unique needs of pediatric liver transplant recipients. The occurrence of SSIs remains complex and is influenced by various factors beyond the PAP regimen. Multicentric efforts to develop effective prevention strategies against SSIs in this vulnerable population are warranted.
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Affiliation(s)
- Nora Bruns
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care Medicine, and Pediatric Neurology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- TNBS, Centre for Translational Neuro- and Behavioural Sciences, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Juliane Hauschild
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care Medicine, and Pediatric Neurology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Elke Lainka
- Department of Pediatrics II, Pediatric Gastroenterology, Hepatology and Liver Transplantation, University Children's Hospital, Essen, Germany
| | - Christian Dohna-Schwake
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care Medicine, and Pediatric Neurology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- TNBS, Centre for Translational Neuro- and Behavioural Sciences, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- West German Centre of Infectious Diseases, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
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Kanamori H, Yamada Y, Ito Y, Shirosaki K, Yamagishi S, Maeda Y, Kudo Y, Umeyama T, Takahashi N, Kato M, Hasegawa Y, Matsubara K, Shinoda M, Obara H, Irie R, Tsujikawa H, Okita H, Nguyen PT, Saigo K, Mitsunaga S, Inoue I, Kitagawa Y, Kuroda T. Noninvasive graft monitoring using donor-derived cell-free DNA in Japanese liver transplantation. Hepatol Res 2024; 54:300-314. [PMID: 37850337 DOI: 10.1111/hepr.13978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 09/06/2023] [Accepted: 10/13/2023] [Indexed: 10/19/2023]
Abstract
AIM To evaluate the use of donor-derived cell-free DNA (dd-cfDNA) in diagnosing graft injuries in Japanese liver transplantation (LTx), including family-related living donors. METHODS A total of 321 samples from 10 newly operated LTx recipients were collected to monitor the early dynamics of dd-cfDNA levels after LTx. Fifty-five samples from 55 recipients were collected during protocol biopsies (PB), whereas 36 samples from 27 recipients were collected during event biopsies, consisting of 11 biopsy-proven acute rejection (AR), 20 acute dysfunctions without rejection (ADWR), and 5 chronic rejections. The levels of dd-cfDNA were quantified using a next-generation sequencer based on single nucleotide polymorphisms. RESULTS The dd-cfDNA levels were elevated significantly after LTx, followed by a rapid decline to the baseline in patients without graft injury within 30 days post-LTx. The dd-cfDNA levels were significantly higher in the 11 samples obtained during AR than those obtained during PB (p < 0.0001), which decreased promptly after treatment. The receiver operator characteristic curve analysis of diagnostic ability yielded areas under the curve of 0.975 and 0.897 for AR (rejection activity index [RAI] ≥3) versus PB and versus non-AR (ADWR + PB). The dd-cfDNA levels during AR were elevated earlier and correlated more strongly with the RAI (r = 0.740) than aspartate aminotransferase/alanine aminotransferase. The dd-cfDNA levels were neither associated with graft fibrosis based on histology nor the status of donor-specific antibodies in PB samples. CONCLUSIONS Donor-derived cell-free DNA serves as a sensitive biomarker for detecting graft injuries in LTx. Further large-scale cohort studies are warranted to optimize its use in differentiating various post-LTx etiologies.
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Affiliation(s)
- Hiroki Kanamori
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yohei Yamada
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yoko Ito
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Koji Shirosaki
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Satoko Yamagishi
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yutaro Maeda
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yumi Kudo
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Tomoshige Umeyama
- Department of Pediatric Surgery, St Luke's International Hospital, Tokyo, Japan
| | - Nobuhiro Takahashi
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Mototoshi Kato
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yasushi Hasegawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Kentaro Matsubara
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Masahiro Shinoda
- Digestive Diseases Center, International University of Health and Welfare School of Medicine, Mita Hospital, Tokyo, Japan
| | - Hideaki Obara
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Rie Irie
- Department of Diagnostic Pathology, Nippon Koukan Hospital, Kawasaki, Japan
| | - Hanako Tsujikawa
- Division of Diagnostic Pathology, Keio University School of Medicine, Tokyo, Japan
| | - Hajime Okita
- Division of Diagnostic Pathology, Keio University School of Medicine, Tokyo, Japan
| | | | - Kenichi Saigo
- Department of Transplantation Surgery, Japan Community Health Care Organization, Chiba Hospital, Chiba, Japan
| | - Shigeki Mitsunaga
- Human Genetics Laboratory, National Institute of Genetics, Mishima, Japan
| | - Ituro Inoue
- Human Genetics Laboratory, National Institute of Genetics, Mishima, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Tatsuo Kuroda
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
- Kanagawa Children's Medical Center, Kanagawa, Japan
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Antala S, DiNorcia J, Bucuvalas J. Balancing immunosuppression in pediatric liver transplantation: Playing the long game. Pediatr Transplant 2023; 27:e14575. [PMID: 37439035 DOI: 10.1111/petr.14575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 07/03/2023] [Indexed: 07/14/2023]
Abstract
The overarching goal in the care of pediatric liver transplant recipients is to optimize allograft and patient health. Balancing immunosuppression to maintain allograft health while avoiding medication side effects is essential for long-term survival and optimal quality of life in pediatric liver transplant recipients. Utilizing precision medicine to personalize immunosuppression, which includes minimization and withdrawal, is core to this effort. The unique anatomy and physiology of the liver make it more tolerant to immune-mediated injury and a more favorable organ for immunosuppression minimization and withdrawal. However, several challenges exist. Standard biochemical values and histologic features may not reliably predict allograft health after a reduction in immunosuppression. Additionally, biochemical values alone do not reliably identify which patients can successfully develop operational tolerance, as there may be occult allograft injury despite normal liver enzymes. Finally, the durability of tolerance after successful reduction in immunosuppression remains uncertain over time. Innovative tools show promise in circumventing these challenges, but more research is needed to determine actual clinical utility. While immunosuppression-free transplant may not be a current reality for most pediatric liver transplant recipients, strategies to safely minimize immunosuppression without compromising allograft health are within reach. Each liver allograft and recipient pair requires a different degree of immune modulation, and through a structured process of minimization and withdrawal, immunosuppression can indeed be tailored in a precise, personalized way to optimize outcomes. This review focuses on the progress that has been made to individualize immunosuppression in pediatric liver transplantation to ensure optimal allograft and recipient health.
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Affiliation(s)
- Swati Antala
- Department of Pediatrics, Icahn School of Medicine, Kravis Children's Hospital at Mount Sinai, New York City, New York, USA
| | - Joseph DiNorcia
- Recanati-Miller Transplantation Institute, Mount Sinai Hospital, New York City, New York, USA
| | - John Bucuvalas
- Department of Pediatrics, Icahn School of Medicine, Kravis Children's Hospital at Mount Sinai, New York City, New York, USA
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King LY, Kosmach-Park B, Parish A, Niedzwiecki D, Jackson WE, Vittorio JM. Current approach to health care transition and integration into adult care for pediatric liver transplant recipients: A call for partnership. Clin Transplant 2023; 37:e14990. [PMID: 37105553 DOI: 10.1111/ctr.14990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 01/23/2023] [Accepted: 04/02/2023] [Indexed: 04/29/2023]
Abstract
Despite the increased risk of non-adherence, allograft rejection, and mortality following transfer from pediatric to adult care in liver transplantation (LT), there is no standardized approach to health care transition (HCT). Two electronic national surveys were developed and distributed to members of the Society for Pediatric Liver Transplantation and all adult LT programs in the United States to examine current HCT practices. Responses were received from 40 pediatric and 79 adult centers. Pediatric centers were more likely to focus on HCT noting the presence of a transition/transfer policy (60.2% vs. 39.2%), transition clinic (51.6% vs. 16.5%), and the routine use of transition readiness assessment tools (54.8% vs. 10.2%). Perceived barriers to HCT were similar among pediatric and adult respondents and included patient willingness to transfer and participate in care, failure to show for appointments, and lack of sufficient time and staffing. These results highlight the need for an increased awareness of HCT at both pediatric and adult LT centers. The path to improvement requires a partnership between pediatric and adult providers. Recognizing the importance of a comprehensive HCT program initiated in pediatrics and continued throughout young adulthood with ongoing support by the adult team is essential.
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Affiliation(s)
- Lindsay Yount King
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Beverly Kosmach-Park
- Department of Transplant Surgery, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Alice Parish
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Donna Niedzwiecki
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Whitney Erika Jackson
- Department of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
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Wischlen E, Boillot O, Rivet C, Lachaux A, Bouvier R, Hervieu V, Scoazec JY, Collardeau-Frachon S, Dumortier J, Laverdure N. Are protocol graft biopsies after pediatric liver transplantation useful? Experience in a single center over 20 years. Clin Transplant 2023; 37:e14898. [PMID: 36585804 DOI: 10.1111/ctr.14898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 12/16/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND The role of protocol liver biopsies (PLB) in the follow-up of pediatric liver transplant recipients remains questionable. This single-center retrospective study aimed to evaluate their clinical impact on the long-term management of pediatric liver transplant recipients. METHODS We described histopathological lesions and clinical consequences for patient management of PLB performed 1, 5, 10, 15, 20, and 25 years after pediatric liver transplantation (LT). RESULTS A total of 351 PLB performed on 133 patients between 1992 and 2021 were reviewed. PLB found signs of rejection in 21.7% of cases (76/351), and moderate to severe fibrosis in 26.5% of cases (93/351). Overall, 264 PLB (75.2%) did not cause any changes to patient care. Immunosuppression was enhanced after 63 PLB, including 23 cases of occult rejection. The 1-year PLB triggered significantly more changes, while biopsies at 15, 20, and 25 years produced the lowest rates of subsequent modifications. PLB had a significantly higher probability of inducing therapeutic changes if the patient had abnormal biological or imaging results (odds ratio [OR] 2.82 and 2.06), or a recent history of rejection or bacterial infection (OR 2.22 and 2.03). CONCLUSION Our results suggest that, although it often does not prompt any treatment changes, PLB could be performed because of its ability to detect silent rejection requiring an increase in immunosuppression. PLB could be carried out 1, 5, and 10 years after LT and then every 10 years in patients with normal biological and imaging results and no recent complications, while other patients could be kept on a 5-year protocol.
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Affiliation(s)
- Emma Wischlen
- Department of Pediatric Hepatogastroenterology and Nutrition, Femme-Mère-Enfant Hospital, Hospices Civils de Lyon, Lyon, France
| | - Olivier Boillot
- Department of Digestive Diseases, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France.,University Claude Bernard Lyon 1, Lyon, France
| | - Christine Rivet
- Department of Pediatric Hepatogastroenterology and Nutrition, Femme-Mère-Enfant Hospital, Hospices Civils de Lyon, Lyon, France
| | - Alain Lachaux
- Department of Pediatric Hepatogastroenterology and Nutrition, Femme-Mère-Enfant Hospital, Hospices Civils de Lyon, Lyon, France.,University Claude Bernard Lyon 1, Lyon, France
| | - Raymonde Bouvier
- University Claude Bernard Lyon 1, Lyon, France.,Department of Pathology, Hospices Civils de Lyon, Lyon, France
| | - Valérie Hervieu
- University Claude Bernard Lyon 1, Lyon, France.,Department of Pathology, Hospices Civils de Lyon, Lyon, France
| | - Jean-Yves Scoazec
- Institut Gustave Roussy, Department of Pathology, Villejuif and Université Paris Saclay, France
| | - Sophie Collardeau-Frachon
- University Claude Bernard Lyon 1, Lyon, France.,Department of Pathology, Hospices Civils de Lyon, Lyon, France
| | - Jérôme Dumortier
- Department of Digestive Diseases, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France.,University Claude Bernard Lyon 1, Lyon, France
| | - Noémie Laverdure
- Department of Pediatric Hepatogastroenterology and Nutrition, Femme-Mère-Enfant Hospital, Hospices Civils de Lyon, Lyon, France
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Health Care Transition for Adolescents and Young Adults With Pediatric-Onset Liver Disease and Transplantation: A Position Paper by the North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr 2023; 76:84-101. [PMID: 35830731 DOI: 10.1097/mpg.0000000000003560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Advances in medical therapies and liver transplantation have resulted in a greater number of pediatric patients reaching young adulthood. However, there is an increased risk for medical complications and morbidity surrounding transfer from pediatric to adult hepatology and transplant services. Health care transition (HCT) is the process of moving from a child/family-centered model of care to an adult or patient-centered model of health care. Successful HCT requires a partnership between pediatric and adult providers across all disciplines resulting in a transition process that does not end at the time of transfer but continues throughout early adulthood. Joint consensus guidelines in collaboration with the American Society of Transplantation are presented to facilitate the adoption of a structured, multidisciplinary approach to transition planning utilizing The Six Core Elements of Health Care Transition TM for use by both pediatric and adult specialists. This paper provides guidance and seeks support for the implementation of an HCT program which spans across both pediatric and adult hepatology and transplant centers.
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Memaran N, Wilke H, Sugianto RI, Baumann U, Bauer E, Swallow M, Beuke E, Junge N, Pfister ED, Grabitz C, Richter N, Goldschmidt I, Schmidt BMW, Melk A. Telomere length is associated with intima-media thickness in pediatric liver transplant patients: A prospective cohort study. Liver Transpl 2022; 28:1766-1775. [PMID: 35666175 DOI: 10.1002/lt.26524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 05/16/2022] [Accepted: 05/20/2022] [Indexed: 01/13/2023]
Abstract
Leukocyte telomere length (LTL) is a marker for biological age. Pediatric liver transplant recipients show a high rate of subclinical atherosclerosis, indicated by elevated intima-media thickness (IMT). We hypothesized that atherosclerosis is associated with biological age in these patients and investigated the course of LTL over time. We measured LTL from peripheral blood leukocytes by quantitative polymerase chain reaction and IMT from 97 pediatric patients after liver transplantation in a prospective cohort study. Of the patients, 71% (n = 69) had two or more assessments (total, 228 observations; median follow-up, 1.1 years). Lower LTL was associated with higher IMT (β = -0.701, p = 0.01) and higher aspartate aminotransferase (β = -0.001, p = 0.02), adjusted for age, sex, and age at transplantation. Of the patients, 45% showed decreasing LTL over time, whereas 55% exhibited stable LTL. Patients with stable LTL showed a decrease in IMT (median, -0.02 mm/year) and a decrease of tacrolimus trough levels (median, -0.08 μg/L/year). LTL is associated with IMT independent of age in pediatric liver transplant patients, suggesting that early aging contributes to the high burden of subclinical cardiovascular damage and may furthermore negatively affect the graft.
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Affiliation(s)
- Nima Memaran
- Pediatric Nephrology, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Hannes Wilke
- Pediatric Nephrology, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Rizky I Sugianto
- Pediatric Nephrology, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Ulrich Baumann
- Pediatric Gastroenterology and Hepatology, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Elena Bauer
- Pediatric Nephrology, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Maxine Swallow
- Pediatric Nephrology, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Esther Beuke
- Pediatric Nephrology, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Norman Junge
- Pediatric Gastroenterology and Hepatology, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Eva D Pfister
- Pediatric Gastroenterology and Hepatology, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Carl Grabitz
- Pediatric Nephrology, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Nicolas Richter
- Department of General, Visceral, and Transplantation Surgery, Hannover Medical School, Hannover, Germany
| | - Imeke Goldschmidt
- Pediatric Gastroenterology and Hepatology, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Bernhard M W Schmidt
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Anette Melk
- Pediatric Nephrology, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
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10
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Education and Psychosocial Factors Predict Odds of Death After Transfer to Adult health Care in Pediatric Liver Transplant Patients. J Pediatr Gastroenterol Nutr 2022; 75:623-628. [PMID: 35767565 DOI: 10.1097/mpg.0000000000003549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES To analyze demographic, psychosocial, and clinical factors in pediatric liver transplant recipients for their association with death or loss to follow up in adulthood. We aimed to better understand known health disparities in transplant outcomes and identify potentially modifiable risk factors prior to transfer. METHODS A retrospective cohort study of children who underwent liver transplantation at a large tertiary transplant center and were transferred to adult care between 2000 and 2015. RESULTS During the study period, 101 qualifying patients were transferred. Ninety-three individuals followed with an adult provider, while 8 were lost to follow up. In total 23 of 93 patients died after transfer (24.7%). Several childhood factors were associated with adult death: Black race [odds ratio (OR) 6.59, P < 0.001]; psychiatric illness or substance use (OR 2.81, P = 0.04); failure to graduate high school before transfer (OR 9.59, P < 0.001); posttransplant tacrolimus medication-level variability index >2.5 (OR 5.36, P = 0.04); provider documentation of medication nonadherence (OR 4.72, P = 0.02); acute cellular rejection (OR 4.44, P = 0.03); the presence of diabetes mellitus (OR 5.71, P = 0.001), and chronic kidney disease (OR 2.82, P = 0.04). Failure to graduate HS was associated with loss to follow up ( P < 0.001). On multivariate analysis, Black race, substance use, diabetes, and failure to graduate HS retained association with adult death (each P < 0.05). CONCLUSIONS Complex, intertwined patient characteristics are associated with increased odds of death in pediatric liver transplant recipients transferred to adult care. Early recognition of high-risk patients and intervention for modifiable factors, such as improved HS graduation and substance use prevention, may improve long-term outcomes.
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11
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Gad EH, Sallam AN, Soliman H, Ibrahim T, Salem TAH, Ali MAH, Al-Sayed Abd-same M, Ayoub I. Pediatric living donor liver transplantation (LDLT): Short- and long-term outcomes during sixteen years period at a single centre- A retrospective cohort study. Ann Med Surg (Lond) 2022; 79:103938. [PMID: 35860167 PMCID: PMC9289343 DOI: 10.1016/j.amsu.2022.103938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 06/01/2022] [Accepted: 06/02/2022] [Indexed: 02/05/2023] Open
Abstract
Background and objectives Pediatric living donor liver transplantation (LDLT) is an effective tool for managing pediatric patients with end-stage liver disease (ESLD) with good long-term graft and patient survival, especially after improvement in peri-operative care, surgical tools and techniques; however, the morbidity and mortality after such a procedure are still a challenging matter. The study aimed to analyze short-and long-term outcomes after pediatric LDLT in a single centre. Methods We retrospectively analyzed 67 pediatric patients who underwent LDLT in the period from April 2003 to July 2018. The overall male/female ratio was 40/27. Results Forty-one (61.2%) of patients had ≥1 early and/or late morbidities; the early (less than 3months) and late (≥3months) ones affected 36(53.7%) and 12(17.9%) of them respectively. The 16-year graft and patient survivals were 35(52.2%) while early and late mortalities were 23(34.3%) and 9(13.4%) respectively. Sepsis and chronic rejection were the most frequent causes of early and late mortalities respectively. Moreover, more packed RBCs transfusion units, bacterial infections, and pulmonary complications were independent predictors of poor patient survival. Conclusions More packed RBCs transfusion units intra-operatively, and post-liver transplant (LT) bacterial infection, sepsis, chronic rejection, as well as pulmonary complications had a negative insult on our patients' outcomes, so proper management of them is mandatory for improving outcomes after pediatric LDLT. More packed RBCs transfusion units intra-operatively had a negative insult on outcomes after paediatric LDLT. Bacterial infection and pulmonary complications led to poor outcomes after paediatric LDLT. Sepsis and chronic rejection led to post paediatric LDLT poor patient outcomes.
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Affiliation(s)
- Emad Hamdy Gad
- Hepatobiliary Surgery, National Liver Institute, Menoufia University, Shebeen Elkoum, Egypt
- Corresponding author..
| | - Ahmed Nabil Sallam
- Hepatobiliary Surgery, National Liver Institute, Menoufia University, Shebeen Elkoum, Egypt
| | - Hosam Soliman
- Hepatobiliary Surgery, National Liver Institute, Menoufia University, Shebeen Elkoum, Egypt
| | - Tarek Ibrahim
- Hepatobiliary Surgery, National Liver Institute, Menoufia University, Shebeen Elkoum, Egypt
| | | | | | | | - Islam Ayoub
- Hepatobiliary Surgery, National Liver Institute, Menoufia University, Shebeen Elkoum, Egypt
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12
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Dogra H, Hind J. Innovations in Immunosuppression for Intestinal Transplantation. Front Nutr 2022; 9:869399. [PMID: 35782951 PMCID: PMC9241336 DOI: 10.3389/fnut.2022.869399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 05/03/2022] [Indexed: 11/13/2022] Open
Abstract
It has been 57 years since the first intestinal transplant. An increased incidence of graft rejection has been described compared to other solid organ transplants due to high immunogenicity of the bowel, which in health allows the balance between of dietary antigen with defense against pathogens. Expanding clinical experience, knowledge of gastrointestinal physiology and immunology have progress post-transplant immunosuppressive drug regimens. Current regimes aim to find the window between prevention of rejection and the risk of infection (the leading cause of death) and malignancy. The ultimate aim is to achieve graft tolerance. In this review we discuss advances in mucosal immunology and technologies informing the development of new anti-rejection strategies with the hope of improved survival in the next generation of transplant recipients.
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13
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Perito ER, Persyn E, Bucuvalas J, Martinez M, Mohammad S, Squires JE, Demetris AJ, Feng S. Graft Fibrosis Over 10 to 15 Years in Pediatric Liver Transplant Recipients: Multicenter Study of Paired, Longitudinal Surveillance Biopsies. Liver Transpl 2022; 28:1051-1062. [PMID: 35029022 DOI: 10.1002/lt.26409] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 12/19/2021] [Accepted: 12/22/2021] [Indexed: 01/13/2023]
Abstract
Previous single-center, cross-sectional studies have reported a steep increase in the prevalence and severity of fibrosis through 10 to 15 years after pediatric liver transplantation. We report a multicenter study of paired surveillance biopsies in a contemporary cohort. Children who underwent liver transplant when younger than 6 years old and had paired surveillance liver biopsies were enrolled (n = 78, 35% girls, median 1.2 years old at transplant). A central pathologist graded inflammation, assessed rejection activity index, and staged fibrosis in the portal, sinusoidal, and perivenular compartments, allowing for calculation of the Liver Allograft Fibrosis Score (LAFSc). Analysis of variance tested associations between fibrosis progression and clinical parameters. The first biopsy, at a median 8.2 years (interquartile range, 5.9-11.6 years) after transplantation, showed absent to mild fibrosis (LAFSc 0-2) in 29%, moderate (LAFSc 3-5) in 56%, and severe (LAFSc 6-7) in 14% of patients. The second biopsy, at a median 4.7 years (IQR, 4.3-5.1 years) later, showed fibrosis progression (LAFSc increased by ≥3) in 10 (13%) and regression (LAFSc decreased by ≥3) in 4 (5%) patients. After adjusting for baseline LAFSc, younger age at transplant was the only risk factor for fibrosis progression. Although fibrosis prevalence and severity 6 to 12 years after transplant was similar to previous reports, fibrosis trajectory during the next 4 to 5 years was stable. Our data may be reassuring for children with consistently normal liver tests. A comprehensive understanding of factors determining allograft health during the very long term is essential to optimizing allograft and patient health.
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Affiliation(s)
- Emily R Perito
- Department of Pediatrics, Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Elodie Persyn
- Institute of Liver Studies, King's College London, London, UK
| | - John Bucuvalas
- Department of Pediatrics, Mount Sinai Kravis Children's Hospital and Recanati/Miller Transplantation Institute, Mount Sinai Health System, New York, NY
| | - Mercedes Martinez
- Department of Surgery, Center for Liver Diseases and Transplantation, Columbia University Irving Medical Center, New York, NY
| | - Saeed Mohammad
- Department of Pediatrics, Siragusa Transplantation Center, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - James E Squires
- Department of Pediatrics, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, PA
| | | | - Sandy Feng
- Department of Surgery, University of California San Francisco, San Francisco, CA
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14
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Osawa I, Ide K, Sakamoto S, Uchida H, Fukuda A, Nishimura N, Haga C, Yoshioka T, Nosaka S, Nakagawa S, Kasahara M. Hematological and biochemical characteristics and diagnostic imaging results in acute T cell-mediated rejection after pediatric liver transplantation. Pediatr Transplant 2022; 26:e14161. [PMID: 34617637 DOI: 10.1111/petr.14161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 08/24/2021] [Accepted: 09/24/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Liver biopsy is the gold standard for diagnosing TCMR after LT. However, complications caused by liver biopsy may occur especially during the immediate post-transplantation period and other effective methods for predicting TCMR have not been established. Thus, we investigated whether hematological and biochemical characteristics and Doppler ultrasonography findings are associated with acute TCMR. METHODS A multiple logistic regression analysis was performed to identify the prognostic factors of acute TCMR, defined as a RAI ≥4. Then, a ROC curve analysis was conducted to evaluate for diagnostic performance. The relationship between prognostic factors and each histological category of RAI was investigated. RESULTS Eighty-nine liver biopsies were performed on 85 patients between January 2012 and December 2019. The RAI of 62 (69.7%) liver biopsies was ≥4. AEC (×104 /μl), direct bilirubin level (mg/dl), and MHVV (cm/s) were found to be associated with acute TCMR (OR: 4.96, 95% CI: 1.44-17.0, p = .011; OR: 1.41, 95% CI: 1.04-1.91, p = .025; OR: 1.05, 95% CI: 1.02-1.08, p < .001, respectively). The area under the ROC curves for predicting acute TCMR was 0.86 (95% CI: 0.78-0.94). There was a correlation between AEC, direct bilirubin level, and MHVV as well as the severity of RAI. CONCLUSIONS AEC, direct bilirubin level, and MHVV were the independent risk factors for acute TCMR. This study could provide information regarding the identification of patients requiring liver biopsy.
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Affiliation(s)
- Ichiro Osawa
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Kentaro Ide
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Seisuke Sakamoto
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Hajime Uchida
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Akinari Fukuda
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Nao Nishimura
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Chizuko Haga
- Department of Pathology, National Center for Child Health and Development, Tokyo, Japan
| | - Takako Yoshioka
- Department of Pathology, National Center for Child Health and Development, Tokyo, Japan
| | - Shunsuke Nosaka
- Division of Radiology, National Center for Child Health and Development, Tokyo, Japan
| | - Satoshi Nakagawa
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Mureo Kasahara
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
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15
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de Ville de Goyet J, Baumann U, Karam V, Adam R, Nadalin S, Heaton N, Reding R, Branchereau S, Mirza D, Klempnauer JL, Fischer L, Kalicinski P, Colledan M, Lopez Santamaria M, de Kleine RH, Chardot C, Yilmaz S, Kilic M, Boillot O, di Francesco F, Polak WG, Verkade HJ. European Liver Transplant Registry: Donor and transplant surgery aspects of 16,641 liver transplantations in children. Hepatology 2022; 75:634-645. [PMID: 34724224 DOI: 10.1002/hep.32223] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 09/12/2021] [Accepted: 10/16/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS The European Liver Transplant Registry (ELTR) has collected data on liver transplant procedures performed in Europe since 1968. APPROACH AND RESULTS Over a 50-year period (1968-2017), clinical and laboratory data were collected from 133 transplant centers and analyzed retrospectively (16,641 liver transplants in 14,515 children). Data were analyzed according to three successive periods (A, before 2000; B, 2000-2009; and C, since 2010), studying donor and graft characteristics and graft outcome. The use of living donors steadily increased from A to C (A, n = 296 [7%]; B, n = 1131 [23%]; and C, n = 1985 [39%]; p = 0.0001). Overall, the 5-year graft survival rate has improved from 65% in group A to 75% in group B (p < 0.0001) and to 79% in group C (B versus C, p < 0.0001). Graft half-life was 31 years, overall; it was 41 years for children who survived the first year after transplant. The late annual graft loss rate in teenagers is higher than that in children aged <12 years and similar to that of young adults. No evidence for accelerated graft loss after age 18 years was found. CONCLUSIONS Pediatric liver transplantation has reached a high efficacy as a cure or treatment for severe liver disease in infants and children. Grafts that survived the first year had a half-life similar to standard human half-life. Transplantation before or after puberty may be the pivot-point for lower long-term outcome in children. Further studies are necessary to revisit some old concepts regarding transplant benefit (survival time) for small children, the role of recipient pathophysiology versus graft aging, and risk at transition to adult age.
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Affiliation(s)
- Jean de Ville de Goyet
- Department for the Treatment and Study of Pediatric Abdominal Diseases and Abdominal Transplantation, Istituto di Ricovero e Cura a Carattere Scientifico, Palermo, Italy
| | - Ulrich Baumann
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.,Paediatric Gastroenterology and Hepatology, Hannover Medical School, Hannover, Germany.,European Liver and Intestine Transplant Association, Padua, Italy
| | - Vincent Karam
- European Liver Transplant Registry, Assistance Publique-Hôpitaux de Paris Hôpital Paul Brousse, Université Paris-Sud, Inserm U 935, Villejuif, France
| | - René Adam
- European Liver and Intestine Transplant Association, Padua, Italy.,European Liver Transplant Registry, Assistance Publique-Hôpitaux de Paris Hôpital Paul Brousse, Université Paris-Sud, Inserm U 935, Villejuif, France
| | - Silvio Nadalin
- Department of General, Visceral and Transplant Surgery, University Hospital Tübingen, Tübingen, Germany
| | | | - Raymond Reding
- Cliniques Universitaires Saint Luc, Université catholique de Louvain, Brussels, Belgium
| | - Sophie Branchereau
- Service de Chirurgie Viscérale Pédiatrique Bicêtre University Hospital, Faculty of Medicine Paris-Sud, Assistance Publique-Hôpitaux de Paris, Le Kremlin Bicêtre, France
| | - Darius Mirza
- Liver Unit, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jürgen L Klempnauer
- Klinik für Viszeral und Transplantations-chirurgie, Hannover Medical School, Hannover, Germany
| | - Lutz Fischer
- Department of Visceral Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Piotr Kalicinski
- Department of Pediatric and Transplant Surgery, Children's Memorial Health Institute, Warsaw, Poland
| | - Michele Colledan
- Università degli studi di Milano Bicocca, ASST Giovanni XXIII, Department of Organ Failure and Transplantation, Bergamo, Italy
| | | | - Ruben H de Kleine
- Department of Surgery, Section of Hepato-Pancreatico-Biliary Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Christophe Chardot
- Service de Chirurgie Pediatrique, Hôpital Necker Enfants Malades, Paris, France
| | - Sezai Yilmaz
- Liver Transplantation Institute, Inonu University, Malatya, Turkey
| | - Murat Kilic
- Liver Transplant Program, Izmir Kent Hospital, Izmir, Turkey
| | - Olivier Boillot
- Pediatric Liver Transplant Surgery, Hôpital Edouard Herriot, Lyon, France
| | - Fabrizio di Francesco
- Department for the Treatment and Study of Pediatric Abdominal Diseases and Abdominal Transplantation, Istituto di Ricovero e Cura a Carattere Scientifico, Palermo, Italy
| | - Wojciech G Polak
- European Liver and Intestine Transplant Association, Padua, Italy.,Erasmus MC, Transplant Institute, Division of Hepatopancreatobiliary and Transplant Surgery, Department of Surgery, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Henkjan J Verkade
- European Liver and Intestine Transplant Association, Padua, Italy.,Department of Pediatrics, University Medical Center Groningen, University of Groningen, Hospital, Groningen, the Netherlands
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- European Liver Transplant Registry, Assistance Publique-Hôpitaux de Paris Hôpital Paul Brousse, Université Paris-Sud, Inserm U 935, Villejuif, France
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16
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Iacob S, Cicinnati V, Kabar I, Hüsing-Kabar A, Radtke A, Iacob R, Baba H, Schmidt HH, Paul A, Beckebaum S. Prediction of late allograft dysfunction following liver transplantation by immunological blood biomarkers. Transpl Immunol 2021; 69:101448. [PMID: 34391882 DOI: 10.1016/j.trim.2021.101448] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 08/09/2021] [Accepted: 08/10/2021] [Indexed: 02/09/2023]
Abstract
BACKGROUND An accelerated course of hepatic fibrosis may occur in liver transplantation (LT) patients despite normal or slightly abnormal liver blood tests. AIM To identify screening tools based on blood biomarkers to predict late allograft dysfunction in LT recipients. METHODS 174 LT recipients were enrolled. Liver biopsy, liver functional tests, cytokine quantitation in serum, as well as soluble MHC class I polypeptide-related sequence A and B (sMICA/sMICB) and soluble UL16 binding protein 2 (sULBP2) were performed. RESULTS Patients with late graft dysfunction had a significantly higher donor age, lower albumin level, higher alanine (ALT) and aspartate aminotransferase (AST), gamma-glutamyl transpeptidase (GGT), total bilirubin and alkaline phosphatase (ALP), higher sMICA, sULBP2, higher interleukin (IL) 6, interferon γ and lower IL10 in serum as compared to recipients without allograft dysfunction. In order to provide a better statistical accuracy for discriminating 5-year allograft dysfunction from other less progressive subtype of allograft injury, we established a predictive model, based on 7 parameters (serum ALP, ALT, AST, GGT, sMICA, IL6 and albumin) which provided an Area Under the Receiver Operating Characteristics (AUROC) curve of 0.905. CONCLUSIONS Blood-based biomarkers can significantly improve prediction of late liver allograft outcome in LT patients. The new developed score comprising serum parameters, with an excellent AUROC, can be reliably used for diagnosing late allograft dysfunction in transplanted patients.
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Affiliation(s)
- Speranta Iacob
- Center for Digestive Diseases and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania; Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.
| | - Vito Cicinnati
- Department of Medicine B for Gastroenterology and Hepatology, University Hospital Muenster, 48149 Muenster, Germany
| | - Iyad Kabar
- Department of Medicine B for Gastroenterology and Hepatology, University Hospital Muenster, 48149 Muenster, Germany
| | - Anna Hüsing-Kabar
- Department of Medicine B for Gastroenterology and Hepatology, University Hospital Muenster, 48149 Muenster, Germany
| | - Arnold Radtke
- Department of General, Visceral and Transplant Surgery, Comprehensive Cancer Center, University of Tübingen, 72076 Tübingen, Germany
| | - Razvan Iacob
- Center for Digestive Diseases and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania; Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Hideo Baba
- Institute for Pathology, University Hospital Essen, 45147 Essen, Germany
| | - Hartmut H Schmidt
- Department of Medicine B for Gastroenterology and Hepatology, University Hospital Muenster, 48149 Muenster, Germany
| | - Andreas Paul
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, 45147 Essen, Germany
| | - Susanne Beckebaum
- Department of Medicine B for Gastroenterology and Hepatology, University Hospital Muenster, 48149 Muenster, Germany
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17
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Leiskau C, Junge N, Pfister ED, Goldschmidt I, Mutschler F, Laue T, Ohlendorf J, Nasser H, Beneke J, Richter N, Vondran F, Baumann U. Recipient-Specific Risk Factors Impairing Patient and Graft Outcome after Pediatric Liver Transplantation-Analysis of 858 Transplantations in 38 Years. CHILDREN-BASEL 2021; 8:children8080641. [PMID: 34438532 PMCID: PMC8393592 DOI: 10.3390/children8080641] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 07/19/2021] [Accepted: 07/22/2021] [Indexed: 12/19/2022]
Abstract
(1) Background and Aim: Despite excellent long-term results in pediatric liver transplantation (pLTx), mortality and graft loss still are to be diminished. We aim to describe time-dependent changes and long-term outcome of a large single-center pLTx cohort and to identify independent recipient-related risk factors impairing patient and graft survival. (2) Methods: This is a retrospective single-center study analyzing all pediatric liver transplants from 1983–2020. Risk factors for mortality and graft loss were identified by univariable and multi-linear regression analysis. (3) Results: We analyzed 858 liver transplantations in 705 pediatric patients. Five-year patient/graft survival increased from 60.9%/48.0% (1983–1992) to 97.5%/86.5% (OR = 12.5; p < 0.0001/OR = 6.5; p < 0.0001) (2014–2020). Indications changed significantly over time, with a higher proportion of patients being transplanted for malignancies and metabolic disease and indications of PFIC and α1AT-deficiency declining. The era of transplantation (log7.378/9.657; p < 0.0001) and indication of acute liver failure (log = 1.944/2.667; HR = 2.015/1.772; p = 0.0114/0.002) impairs patient/graft survival significantly in the multivariate analysis. Furthermore, patient survival is worsened by re-transplantation (log = 1.755; HR = 1.744; p = 0.0176) and prolonged waiting times in high-urgency status (log = 2.588; HR = 1.073; p = 0.0026), whereas the indication of biliary atresia improved outcome (log = 1.502; HR = 0.575; p = 0.0315). Graft survival was additionally impaired by pre-existing portal vein thrombosis (log = 1.482; HR = 2.016; p = 0.0330). (4) Conclusions: Despite more complex indications, patient and graft survival after pLTx continue to improve.. Acute liver failure remains the indication with poorest outcome, and listing for high urgency liver transplantation should be considered carefully and early to keep waiting time on HU list short. Furthermore, pre-transplant portal vein thrombosis should be prevented whenever possible to improve graft survival.
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Affiliation(s)
- Christoph Leiskau
- Pediatric Gastroenterology, Hepatology and Liver Transplantation, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, 30625 Hannover, Germany; (N.J.); (E.-D.P.); (I.G.); (F.M.); (T.L.); (J.O.); (H.N.); (U.B.)
- Pediatric Gastroenterology, Department of Pediatrics and Adolescent Medicine, University Medical Centre Göttingen, Georg August University Göttingen, 37073 Göttingen, Germany
- Correspondence: ; Tel.: +49-551-39-67019
| | - Norman Junge
- Pediatric Gastroenterology, Hepatology and Liver Transplantation, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, 30625 Hannover, Germany; (N.J.); (E.-D.P.); (I.G.); (F.M.); (T.L.); (J.O.); (H.N.); (U.B.)
| | - Eva-Doreen Pfister
- Pediatric Gastroenterology, Hepatology and Liver Transplantation, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, 30625 Hannover, Germany; (N.J.); (E.-D.P.); (I.G.); (F.M.); (T.L.); (J.O.); (H.N.); (U.B.)
| | - Imeke Goldschmidt
- Pediatric Gastroenterology, Hepatology and Liver Transplantation, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, 30625 Hannover, Germany; (N.J.); (E.-D.P.); (I.G.); (F.M.); (T.L.); (J.O.); (H.N.); (U.B.)
| | - Frauke Mutschler
- Pediatric Gastroenterology, Hepatology and Liver Transplantation, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, 30625 Hannover, Germany; (N.J.); (E.-D.P.); (I.G.); (F.M.); (T.L.); (J.O.); (H.N.); (U.B.)
| | - Tobias Laue
- Pediatric Gastroenterology, Hepatology and Liver Transplantation, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, 30625 Hannover, Germany; (N.J.); (E.-D.P.); (I.G.); (F.M.); (T.L.); (J.O.); (H.N.); (U.B.)
| | - Johanna Ohlendorf
- Pediatric Gastroenterology, Hepatology and Liver Transplantation, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, 30625 Hannover, Germany; (N.J.); (E.-D.P.); (I.G.); (F.M.); (T.L.); (J.O.); (H.N.); (U.B.)
| | - Hamoud Nasser
- Pediatric Gastroenterology, Hepatology and Liver Transplantation, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, 30625 Hannover, Germany; (N.J.); (E.-D.P.); (I.G.); (F.M.); (T.L.); (J.O.); (H.N.); (U.B.)
| | - Jan Beneke
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Hannover Medical School, 30625 Hannover, Germany;
| | - Nicolas Richter
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, 30625 Hannover, Germany; (N.R.); (F.V.)
| | - Florian Vondran
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, 30625 Hannover, Germany; (N.R.); (F.V.)
| | - Ulrich Baumann
- Pediatric Gastroenterology, Hepatology and Liver Transplantation, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, 30625 Hannover, Germany; (N.J.); (E.-D.P.); (I.G.); (F.M.); (T.L.); (J.O.); (H.N.); (U.B.)
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18
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Katz M, Gillespie S, Stevens JP, Hall L, Kolachala V, Ford R, Levin K, Gupta NA. African American Pediatric Liver Transplant Recipients Have an Increased Risk of Death After Transferring to Adult Healthcare. J Pediatr 2021; 233:119-125.e1. [PMID: 33667506 DOI: 10.1016/j.jpeds.2021.02.069] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 02/10/2021] [Accepted: 02/25/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To analyze the long-term outcomes in pediatric liver transplant recipients after they have transferred to an adult provider and assess for racial disparities in health outcomes. STUDY DESIGN This is a single-center, retrospective review of pediatric patients who underwent liver transplantation between July 1990 and August 2015 at a tertiary healthcare system with a large transplant center. Patient mortality and retransplantation were assessed after transfer to adult care. RESULTS There were 120 patients who were transferred, of whom 19 did not meet the inclusion criteria. Of the remaining 101 patients, 64 (63%) transferred care to a nearby affiliated tertiary adult facility, 29 (29%) were followed by other healthcare systems, and 8 (8%) were lost to follow-up. Of the patients followed at our affiliated adult center, 18 of the 64 (28%) died. Of those 18 deaths, 4 (22%) occurred within the first 2 years after transfer, and 10 (55%) within 5 years of transfer. Four patients were retransplanted by an adult provider, of whom 2 eventually received a third transplant. African Americans had higher rates of death after transfer than patients of other races (44% mortality vs 16%, representing 67% of all cases of death; P = .032), with nearly 50% mortality at 20 years from time of transplantation. CONCLUSIONS Death is common in pediatric liver transplant recipients after transfer to adult care, with African Americans having disproportionately higher mortality. This period of transition of care is a vulnerable time, and measures must be taken to ensure the safe transfer of young adults with chronic health care needs.
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Affiliation(s)
- Mikaela Katz
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Scott Gillespie
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - James P Stevens
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA; Transplant services, Children's Healthcare of Atlanta, Atlanta, GA
| | - Lori Hall
- Transplant services, Children's Healthcare of Atlanta, Atlanta, GA
| | - Vasantha Kolachala
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Ryan Ford
- Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Keri Levin
- Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Nitika A Gupta
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA; Transplant services, Children's Healthcare of Atlanta, Atlanta, GA.
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19
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Donor-Specific and Auto-Antibodies in Pediatric Liver Transplant: When Are They Important? What Do They Mean? J Pediatr Gastroenterol Nutr 2021; 72:643-644. [PMID: 33720098 DOI: 10.1097/mpg.0000000000003093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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20
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Romano DN, Mokuolu DC, Katz DJ, DeMaria S. Orthotopic liver transplant in the pregnant recipient: A systematic review of preoperative management and maternal and fetal outcomes. Clin Transplant 2021; 35:e14269. [PMID: 33615548 DOI: 10.1111/ctr.14269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 02/01/2021] [Accepted: 02/13/2021] [Indexed: 11/27/2022]
Abstract
Severe liver dysfunction requiring transplantation is a major event at any stage of life, but for those requiring liver transplantation while pregnant, two lives hang in the balance. Available evidence on this relatively rare event consists solely of case reports and have yet to be reviewed or synthesized. We performed a systematic literature review and analyzed reports of 22 patients who underwent liver transplantation during pregnancy. This review describes the reported etiologies of hepatic failure in pregnant patients requiring transplantation, perioperative anesthetic management techniques, and the maternal and fetal clinical outcomes.
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Affiliation(s)
- Diana N Romano
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Division of Liver Transplant Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Debbie C Mokuolu
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Daniel J Katz
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Division of Obstetric Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samuel DeMaria
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Division of Liver Transplant Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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21
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Stevens JP, Hall L, Gupta NA. TRANSITION of Pediatric Liver Transplant Patients to Adult Care: a Review. Curr Gastroenterol Rep 2021; 23:3. [PMID: 33523312 DOI: 10.1007/s11894-020-00802-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Many pediatric liver transplant patients are surviving to adulthood, and providers have come to recognize the importance of effectively transitioning these patients to an adult hepatologist. The review aims to analyze the most recent literature regarding patient outcomes after transition, barriers to successful transition, recommendations from clinicians and medical societies regarding transition programs, and to provide personal insights from our experience in transitioning liver transplant recipients. RECENT FINDINGS While results were variable between studies, many recent reports show significant morbidity and mortality in patients following transition to adult care. Medical non-adherence is frequently seen in adolescents and young adults both prior to and after transition, and is consistently associated with higher rates of rejection, graft loss, and death. In general, transplant programs with a formal transition process had better patient outcomes though recent findings are mostly-single center and direct comparison between programs is difficult. Societal recommendations for how to create a transition program contain a number of common themes that we have categorized for easier understanding. Successful transition is vital to the continued health of pediatric liver transplant patients. While an effective transition program includes a number of key components, it should be individualized to best function within a given transplant center. Here, we have reviewed a number of recent single-center retrospective studies on transition, but multi-site retrospective or prospective data is lacking, and is a fertile area for future research.
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Affiliation(s)
- James P Stevens
- Department of Pediatrics, Division of Gastronterology, Hepatology and Nutrition, Emory University School of Medicine, Atlanta, GA, USA.,Transplant Services, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Lori Hall
- Transplant Services, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Nitika Arora Gupta
- Department of Pediatrics, Division of Gastronterology, Hepatology and Nutrition, Emory University School of Medicine, Atlanta, GA, USA. .,Transplant Services, Children's Healthcare of Atlanta, Atlanta, GA, USA. .,, Atlanta, USA.
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22
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Health Care Transition: A Time of Increased Vulnerability for Pediatric Liver Transplant Recipients. J Pediatr Gastroenterol Nutr 2020; 71:704-706. [PMID: 32925552 DOI: 10.1097/mpg.0000000000002938] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Improvements in pediatric liver transplantation (LT) have led to an increased number of patients reaching young adulthood. Young adult LT recipients transferring from pediatric to adult models of care have increased rates of rejection, graft loss, and medical complications. The goal of a health care transition program is to optimize health and assist youth in reaching their full potential. The means to achieve this goal requires an organized transition process to support youth in acquiring independent health care skills, preparing for an adult model of care, and transferring to new providers without disruption in treatment. This can only be achieved through a multidisciplinary approach to transition planning. This is often a labor and resource-intensive undertaking, which may not receive the necessary support from local institutions. Widespread implementation requires the assistance and endorsement from governing organizations at the national and international level.
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23
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Zhang T, Barrett S, Cotton R, Galvan NTN, O'Mahony C, Moore Vierling J, Goss JA, Rana A. Pediatric length-of-stay index following liver transplantation. Pediatr Transplant 2020; 24:e13779. [PMID: 32720748 DOI: 10.1111/petr.13779] [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: 12/20/2019] [Revised: 04/21/2020] [Accepted: 06/10/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND PELD scores are used to reduce waitlist mortality, but they do not accurately predict likelihood of prolonged length-of-stay or higher costs associated with it. This study aims to create a pediatric length-of-stay (LOS) index to predict increased risk of prolonged stay following liver transplantation. METHODS The scoring system generated predicts length-of-stay following pediatric liver transplantation. With univariate and multivariate analyses on data from 5669 pediatric liver transplant recipients, independent recipient/donor risk factors for prolonged stay (>30 days) were identified. Multiple imputations accounted for missing variables. RESULTS The most significant factors were ICU admission (OR 2.92, CI 2.27-3.75), recipient bilirubin >32 (OR 2.35, CI 1.70-3.25), and hemodialysis 1 week before transplantation (OR 2.27, CI 1.57-3.27). The LOS index assigns weighted scoring points to factors to predict prolonged stay (C-statistic of .72). The index demonstrated discrimination across the population after dividing it into quartiles for prolonged stay. CONCLUSIONS The pediatric LOS index, utilizing 13 donor/recipient factors, can assess the risk for pediatric liver transplantation prolonged stay. Important predictive factors are hemodialysis, ICU admission, recipient weight and bilirubin, and recipient life support status.
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Affiliation(s)
- Theodore Zhang
- Department of Student Affairs, Baylor College of Medicine, Houston, TX, USA
| | - Spencer Barrett
- Department of Student Affairs, Baylor College of Medicine, Houston, TX, USA
| | - Ronald Cotton
- Division of Abdominal Transplantation, Michael E DeBakey Department of General Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Nhu Thao Nguyen Galvan
- Division of Abdominal Transplantation, Michael E DeBakey Department of General Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Christine O'Mahony
- Division of Abdominal Transplantation, Liver Center, Department of General Surgery, Baylor College of Medicine, Houston, TX, USA
| | - John Moore Vierling
- Division of Gastroenterology, Nutrition & Hepatology, Baylor College of Medicine, Houston, TX, USA
| | - John A Goss
- Division of Abdominal Transplantation, Liver Center, Department of General Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Abbas Rana
- Division of Abdominal Transplantation, Michael E DeBakey Department of General Surgery, Baylor College of Medicine, Houston, TX, USA
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24
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Reyes JD, Dick AA, Hendele JB, Perkins JD, Hsu EK. Adults transplanted as children as retransplant candidates: Analysis of outcomes support optimism in a population mislabeled as high risk. Clin Transplant 2020; 34:e13880. [PMID: 32282089 DOI: 10.1111/ctr.13880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/02/2020] [Accepted: 04/05/2020] [Indexed: 11/29/2022]
Abstract
Adult liver transplant programs have heretofore been hesitant to perform liver retransplantation in adult patients who underwent primary liver transplantation as a child (P_A). Areas of concern include: (a) potential disruption in care when transferring from a pediatric to an adult transplant center; (b) generally inferior outcomes of retransplantation; (c) reputation of young adults for non-adherence to post-transplant regimen; and (d) potential higher work effort for equivalent outcomes. To examine these concerns, we reviewed data on all US liver adult retransplants from 10/01/1987 to 9/30/2017. We propensity matched the P_A patients to patients who received both primary and retransplantation as adults (A_A), with ≥550 days between transplants. A mixed Cox proportional hazards model with program size and time period of transplantation as random variables revealed that retransplantation of P_A patients produced no significantly different graft survival or patient survival rates than retransplantation of the matched A_A patients. Therefore, inferior rates of liver retransplantation in these patients and concerns about continuity of care in changing transplant programs are not as believed in the wider liver transplant community. In conclusion, liver transplant centers should be optimistic about retransplanting adults who received their primary transplants as children.
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Affiliation(s)
- Jorge D Reyes
- Division of Transplantation, Department of Surgery, University of Washington, Seattle, Washington.,Section of Pediatric Transplantation, Seattle Children's Hospital, Seattle, Washington
| | - Andre A Dick
- Division of Transplantation, Department of Surgery, University of Washington, Seattle, Washington.,Section of Pediatric Transplantation, Seattle Children's Hospital, Seattle, Washington
| | - James B Hendele
- Division of Transplantation, Department of Surgery, University of Washington, Seattle, Washington
| | - James D Perkins
- Division of Transplantation, Department of Surgery, University of Washington, Seattle, Washington
| | - Evelyn K Hsu
- Section of Pediatric Transplantation, Seattle Children's Hospital, Seattle, Washington.,Division of Gastroenterology and Hepatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
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25
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Tran LT, Carullo PC, Banh DPT, Vitu C, Davis PJ. Pediatric Liver Transplantation: Then and Now. J Cardiothorac Vasc Anesth 2020; 34:2028-2035. [PMID: 32241678 DOI: 10.1053/j.jvca.2020.02.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 02/11/2020] [Indexed: 12/20/2022]
Abstract
This paper reviews the past 50 years of liver transplantation in children from the perspective of patient demographics, perioperative patient management, surgical techniques, immunosuppression and patient outcomes.
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Affiliation(s)
- Lieu T Tran
- Department of Pediatric Anesthesiology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Philip C Carullo
- Department of Pediatric Anesthesiology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Diem Phuc T Banh
- Department of Pediatric Anesthesiology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Chelsea Vitu
- Department of Pediatric Anesthesiology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Peter J Davis
- Department of Pediatric Anesthesiology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA.
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