Liver transplantation in children: state of the art and future perspectives

Changes in the epidemiology and clinical characteristics of viral gastroenteritis among hospitalized children in the Mainland of China: a retrospective study from 2016 to 2020

BACKGROUND

Acute gastroenteritis (AGE) causes significant morbidity in children worldwide; however, the disease burden of children hospitalized with viral gastroenteritis in China has been rarely described. Through this study, we analyzed the data of hospitalized children with viral gastroenteritis to explore the changes in the epidemiology and clinical characteristics of viral gastroenteritis in the mainland of China.

METHODS

Data were extracted from Futang Children's Medical Development Research Center (FRCPD), between 2016 and 2020, across 27 hospitals in 7 regions. The demographics, geographic distribution, pathogenic examination results, complications, hospital admission date, length of hospital stays, hospitalization charges and outcomes were collected and analyzed.

RESULTS

Viral etiological agents included rotavirus (RV), adenovirus (ADV), norovirus (NV) and coxsackievirus (CV) that were detected in 25,274 (89.6%), 1,047 (3.7%), 441 (1.5%) and 83 (0.3%) cases. There was a higher prevalence of RV and NV infection among children younger than 3 years of age. RV and NV had the highest detection rates in winter, while ADV in summer. Children with viral gastroenteritis were often accompanied by other diseases, such as myocardial diseases (10.98-31.04%), upper respiratory tract diseases (1.20-20.15%), and seizures (2.41-14.51%). Among those cases, the co-infection rate with other pathogens was 6.28%, with Mycoplasma pneumoniae (M. pneumoniae), Epstein-Barr virus (EBV), and influenza virus (FLU) being the most common pathogens. The median length of stay was 5 days, and the median cost of hospitalization corresponded to587 US dollars.

CONCLUSIONS

This finding suggests that viral gastroenteritis, especially those caused by RV, is a prevalent illness among younger children. Co-infections and the presence of other diseases are common. The seasonality and regional variation of viral etiological agents highlight the need for targeted prevention and control measures. Although viral gastroenteritis rarely leads to death, it also results in a significant economic burden on healthcare systems.

Transplanting Livers in Young Children - Looking Back at 100 Cases

Introduction

Despite advances in medical therapy, liver replacement continues to be the only definitive mode of therapy for children with end-stage liver disease (ESLD). However, its acceptance in India has been discouraging more due to financial and logistic reasons than the availability of expertise. This report outlines our journey and highlights issues pertinent to circumstances in an emerging economy like India.

Aim

The aim is to review a single center's 100 case experience with liver transplantation (LT).

Materials and Methods

A prospective analysis of all children who underwent LT since 2005 at our institute was done. The data were collated from a maintained structured database.

Results

Hundred children underwent LT. Sixty-four were boys. Age ranged from 5 to 144 months, with a median of 17 months. The mean weight of the cohort was 7.5 kg (ranging from 3.7 to 31.5 kg), with 60% of our children weighing between 5 and 10 kg. Biliary atresia is the most common indication (57%); others include metabolic disorders, progressive familial intrahepatic cholestasis, and hepatoblastoma. Two patients were for acute liver failure. Ninety-one children underwent live donor LT (mothers being the majority of the donors). None of the donors had any major postoperative complications. Major intraoperative complications include sepsis (39%), vascular complications (17%), biliary leak (11%), and intestinal complications (11%). Early postoperative deaths occurred in 18% of patients with sepsis being most common cause. The mean follow-up was 8.5 years and the overall survival is 70%. The mean survival is time (months) = 176.1. All surviving patients were followed up and had achieved good catch up growth by 3rd and 5th years posttransplant. The long-term sequalae include recurrent intercurrent infections, graft rejection (9%), posttransplant lymphoproliferative disease (5%), and portal vein stenosis (5%).

Conclusion

Our experience demonstrates the feasibility of LT in children with ESLD in India. With longer-living grafts, patients often struggle with other issues such as compliance with follow-up, financial issues, recurrent infections, and neurological problems. Close monitoring with regular follow-up of patients helps in early recognition and treatment of late-onset complications, thus helping the overall long-term outcomes.

The Ratio of Intraoperative Red Blood Cell Transfusion to Blood Loss Associated with Early Postoperative Complications in Pediatric Liver Transplantation Patients

Introduction

Liver transplantation (LT) is an operation purposed to save the lives of children with acute or chronic liver diseases, hepatic tumors, and some genetic and metabolic diseases. However, patients who underwent LT have a significant risk of intraoperative blood loss and red blood cell (RBC) transfusion, especially in pediatric patients.

Methods

In this study, 569 pediatric patients (<18 years old) who underwent LT at a tertiary university hospital between 2013 and 2020 were included. Multiple logistic regression was used to analyze the association between the ratio of intraoperative RBC transfusion to blood loss (IRTBL) and the complications after LT in pediatric patients. IRTBL was divided into quartiles in the adjusted model. Odds ratios, 95% confidence intervals, and p values for trends were calculated. Restricted cubic spline (RCS) regression was used to evaluate the nonlinear association between IRTBL and complications.

Results

Compared with the lowest level and the highest level of IRTBL, Q2 and Q3 quartiles of IRTBL showed significantly positive association with early complications. A significantly nonlinear association was observed between the IRTBL and early complications in the RCS model with the multiple adjustments of potential covariates (P overall<0.01, P nonlinear<0.01). However, no significant association was observed between late complications and IRTBL.

Conclusion

In this study, we found there was a nonlinear relationship between the ratio of IRTBL and early postoperative complications in pediatric LT patients, which provides a theoretical basis for RBC transfusion in pediatric LT patients.

Treatment strategies for hepatic artery complications after pediatric liver transplantation: A systematic review

This study aimed to evaluate the effectiveness of different treatments for hepatic artery thrombosis (HAT) and hepatic artery stenosis (HAS) after pediatric liver transplantation. We systematically reviewed studies published since 2000 that investigated the management of HAT and/or HAS after pediatric liver transplantation. Studies with a minimum of 5 patients in one of the treatment methods were included. The primary outcomes were technical success rate and graft and patient survival. The secondary outcomes were hepatic artery patency, complications, and incidence of HAT and HAS. Of 3570 studies, we included 19 studies with 328 patients. The incidence was 6.2% for HAT and 4.1% for HAS. Patients with an early HAT treated with surgical revascularization had a median graft survival of 45.7% (interquartile range, 30.7%-60%) and a patient survival of 61.3% (interquartile range, 58.7%-66.9%) compared with the other treatments (conservative, endovascular revascularization, or retransplantation). As for HAS, endovascular and surgical revascularization groups had a patient survival of 85.7% and 100% (interquartile range, 85%-100%), respectively. Despite various treatment methods, HAT after pediatric liver transplantation remains a significant issue that has profound effects on the patient and graft survival. Current evidence is insufficient to determine the most effective treatment for preventing graft failure.

Liver transplantation in ornithine transcarbamylase deficiency: A retrospective multicentre cohort study

Ornithine transcarbamylase deficiency (OTCD) is an X-linked defect of ureagenesis and the most common urea cycle disorder. Patients present with hyperammonemia causing neurological symptoms, which can lead to coma and death. Liver transplantation (LT) is the only curative therapy, but has several limitations including organ shortage, significant morbidity and requirement of lifelong immunosuppression. This study aims to identify the characteristics and outcomes of patients who underwent LT for OTCD. We conducted a retrospective study for OTCD patients from 5 UK centres receiving LT in 3 transplantation centres between 2010 and 2022. Patients' demographics, family history, initial presentation, age at LT, graft type and pre- and post-LT clinical, metabolic, and neurocognitive profile were collected from medical records. A total of 20 OTCD patients (11 males, 9 females) were enrolled in this study. 6/20 had neonatal and 14/20 late-onset presentation. 2/20 patients had positive family history for OTCD and one of them was diagnosed antenatally and received prospective treatment. All patients were managed with standard of care based on protein-restricted diet, ammonia scavengers and supplementation with arginine and/or citrulline before LT. 15/20 patients had neurodevelopmental problems before LT. The indication for LT was presence (or family history) of recurrent metabolic decompensations occurring despite standard medical therapy leading to neurodisability and quality of life impairment. Median age at LT was 10.5 months (6-24) and 66 months (35-156) in neonatal and late onset patients, respectively. 15/20 patients had deceased donor LT (DDLT) and 5/20 had living related donor LT (LDLT). Overall survival was 95% with one patient dying 6 h after LT. 13/20 had complications after LT and 2/20 patients required re-transplantation. All patients discontinued dietary restriction and ammonia scavengers after LT and remained metabolically stable. Patients who had neurodevelopmental problems before LT persisted to have difficulties after LT. 1/5 patients who was reported to have normal neurodevelopment before LT developed behavioural problems after LT, while the remaining 4 maintained their abilities without any reported issues. LT was found to be effective in correcting the metabolic defect, eliminates the risk of hyperammonemia and prolongs patients' survival.

Duct-to-Duct Anastomosis Versus Bilioenteric Anastomosis for Pediatrics Living Donor Liver Transplantation: A Systematic Review and Meta-Analysis

With an incidence exceeding 30%, biliary complications after pediatric liver transplantation remain a great challenge. In addition, the database includes numerous controversial papers about the safety of duct-to-duct anastomosis compared to Reux-en-Y hepaticojejunostomy for pediatric living donor liver transplantation (LDLT). We aim to compare the two techniques in pediatric LDLT by conducting a systematic review and meta-analysis. PUBMED, Web of Science, Scopus, and Cochrane Library were searched for eligible studies from 1989 to October 2022. According to our eligibility criteria, seven articles (561 pediatric LDLT) were included in our study. On one hand, DD anastomosis is associated with a higher rate of biliary stricture in comparison to RYHJ (OR: 2.47, 95% CI = 1.20-5.09, P = 0.01; I2 = 12%). On the other hand, the incidence of cholangitis was higher in RYHJ (OR: 0.10 95% CI = 0.01- 0.84, P = 0.03; I2 = 0%). However, there was no significant difference in the overall incidence of complications, leakage and mortality between the two groups (overall incidence of complication OR: 1.12, 95% CI = 0.34-3.68, P = 0.86; I2 = 62%), (Leakage OR: 2.22, 95% CI = 0.79-6.23, P = 0.13; I2 = 18%) and (Mortality OR: 2.53, 95% CI = 0.61-10.57, P = 0.30; I2 = 0%). In conclusion, with a lower incidence of cholangitis, an equal overall incidence of biliary complication, and the possibility of RY conversion in case of stricture, DD anastomosis offers a feasible, safe, and more physiological alternative to RYHJ for pediatric LDLT.

Kidney injury associated with liver transplantation

INTRODUCTION

Kidney injury associated with paediatric liver transplantation (LT) is common, but its evaluation is challenging. Our aim was to analyse the presence of perioperative acute kidney injury (AKI) and study the prevalence of chronic kidney disease (CKD) using different glomerular filtration rate (GFR) estimation formulas.

METHODS

We conducted a cross-sectional study in a cohort of children aged less than 18 years with a history of LT followed up for 5.42 years. We estimated the GFR using the creatinine-based Schwartz bedside formula (2009), the cystatin C-based Caucasian Asian Pediatric and Adult cohort (CAPA) equation and the combined Full-Age Spectrum (FAS) formula as modified by Pottel. We analysed the agreement between them using the Bland-Altman method and the kappa statistic. We measured the albumin level in urine, the urine volume adjusted to 100 mL of GFR and blood pressure. We performed univariate and multivariate analyses of the risk factors associated with CKD.

RESULTS

The sample included 52 patients with a median age of 9.21 years. Fifteen (28.8%) had AKI. Five (10%) had CKD and the only associated risk factor was acute liver failure at the time of LT (odds ratio, 8.57; P = 0.04). There was poor agreement between the different estimation formulas. One patient was classified as having CKD with the Schwartz formula compared to four patients with the CAPA and the Pottel combined FAS formulas. Up to 42% of children without CKD had some positive marker of kidney injury.

CONCLUSIONS

The exclusive use of the 2009 Schwartz bedside formula to estimate GFR may lead to underdiagnosis of CKD in children post LT. Other markers of kidney injury are common, and their detection may help prevent the progression of CKD.

International Liver Transplantation Society Global Census: First Look at Pediatric Liver Transplantation Activity Around the World

BACKGROUND

Over 16 000 children under the age of 15 died worldwide in 2017 because of liver disease. Pediatric liver transplantation (PLT) is currently the standard of care for these patients. The aim of this study is to describe global PLT activity and identify variations between regions.

METHODS

A survey was conducted from May 2018 to August 2019 to determine the current state of PLT. Transplant centers were categorized into quintile categories according to the year they performed their first PLT. Countries were classified according to gross national income per capita.

RESULTS

One hundred eight programs from 38 countries were included (68% response rate). 10 619 PLTs were performed within the last 5 y. High-income countries performed 4992 (46.4%) PLT, followed by upper-middle- (4704 [44·3%]) and lower-middle (993 [9·4%])-income countries. The most frequently used type of grafts worldwide are living donor grafts. A higher proportion of lower-middle-income countries (68·7%) performed ≥25 living donor liver transplants over the last 5 y compared to high-income countries (36%; P = 0.019). A greater proportion of programs from high-income countries have performed ≥25 whole liver transplants (52.4% versus 6.2%; P = 0.001) and ≥25 split/reduced liver transplants (53.2% versus 6.2%; P < 0.001) compared to lower-middle-income countries.

CONCLUSIONS

This study represents, to our knowledge, the most geographically comprehensive report on PLT activity and a first step toward global collaboration and data sharing for the greater good of children with liver disease; it is imperative that these centers share the lead in PLT.

A European International Multicentre Survey on the Current Practice of Perioperative Antibiotic Prophylaxis for Paediatric Liver Transplantations

(1) Background: Postoperative infections are major contributors of morbidity and mortality after paediatric liver transplantation (pLTX). Evidence and recommendations regarding the most effective antimicrobial strategy are lacking. (2) Results: Of 39 pLTX centres, 20 responded. Aminopenicillins plus ß-lactamase inhibitors were used by six (30%) and third generation cephalosporins by three (15%), with the remaining centres reporting heterogenous regimens. Broad-spectrum regimens were the standard in 10 (50%) of centres and less frequent in the 16 (80%) centres with an infectious disease specialist. The duration ranged mainly between 24-48 h and 3-5 days in the absence and 3-5 days or 6-10 days in the presence of risk factors. Strategies regarding antifungal, antiviral, adjunctive antimicrobial, and surveillance strategies varied widely. (3) Methods: This international multicentre survey endorsed by the European Liver Transplant Registry queried all European pLTX centres from the registry on their current practice of perioperative antibiotic prophylaxis and antimicrobial strategies via an online questionnaire. (4) Conclusions: This survey found great heterogeneity regarding all aspects of postoperative antimicrobial treatment, surveillance, and prevention of infections in European pLTX centres. Evidence-based recommendations are urgently needed to optimise antimicrobial strategies and reduce the spectrum and duration of antimicrobial exposure.

Oral findings in children on liver transplantation programming: a scoping review

OBJECTIVE

To identify oral characteristics found in children with liver disease in programming for liver transplantation.

DATA SOURCE

The methodology was written according to PRISMA-ScR. We adopted the methodological framework and recommendations for this type of review by Arksey and O'Malley and the Joanna Briggs Institute. The protocol was registered in the Open Science Framework (https://doi.org/10.17605/OSF.IO/QCU4W). A systematic search (Medline/PubMed, Scopus, Web of Science, and ProQuest) was conducted to identify studies that met the inclusion criteria: systematic reviews; prospective clinical trials (parallel or crossover group designs); observational studies (cohort, case-control, and cross-sectional studies); clinical case series; and case reports evaluating children with liver disease in preparation for transplantation. The last search was conducted in July 2021, and no restrictions were imposed as to language or year of publication. Studies presenting mixed data with post-transplant evaluation, and studies evaluating not only liver transplantation but also other solid organs were excluded. Screening, inclusion, and data extraction were performed by two reviewers independently. A narrative synthesis was conducted to describe the findings of the study.

DATA SYNTHESIS

The bibliographic search identified 830 references. A total of 21 articles were read in their entirety after the inclusion criteria assessment. Finally, after evaluating the exclusion criteria, only 3 studies were considered for the qualitative analysis.

CONCLUSIONS

Children with liver disease in preparation for transplantation may present enamel defects, tooth pigmentation, caries, gingivitis, and opportunistic infections such as candidiasis.

Predicting graft failure in pediatric liver transplantation based on early biomarkers using machine learning models

The early detection of graft failure in pediatric liver transplantation is crucial for appropriate intervention. Graft failure is associated with numerous perioperative risk factors. This study aimed to develop an individualized predictive model for 90-days graft failure in pediatric liver transplantation using machine learning methods. We conducted a single-center retrospective cohort study. A total of 87 liver transplantation cases performed in patients aged < 12 years at the Severance Hospital between January 2010 and September 2020 were included as data samples. Preoperative conditions of recipients and donors, intraoperative care, postoperative serial laboratory parameters, and events observed within seven days of surgery were collected as features. A least absolute shrinkage and selection operator (LASSO) -based method was used for feature selection to overcome the high dimensionality and collinearity of variables. Among 146 features, four variables were selected as the resultant features, namely, preoperative hepatic encephalopathy, sodium level at the end of surgery, hepatic artery thrombosis, and total bilirubin level on postoperative day 7. These features were selected from different times and represent distinct clinical aspects. The model with logistic regression demonstrated the best prediction performance among various machine learning methods tested (area under the receiver operating characteristic curve (AUROC) = 0.898 and area under the precision-recall curve (AUPR) = 0.882). The risk scoring system developed based on the logistic regression model showed an AUROC of 0.910 and an AUPR of 0.830. Together, the prediction of graft failure in pediatric liver transplantation using the proposed machine learning model exhibited superior discrimination power and, therefore, can provide valuable information to clinicians for their decision making during the postoperative management of the patients.

Systematic review: The quality of life of patients with biliary atresia

BACKGROUND

The quality of life of patients with Biliary Atresia (BA) have not been systematically examined. The goal of this meta-analysis is to determine patients' postoperative health-related Quality of life (HrQoL) with native or transplanted livers.

METHODS

From 2000 to August 2021, a literature-based search for relevant cohorts was conducted using Pubmed/Medline, the Cochrane Library, and Embase. Original research on BA, Hepatoportoenterostomy (HPE), portoenterostomy, Kasai, Liver transplantation and HrQoL was included. Using RevMan, a forest plot analysis of HrQoL after surgical treatment after BA was calculated (version 5.4). Using MetaXL, a pooled prevalence for cholangitis, secondary liver transplantation, or related malformations was computed (version 5.3).

RESULTS

Nine studies compared individuals with BA to an age-matched healthy control group. 4/9 (n = 352) of these studies found poorer scores for BA patients, while 5/9 (n = 81) found equivalent health status. Factors associated with HrQoL: older age at the time of the survey was linked to greater HrQoL; whereas females, higher total bilirubin and the amount of immunosuppressive medicines were associated with lower HrQoL in BA patients.

CONCLUSION

The current study emphasises the critical need to improve the many parameters influencing HrQoL in BA patients, as well as the methods utilized to assess those factors. This includes immunosuppression, withdrawal from polydrug regimes and recognizing the differences in disease burden between males and females.

TYPE OF STUDY

Systematic review.

LEVEL OF EVIDENCE

Level III.

Management and outcome of hepatic artery thrombosis with whole-liver transplantation using donors less than one year of age

BACKGROUND/PURPOSE

The incidence of hepatic artery thrombosis (HAT) in recipients is high after pediatric LT using young donors. In this study we investigated the management and outcome of HAT after whole-LT using donors less than one year of age. And evaluate the safety of pediatric donors, and increase the utilization of pediatric donors overall.

METHODS

We retrospectively analyzed the clinical data encompassing children who underwent whole-liver transplantation in our department from January 2014 to December 2019. Recipients receiving a liver from a donor ≥1 month and ≤12 months were included, and a total of 110 patients were included in this study.

RESULTS

The results showed an incidence for HAT of 20% and the median time to HAT diagnosis was 3.0 (2.0, 5.3) days post-operation. Anticoagulant therapy was used for 19 cases and 94.7% of them achieved hepatic artery recanalization or collateral formation. The median time of recanalization was 12 (5, 15) days. Bile leakage and biliary strictures occurring in the HAT group were higher than in the non HAT group (13.6% vs. 1.1% and 31.8% vs. 3.4%). There were no significant differences in the survival rates of recipients or grafts among the two groups (P = 0.474, P = 0.208, respectively).

CONCLUSION

We confirmed that the incidence of HAT in LT recipients use donors less than 1 year is high, but recanalization can be performed using anticoagulant therapy. Although biliary complications increased significantly after HAT, the survival rates of patients and grafts were satisfactory.

LEVEL OF EVIDENCE

Level III.

Pediatric Liver Transplantation: Caregivers' Quality of Life

PURPOSE

The survival rate of pediatric patients undergoing liver transplantation has increased considerably. Despite this, the period after transplantation is still complex and poses several challenges to the recipient's family, which is responsible for care management. Recently, more attention has been paid to the impact of this complex procedure on the quality of life of caregivers. Hence, this study is aimed at assessing the quality of life of caregivers of patients who have undergone liver transplantation and the aspects that influence it.

METHODS

This was an observational and cross-sectional study. From November 2020 to January 2021, short-form-36 questionnaires and additional questions were given to the main caregivers of children and adolescents who underwent pediatric liver transplantation.

RESULTS

Thirty-eight questionnaires were completed and the results revealed a lower quality of life in comparison to Brazilian standards, primarily in the mental domains (41.8±14.1 vs. 51.1±2.8; p<0.001). It did not show a significant association with socioeconomic or transplant-related factors, but it did show a negative impact on parents' perception of the child's health. Parents who reported worse health status for their children had a lower mental quality of life (44.1±13.8 vs. 33.3±12.6; p<0.05).

CONCLUSION

The caregivers of transplanted children have a lower quality of life than those of the local population. Psychological assistance should be routinely provided to parents for long-term follow-up to mitigate potential negative effects on the transplanted child's care.

Care readiness and positive feelings of family caregivers of children with liver transplantation in China: A cross-sectional study

AIM

This research aimed to explore the level of care readiness and positive feelings of family caregivers of children with liver transplantation, and predictive factors of care readiness were alsoinvestigated.

BACKGROUND

Children with liver transplant require high level and extensive postoperative care. Family caregivers lack professional care knowledge and experience for surgical trauma, postoperative care, anti rejection drug guidance and so on. Good care readiness can not only promote family caregivers to improve their positive emotions and physical and mental health, but also play a positive role in the recovery of children's diseases. Therefore, efforts are needed to improve the readiness of family caregivers.

DESIGN/METHODS

A total of 107 family caregivers of children undergoing liver transplantation participated in this cross-sectional study. Sociodemographic data, disease characteristics, and measures of care readiness and positive feelings were collected using questionnaires.The Care Preparedness Scale (CPS) was used to assess care readiness, and the Positive Aspects of Caregiving (PAC) was used to assess positive feelings of family caregivers of children with liver transplantation. This paper adhered to the STROBE guidelines.

RESULTS

According to the statistical results, the total score of the CPS was 18.07 ± 5.51, and that of the PAC was 26.63 ± 4.05. There was a positive correlation between care readiness and positive feelings (r = 0.413, p < 0.05). Multiple linear step-wise regression analysis revealed that the total score of the PAC, undernourishment, caregiver education, relationship with children and care trainingresidence were the independent influencing factors of the readiness of caregivers (p < 0.05).

CONCLUSIONS

The care readiness of the family caregivers of children with liver transplantation was at a medium level. Medical personnel can implement targeted health education and carry out personalized care skill training to improve the positive feelings of caregivers and then improve the readiness of caregivers.

Clinical features and prognostic factors in patients with microvascular infiltration of hepatocellular carcinoma: Development and validation of a nomogram and risk stratification based on the SEER database

Background

The goal is to establish and validate an innovative prognostic risk stratification and nomogram in patients of hepatocellular carcinoma (HCC) with microvascular invasion (MVI) for predicting the cancer-specific survival (CSS).

Methods

1487 qualified patients were selected from the Surveillance, Epidemiology and End Results (SEER) database and randomly assigned to the training cohort and validation cohort in a ratio of 7:3. Concordance index (C-index), area under curve (AUC) and calibration plots were adopted to evaluate the discrimination and calibration of the nomogram. Decision curve analysis (DCA) was used to quantify the net benefit of the nomogram at different threshold probabilities and compare it to the American Joint Committee on Cancer (AJCC) tumor staging system. C-index, net reclassification index (NRI) and integrated discrimination improvement (IDI) were applied to evaluate the improvement of the new model over the AJCC tumor staging system. The new risk stratifications based on the nomogram and the AJCC tumor staging system were compared.

Results

Eight prognostic factors were used to construct the nomogram for HCC patients with MVI. The C-index for the training and validation cohorts was 0.785 and 0.776 respectively. The AUC values were higher than 0.7 both in the training cohort and validation cohort. The calibration plots showed good consistency between the actual observation and the nomogram prediction. The IDI values of 1-, 3-, 5-year CSS in the training cohort were 0.17, 0.16, 0.15, and in the validation cohort were 0.17, 0.17, 0.17 (P<0.05). The NRI values of the training cohort were 0.75 at 1-year, 0.68 at 3-year and 0.67 at 5-year. The DCA curves indicated that the new model more accurately predicted 1-year, 3-year, and 5-year CSS in both training and validation cohort, because it added more net benefit than the AJCC staging system. Furthermore, the risk stratification system showed the CSS in different groups had a good regional division.

Conclusions

A comprehensive risk stratification system and nomogram were established to forecast CSS for patients of HCC with MVI.

The survival rate of liver transplantation in children: a systematic review and meta-analysis

Liver transplantation is a life-saving treatment for children who are in liver failure. The survival rate index is used to assess the success rate of liver transplantation. The study aimed to assess the survival rate of liver transplantation in children. We searched 5 international databases in this study, including Medline/PubMed, ProQuest, Scopus, Web of Knowledge, and Google Scholar, for published articles by the end of 2020. Also, meta-regression analysis was performed based on the year of the study, and subgroup analysis was performed according to continents. A total of 425 titles were reviewed. Based on the results, 96 articles were entered in the meta-analysis. Established on the random-effect model, the survival rates of 1, 3, 5, and 10 years of transplantation were 86.62%, 77.74%, 73.95%, and 68.60%, respectively. Also, based on the meta-regression results, there was a relationship between the year of the study and the survival rate, as the study year gets more recent, the survival rate is increased. This study can provide documented and comprehensive evidence which can be the basis of many policies and decisions in various sectors of health development, including evaluating treatment options and health interventions in transplantation.

Motor outcomes in young children pre-and one-year post-liver transplant

BACKGROUND

Motor skill acquisition plays an important role in physical activity participation and overall social and physical health. Limited studies have examined motor development in children pre-and post-liver transplant (LT).

METHODS

Retrospective review of motor outcomes in children <6 years old with cholestatic liver disease assessed pre-and 1-year post-isolated LT. Measures include Alberta Infant Motor Scale and Peabody Developmental Motor Scales (gross motor quotient (GMQ), fine motor quotient (FMQ), and total motor quotient (TMQ)). Association of medical variables with motor outcomes was explored.

RESULTS

Participants included 33 (58% male) children with diagnoses of biliary atresia (70%), Alagille syndrome (21%), and others (9%). Median age at LT was 10 (IQR 7.0-20.5) months. Pre-LT >75% of children were at risk for motor delay (≤10^th percentile on AIMS/ ≥1SD below mean GMQ). Post-LT, 52% scored ≥1 SD below the mean GMQ compared with 22% FMQ. Children at risk/delayed pre-LT had an increased risk of motor delay on GMQ post-LT (odds ratio 11.43, 95% CI 1.12-116.7, p = .017). Higher INR pre-LT correlated with lower TMQ post-LT (r = -.51, p = .003). Longer waitlist time correlated with lower FMQ post-LT (r = .41, p = .03). GMQ post-LT and height z-scores pre-LT (r = .46, p = .02) and post-LT (r = .45, p < .01) were positively correlated. There was no correlation with presence of ascites, weight z-score, length of hospitalization, and age at LT.

CONCLUSIONS

Young children have increased risk of motor delay pre-LT, which may persist post-LT. Severity of liver disease and growth delays may impact motor development, highlighting the need for ongoing rehabilitation pre- and post-LT.

Biliary complications in pediatric liver transplantation: findings of percutaneous transhepatic cholangiography in a large single-center cohort

BACKGROUND

Although biliary complications after orthotopic liver transplantation represent a common source of morbidity and mortality, decreasing graft survival, consensus is lacking on their management in the pediatric population.

OBJECTIVE

The aim of this study was to present the prevalence of such biliary complications and their interventional radiologic management with representative images.

MATERIALS AND METHODS

This retrospective study reports our experience with percutaneous transhepatic cholangiography in the management of biliary complications after orthotopic liver transplantation in pediatric patients. This study enrolled all pediatric patients (<18 years old) who underwent percutaneous transhepatic cholangiography for the management of biliary complications after orthotopic liver transplantation at a tertiary care center between January 2010 and December 2020. Diagnosis of biliary complications and indication to perform percutaneous transhepatic cholangiography were based on clinical, laboratory or radiologic data.

RESULTS

Among the 301 orthotopic liver transplantations, 78 (26%) developed biliary complications that were managed by interventional radiology: these included 52 (17.3%) biliary strictures, 19 (6.3%) bile leaks, 5 (1.7%) biliary stones, 1 (0.3%) iatrogenic biliary obstruction and 1 (0.3%) vanishing syndrome. The median time interval between orthotopic liver transplantation and the diagnosis of biliary complications was 6.0 years (interquartile range [IQR] 8.2 years). Percutaneous transhepatic cholangiography and biliary duct catheterization were successful in all cases, with low rates of complications that were variable among subgroups.

CONCLUSION

A wide spectrum of biliary complications can occur after pediatric orthotopic liver transplantation. In this large single-center experience, we highlight the value of percutaneous transhepatic cholangiography in their diagnosis and management. Percutaneous treatments in pediatric patients are safe and effective, providing resolution or serving as a bridge to surgery, including re-transplantation.

Pediatric liver transplantation outcomes from a single center in Thailand

BACKGROUND

Liver transplantation (LT) has become an acceptable curative method for children with several liver diseases, especially irreversible acute liver failure and chronic liver diseases. King Chulalongkorn Memorial Hospital is one of Thailand’s largest liver transplant centers and is responsible for many pediatric cases.

AIM

To report the experience with pediatric LT and evaluate outcomes of living-related vs deceased-donor grafts.

METHODS

This evaluation included children who underwent LT between August 2004 and November 2019. Data were retrospectively reviewed, including demographics, diagnoses, laboratory values of donors and recipients, the pediatric end-stage liver disease (PELD) or model for end-stage liver disease (MELD) score, graft source, wait time, perioperative course, postoperative complications, and survival rates. Continuous data were reported using the median and interquartile range. The Mann–Whitney U-test was used to compare the wait time between the living-related and deceased-donor groups. The chi-square or Fisher's exact test were used to compare the frequencies of between-group complications. Survival rates were calculated using the Kaplan–Meier method.

RESULTS

Ninety-four operated pediatric liver transplant patients were identified (54% were females). The median age at transplantation was 1.2 (0.8-3.8) years. The median PELD and MELD scores were 20 (13-26.8) and 19.5 (15.8-26.3), respectively. Most grafts (81.9%) were obtained from living-related donors. The median wait time for the living donors was significantly shorter compared with the deceased donors at 1.6 (0.3-3.1) mo vs 11.2 (2.1-33.3) mo (P = 0.01). Most patients were diagnosed with biliary atresia (74.5%), and infection was the most common complication within 30 d post-transplantation (14.9%). Without a desensitization protocol, 9% of transplants were ABO-incompatible. Eight hepatitis B core antibodies (anti-HBc)-negative recipients received positive anti-HBc grafts without different observed complications. The overall survival rate was 93.6% and 90.3% at 1 and 5 years, respectively. No graft loss during follow-up was noted among survivors.

CONCLUSION

A significant number of pediatric LT cases were reported in Thailand. Based on relatively comparable outcomes, ABO-incompatible and HBc antibody-positive grafts may be considered in an organ shortage situation.

Therapeutic potential of living donor liver transplantation from heterozygous carrier donors in children with propionic acidemia

Background

Current world experience regarding living donor liver transplantation (LDLT) in the treatment of propionic acidemia (PA) is limited, especially in terms of using obligate heterozygous carriers as donors. This study aimed to evaluate the clinical outcomes of LDLT in children with PA.

Methods

From November 2017 to January 2020, 7 of the 192 children who underwent LDLT at our institution had been diagnosed with PA (median age, 2.1 years; range, 1.1–5.8 years). The primary indication for transplantation was frequent metabolic decompensations in 6 patients and preventative treatment in 1 patient. Of the seven parental living donors, six were genetically proven obligate heterozygous carriers.

Results

During a median follow-up of 23.9 months (range, 13.9–40.2 months), all patients were alive with 100% allograft survival, and no severe transplant-related complications occurred. In the case of liberalized protein intake, they did not suffer metabolic decompensation or disease-related complications and made progress in neurodevelopmental delay and body growth, as well as blood and urinary metabolite levels. In one patient with pre-existing mild dilated cardiomyopathy, her echocardiogram results completely normalized 13.8 months post-transplant. All living donors recovered well after surgery, with no metabolic decompensations or procedure-related complications. Western blotting revealed that the hepatic expressions of PCCA and PCCB in one of the heterozygous donors were comparable to those of the normal healthy control at the protein level.

Conclusions

LDLT using partial liver grafts from asymptomatic obligate heterozygous carrier donors is a viable therapeutic option for selected PA patients, with no negative impact on donors’ and recipients' clinical courses.

Wilson Disease in Children; Chelation Therapy or Liver Transplantation? A 10-Year Experience from Pakistan

Background

Wilson disease (WD) is a rare genetic disorder with vast clinical presentations and a higher incidence in areas where consanguinity is common. Most patients can be treated with oral chelation, but some require advanced surgical intervention, like liver transplantation (LT). This study aims to review outcomes of WD patients presenting to a tertiary care center over a period of 10 years.

Material/Methods

This retrospective analysis was conducted at Shifa International Hospital, Islamabad, Pakistan. Patients <18 years who were diagnosed with WD per ESPAGHAN guidelines from 2010 to 2020 were included. Presentation, diagnosis, treatment, and LT and its complications were recorded. Follow-ups were recorded, and patients were contacted by phone in cases of interrupted follow-up. Frequencies and percentages of variables were calculated.

Results

A total of 48 patients with WD were identified. Symptomatic disease was seen in 45 patients, with 3 diagnosed on screening. The hepatic form was common (62.2%). Mean age at diagnosis was 9.74 (range 5–17) years, 28 (58.3%) were male, while 17 (35.4%) were female. Urinary copper was increased in all patients (645.82±528.40). Oral treatment with penicillamine was given to 34 (75.5%) patients; 4 (8.9%) died while on oral treatment. Living donor LT was performed in 11 (22.9%) patients, who had a mean King’s Wilson index of 11 (range, 6–14). Currently, all LT patients are alive, with maximum graft survival of 7 years.

Conclusions

LT offers a promising treatment with good outcomes in pediatric WD. However, timely diagnosis and management with oral chelation therapy can prolong survival without LT.

Progress in clinical diagnosis and treatment of cavernous transformation of the portal vein

Cavernous transformation of the portal vein (CTPV) refers to the compensatory neoformation of venous collaterals around the hepatic portal after the main portal vein or its branches are blocked, in order to maintain liver blood perfusion. This disease is relatively rare, and in clinical practice, its etiology, diagnosis, and treatment are not well understood. Patients with portal hypertension-related syndromes need to receive active treatment. The main goal of treatment is to prevent upper gastrointestinal hemorrhage and hypersplenism caused by portal hypertension, and to restore hepatopetal portal blood perfusion. It is necessary to fully assess the patient's condition and understand the best indications for each treatment. On this basis, we should adopt individualized comprehensive treatment strategies. This article reviews the latest advances in the understanding of the etiology, diagnosis, classification, and treatment of CTPV.

Growth Factors Assessed during Kasai Procedure in Liver and Serum Are Not Predictive for the Postoperative Liver Deterioration in Infants with Biliary Atresia

Background: Biliary atresia (BA) is a neonatal cholangiopathy characterized by progressive destruction of the biliary system resulting in liver cirrhosis. Residual bile drainage can temporarily be achieved through Kasai portoenterostomy (KPE) and some children show long-term survival with their native liver. However, most children eventually require liver transplantation (LTX). As several growth factors (GF) and chemokines have been shown to promote fibrogenesis in the liver, we assessed whether GF are predictive for the course of disease. Material and Methods: Liver and sera samples were collected from 49 infants with BA during KPE. Levels of 13 different GF were measured by multiplex immunoassay. Patient outcomes were stratified into favorable (bilirubin < 20 µmol/L at 2-year follow-up) and unfavorable (LTX). GF levels were compared between groups by a t-test, correlation coefficients were calculated, and principal component analyses performed. Results: Twenty-two patients showed a favorable and 27 an unfavorable disease course. No relation of GF and outcome could be established. In both groups, high levels of SDF-1alpha/CXCL12 (1473.0 ± 497.5 pg/mL), FGF2 (301.2 ± 207.8 pg/mL), and VEGF-a (209.0 ± 146.4 pg/mL) levels were measured within the liver, followed (in descending order) by PDGF-bb, LIF, GM-CSF, BDNF, VEGF-d, beta-NGF, IL-7, SCF, PIGF-1, and EGF. Serum marker levels showed much higher mean variation compared to hepatic values and no correlation to the protein microenvironment in the liver. Conclusions: Our study demonstrates high amounts of GF in livers from infants with BA at KPE, but no correlation to the outcome or serum values could be established. Our data suggest that local or systemic GF levels are unsuitable for prediction of the disease course. Collectively, we conclude that in BA the degree of proliferative activity caused by GF is a dismissible factor for the further course of disease.

Perioperative blood transfusion decreases long-term survival in pediatric living donor liver transplantation

BACKGROUND

The impact of perioperative blood transfusion on short- and long-term outcomes in pediatric living donor liver transplantation (PLDLT) must still be ascertained, mainly among young children. Clinical and surgical postoperative complications related to perioperative blood transfusion are well described up to three months after adult liver transplantation.

AIM

To determine whether transfusion is associated with early and late postoperative complications and mortality in small patients undergoing PLDLT.

METHODS

We evaluated the effects of perioperative transfusion on postoperative complications in recipients up to 20 kg of body weight, submitted to PLDLT. A total of 240 patients were retrospectively allocated into two groups according to postoperative complications: Minor complications (n = 109) and major complications (n = 131). Multiple logistic regression analysis identified the volume of perioperative packed red blood cells (RBC) transfusion as the only independent risk factor for major postoperative complications. The receiver operating characteristic curve was drawn to identify the optimal volume of the perioperative RBC transfusion related to the presence of major postoperative complications, defining a cutoff point of 27.5 mL/kg. Subsequently, patients were reallocated to a low-volume transfusion group (LTr; n = 103, RBC ≤ 27.5 mL/kg) and a high-volume transfusion group (HTr; n = 137, RBC > 27.5 mL/kg) so that the outcome could be analyzed.

RESULTS

High-volume transfusion was associated with an increased number of major complications and mortality during hospitalization up to a 10-year follow-up period. During a short-term period, the HTr showed an increase in major infectious, cardiovascular, respiratory, and bleeding complications, with a decrease in rejection complications compared to the LTr. Over a long-term period, the HTr showed an increase in major infectious, cardiovascular, respiratory, and minor neoplastic complications, with a decrease in rejection complications. Additionally, Cox hazard regression found that high-volume RBC transfusion increased the mortality risk by 3.031-fold compared to low-volume transfusion. The Kaplan-Meier survival curves of the studied groups were compared using log-rank tests and the analysis showed significantly decreased graft survival, but with no impact in patient survival related to major complications. On the other hand, there was a significant decrease in both graft and patient survival, with high-volume RBC transfusion.

CONCLUSION

Transfusion of RBC volume higher than 27.5 mL/kg during the perioperative period is associated with a significant increase in short- and long-term postoperative morbidity and mortality after PLDLT.

Successful Treatment of Pediatric Refractory Burkitt Lymphoma PTLD after Liver Transplantation using Anti-CD19 Chimeric Antigen Receptor T-Cell Therapy

In the immunocompromised setting, recipients of solid-organ or hematopoietic stem-cell transplants carry an increased risk of post-transplant lymphoproliferative disorder (PTLD). Burkitt lymphoma (BL) PTLD is a rare form of monomorphic B-cell PTLD, which lacks a standard best treatment. Here, we report the successful treatment of refractory BL-PTLD with autologous anti-CD19 chimeric antigen receptor (CAR) T-cell therapy. A male patient was diagnosed with BL-PTLD, with an increasing Epstein-Barr virus (EBV) viral load, at 21 months after undergoing living liver transplantation from his mother due to neonatal biliary atresia. After 10 cycles rituximab +/- intensive chemotherapy and surgical tumor resection, the tumors significantly advanced. Next-generation sequencing (NGS) was performed on formalin-fixed paraffin-embedded tumor tissue, revealing one mutation in exon 5, TP53: p.A159 V, which may be associated with chemo-resistance. Thus, treatment was started with autologous anti-CD19 CAR T-cell therapy. We administered 9.0 × 10⁶/kg autologous anti-CD19 CAR T-cells, after conditioning with cyclophosphamide and fludarabine. Unexpectedly, the patient experienced only mild (Grade II) cytokine release syndrome (CRS) without neurotoxicity. Finally, he went into complete remission (CR), and has achieved 16-month event-free survival to date. In addition, liver function has remained stably within the normal range without any immunosuppressive therapy. The literature includes only five previously reported BL cases treated with CAR T-cell therapy. In conclusion, the present case suggests that autologous anti-CD19 CAR T-cell therapy may represent a new therapeutic option for some cases of refractory BL-PTLD.Clinical trial number: ChiCTR2000032211.

The Largest Single Center Report on Pediatric Liver Transplantation: Experiences and Lessons Learned

OBJECTIVE

We described our experiences on pediatric liver transplantation (LT) from the largest LT center in the world termed the Shiraz Transplant Center.

BACKGROUND

After the first successful pediatric LT in 1967, pediatric LT has become the routine treatment for children with liver failure worldwide.

METHODS

Data on a total of 1141 pediatric cases of LT were collected. Specifics on baseline and anthropometric characteristics, clinicopathology, prognosis of recipients of LT, and donor characteristics are reported.

RESULTS

Mean age of patients was 7.83 ± 5.55 years old. Most common etiologies for LT were biliary atresia (15.9%), progressive familial intrahepatic cholestasis (13.4%), and Wilson's disease (13.3%), respectively.Whole organs, living donor grafts, and split grafts were used in 47.9%, 41%, and 11.1% of patients, respectively. In-hospital complications were seen among 34.7% of patients and the most common complications were infections (26.8%), bleeding (23.4%), and vascular complications (18%).Median (interquartile range) model for end stage liver disease score was 20 (15, 25). Main causes of death among patients were sepsis (35.2%), followed by post-transplantation lymphoproliferative diseases (10.5%), and primary nonfunction of liver (9%).Patient survival showed improvement over the years (1-year survival of 73.1%, 83.4%, and 84.4%, 2-year survival of 65.2%, 77.1%, and 78.7%, 5-year survival of 58.2%, 72%, and 77.8% for 1997-2007, 2007-2013, and 2013-2019, respectively; P < 0.001).

CONCLUSIONS

This is the largest single-center report on pediatric LT in literature which provides valuable experiences in pediatric LT.

Effect of remote ischemic preconditioning among donors and recipients following pediatric liver transplantation: A randomized clinical trial

BACKGROUND

Studies suggested that remote ischemic preconditioning (RIPC) may effectively lessen the harmful effects of ischemia reperfusion injury during organ transplantation surgery.

AIM

To investigate the protective effects of RIPC on living liver donors and recipients following pediatric liver transplantation.

METHODS

From January 2016 to January 2019 at Renji Hospital Affiliated with Shanghai Jiao Tong University School of Medicine, 208 donors were recruited and randomly assigned to four groups: S-RIPC group (no intervention; n = 55), D-RIPC group (donors received RIPC; n = 51), R-RIPC group (recipients received RIPC, n = 51) and DR-RIPC group (both donors and recipients received RIPC; n = 51). We primarily evaluated postoperative liver function among donors and recipients and incidences of early allograft dysfunction, primary nonfunction and postoperative complications among recipients.

RESULTS

RIPC did not significantly improve alanine transaminase and aspartate aminotransferase levels among donors and recipients or decrease the incidences of early allograft dysfunction, primary nonfunction, and postoperative complications among recipients. Limited protective effects were observed, including a lower creatinine level in the D-RIPC group than in the S-RIPC group on postoperative day 0 (P < 0.05). However, no significant improvements were found in donors who received RIPC. Furthermore, RIPC had no effects on the overall survival of recipients.

CONCLUSION

The protective effects of RIPC were limited for recipients who received living liver transplantation, and no significant improvement of the prognosis was observed in recipients.

Behavior Problems and Cognitive Function in Pediatric Liver Transplant Recipients

BACKGROUND

Liver transplant (LT) is a lifesaving treatment providing excellent clinical outcomes. However, data regarding behavioral and cognitive issues after LT are sparse in Asia. This study aimed to investigate behavior and cognitive problems among pediatric LT recipients.

METHODS

We used the Child Behavior Checklist (CBCL) to evaluate behavior problems and/or the Wechsler Intelligence Scale for Children, Third Edition (WISC-III) to assess cognitive function. Participants were children aged 2 to 18 years who were treated with LT for at least 2 years.

RESULTS

We included 77 children with a median age of 7.8 years (interquartile range, 5.0-10.9). All children were evaluated with the CBCL, and 26 children were available for WISC-III assessment. Approximately one-third (34%) of the children had a total CBCL score above a clinical cutoff for significant behavior problems, and 29% of school-aged children had abnormal competence scores in a clinically significant range. Most of the evaluated children (17 of 26; 65%) had a normal full-scale intelligence quotient. Lower cognitive function was associated with having a single parent (P < .01). Higher behavior problems were associated with lower parental education level (P = .01) and correlated with longer post-transplant duration (Spearman's rho = 0.443; P < .001).

CONCLUSIONS

Significant numbers of children have behavior problems after LT. Most children have normal cognitive function, although a larger sample size is required to confirm this result. Long-term support for cognitive and behavior problems after LT should be implemented, particularly in children with single parents and lower parental education level.

Liver Transplantation in Children: An Overview of Organ Allocation and Surgical Management

Liver transplantation is the standard treatment for children with end-stage liver disease, primary hepatic neoplasms, or liver-localized metabolic defects. Perioperative mortality is almost absent, and long-term survival exceeds 90%. Organ shortage is managed thanks to advances in organ retrieval techniques; living donation and partial liver transplantation almost eliminated waiting list mortality, thus leading to expanding indications for transplantation. The success of pediatric liver transplantation depends on the prompt and early referral of patients to transplant Centers and on the close and integrated multidisciplinary collaboration between pediatricians, hepatologists, surgeons, intensivists, oncologists, pathologists, coordinating nurses, psychologists, and social workers.

Motor development in children 0-2 years pre- and post-LTX, a prospective study

To determine prospectively gross and fine motor development of children <2 years of age, who undergo LTX. In this prospective study, children aged <2 years who undergo LTX were tested using the motor scale of the Bayley Scales of infant and toddler development, 3rd edition Dutch version. Testing was done during screening pre- and post-LTX: at the time of hospital discharge (2-6 weeks), at 3 months, 6 months, and 1 year. Z-scores were calculated. Twenty-nine children participated in this study, 14 boys, median age 6 months, at screening for LTX. Gross motor skills were delayed pre-LTX (Z-score -1.3). Fine motor skills were normal (Z-score 0.3). Immediately post-LTX, both skills reduced, and at 1 year post-LTX, gross motor skills Z-score was -1.0 and fine motor skills Z-score 0.0. Both gross and fine motor skills Z-scores decline post-LTX and tend to recover after 1 year, gross motor skills to low normal and fine motor skills to normal levels. Monitoring of gross motor development and attention on stimulating gross motor development post-LTX remains important, to enable participation in physical activity and sport for health benefits later in life.

Health-Related Quality of Life in Pediatric Liver Transplant Recipients

BACKGROUND

Health-related quality of life (HRQoL) of liver transplantation (LT) recipients has been widely studied because of increased patient longevity. However, studies in developing countries are scanty. We aimed to evaluate psychometric properties of the Thai version of the PedsQL Transplant Module and used it to determine the HRQoL in LT children.

METHODS

We included children aged 2 to 18 years who underwent LT more than 1 year previously. The phase 1 study included a cognitive interview with 20 LT children and their parents using the Thai version of PedsQL Transplant Module and revised the module accordingly. Then, the finalized version was evaluated for psychometric properties in 50 LT children. In phase 2, HRQoL was evaluated in 52 LT children who did not participate in the phase 1 study.

RESULTS

In the Thai PedsQL Transplant Module, both parent report and child self-report had good internal consistency (α = 0.94 and 0.93, respectively) and substantial reliability (interclass correlation coefficient = 0.82 and 0.77, respectively). Median HRQoL scores from the parent report and child self-report were 80 (interquartile range [IQR], 70, 88) and 77 (IQR, 71, 88), respectively. From the parent report, lower HRQoL was associated with opportunistic viral infection (P = .004) and correlated with a greater number of immunosuppressive agents (ρ = -0.346, P = .014). However, none of these factors were significant according to the child self-report.

CONCLUSIONS

The Thai PedsQL Transplant Module has satisfactory psychometric properties. Post-LT children have good HRQoL. To improve their HRQoL, specific attention should be focused on managing viral infection and optimizing immunosuppressive therapy.

Hepatic expression of HGF/C-met and native liver survival in biliary atresia

BACKGROUND

The prognosis of biliary atresia (BA) remains difficult to predict. This study evaluated the roles of hepatocyte growth factor (HGF) and its receptor (C-met) towards clinical outcome and native liver survival.

METHODS

Hepatic HGF and C-met expression were determined using immunohistochemistry from liver biopsies of 41 BA patients during Kasai operation, and 17 non-cholestatic patients. The HGF and C-met expression was visually scored as per its intensity and percentage of stained area. BA patients were classified as high- and low-HGF and C-met receptor status. Native liver survival was compared between the two groups at 3-year follow-up. Data are shown as median and range.

MAIN RESULTS

Median age of BA patients was 2 (1-6) months. Hepatic HGF and C-met staining scores of BA patients were higher than those of non-cholestatic patients (P < 0.0001). There was a correlation between HGF and C-met staining scores (spearman r = 0.77, P < 0.0001). However, there was no association between their expression and early outcome at 6 months post-op. Mean follow-up time was 68.6 months. Survival analysis revealed that native liver survival at 1 year and 3 years were 88% and 77%, respectively. Additionally, 82.6% (19/23) of patients in the low-HGF group survived with native liver, compared with 66.7% (10/15) of those in high-HGF group (P = 0.436). For C-met expression, 78.6% (22/28) of low-score and 70% (7/10) of high score groups survived with native liver (P = 0.673).

CONCLUSIONS

Strong expression of hepatic HGF and its receptor in BA patients was demonstrated. However, the expression was not associated with the early outcome and native liver survival. These results suggest that HGF involved in the liver pathology of BA but its expression cannot be used as a prognostic indicator. Small sample size of patients was a main limitation. Further studies are warranted to validate our findings.

Kindergarten-age neurocognitive, functional, and quality-of-life outcomes after liver transplantation at under 6 years of age

BACKGROUND

We aimed to describe school-entry age neurocognitive, functional, and HRQL outcomes and their predictors after liver transplant done at age <6 years.

METHODS

A prospective cohort of all (n = 69) children surviving liver transplant from 1999 to 2014 were assessed at age 55.4 (SD 7.2) months and 38.6 (12.4) months after transplant. Assessment included: the Wechsler Preschool and Primary Scales of Intelligence, Beery-Buktenica Developmental Test of VMI, Adaptive Behavior Assessment System caregiver-completed questionnaire, and PedsQL 4.0 Generic Core Scales. Univariate and multiple linear regression determined predictors of outcomes at P < .05.

RESULTS

Neurocognitive and functional outcomes were on average within 1 SD of population norms, although shifted to the left (P ≤ .03), with more patients than expected having scores >2 (3.7-5.9 times more, P ≤ .007) SD below population norms. Total and Summary HRQL scores were statistically significantly lower than the healthy normative population (P ≤ .02) and a congenital heart disease group (P ≤ .02), but similar to children with other chronic health conditions; differences often exceeded the MCID and were lowest in the School functioning domain. There were few predictors on multiple linear regressions, and we could not confirm previous studies that suggested various inconsistent predictors of outcomes. Neurocognitive and functional outcomes scores were highly correlated with HRQL scores except for the School functioning domain, but did not fully explain them.

CONCLUSIONS

Long-term follow-up of this vulnerable population is important in order to facilitate support for the patient and family, and early intervention for any difficulties identified.

Logistic Coordination in Pediatric Liver Transplantation: Criteria for Optimization

INTRODUCTION

Logistic organization of the transplantation coordination process aims to synchronize the recovery and recipient team and to reduce to a minimum the graft's cold ischemia time (CIT), which, in turn, is known, to have deleterious effects on the graft and recipient, if prolonged. To determine whether variables influencing the different steps in the coordination process might allow for reducing CIT, this study aimed to analyze these variables.

PATIENTS AND METHODS

Retrospective analysis of 61 pediatric liver transplantations from 2006 to 2015 in the Geneva University Hospitals.

RESULTS

Length of donor hepatectomy was increased for split grafts (P < .0001). Length of recipient hepatectomy was longer in the case of previous surgery (P = .06). The recipient team waiting time for the graft was longer for split grafts (P = .01). The graft waiting time at the recipient site was longer for whole grafts (P = .0005) and increased recipient weight (P = .03). The graft waiting time at the donor site was doubled in the case of recovery of organs after the liver by the same team (P = .007). The graft waiting time at the donor and recipient site not surprisingly increased the CIT (P = .007 and < .0001, respectively).

CONCLUSION

CIT depends on waiting times during the entire coordination process, which largely depends on the estimation of hepatectomy lengths. A more accurate estimation, considering graft type and recipient's previous surgery and weight, might allow for decreasing CIT and consequently improve outcomes after pediatric liver transplantation.

Physical activity and aerobic fitness in children after liver transplantation

To determine physical activity (PA), aerobic fitness, muscle strength, health-related quality of life (HRQOL), fatigue, and participation in children after liver transplantation. Children, 6-12 years, at least one year after liver transplantation, participated in this cross-sectional study. Measurements: Time spent in moderate to vigorous PA (MVPA) was measured using an accelerometer, and aerobic fitness (VO_{2 peak} ) was measured by cardiopulmonary exercise testing. Muscle strength was measured by hand-held dynamometry. Fatigue was measured using the multidimensional fatigue scale, and HRQOL with the Pediatric Quality of life Core scales and leisure activities was measured using the Children's Assessment of Participation and Enjoyment. Outcomes (medians and interquartile range (IQR)) were compared to norm values. Twenty-six children participated in this study (14 boys, age 9.7 years, IQR 7.7;11.4). Children spent 0.8 hours/d (IQR 0.6;1.1) on MVPA. One child met the recommendation of at least 1 hour of MVPA every day of the week. Aerobic fitness was similar to norms (VO_{2 peak} 1.4 _L/min , IQR 1.1;1.7, Z-score -0.3). Z-scores of muscle strength ranged between -1.4 and -0.4 and HRQOL and fatigue between -2.3 and -0.4. Participation was similar to published norms (Z-scores between -0.6 and 0.6). Young children after liver transplantation have similar MVPA patterns and aerobic fitness compared to published norms. Despite lower HRQOL, more fatigue, and less muscle strength, these children have similar participation in daily activities. Although children do well, it remains important to stimulate PA in children after liver transplantation in the context of long-term management.

Hepatocyte growth factor levels in livers and serum at Kasai-portoenterostomy are not predictive of clinical outcome in infants with biliary atresia

Biliary atresia (BA) is characterized by progressive destruction of the biliary system leading to liver fibrosis and deterioration of liver function. Serum hepatocyte growth factor (HGF) has been shown to be increased in cirrhotic diseases including BA. The aim of this study was to investigate the prognostic value of HGF levels in sera and liver tissue for the further disease course. A total of 49 serum and liver samples from infants with BA were acquired during Kasai-portoenterostomy (KPE) and analyzed by multiplex immunoassay including HGF, as marker of liver regeneration, and Interleukin 6 (IL-6) as a marker of inflammation. Both mediators showed no correlation with the outcome defined as favorable (survival with native liver (SNL)) or, in contrast, rapid deterioration of liver function requiring transplantation. Our data suggest that the degree of liver regeneration indicated by high levels of HGF within the liver is a dismissible factor in the post-KPE disease course.

Liver transplantation during infancy: No increased rate of neurological complications

pLT is a highly standardized therapy for children with end-stage liver disease and liver-based metabolic diseases. However, NCs after transplantation occur and especially younger children are considered as more vulnerable and susceptible to NCs. Up to now, detailed data particularly for the very young age group do not exist. We therefore retrospectively studied NCs in children after pLT under age of 24 months. Forty children aged between 19 days and 22 months were evaluated according to type of NC and potential risk factors. NCs occurred in 8/40 patients (20%). All experienced new-onset seizures and in 1/6 surviving patients, seizures evolved into epilepsy. Other NCs were intracerebral abscess (1/8 patients) and subdural hemorrhage (1/8 patients). The overall 3-year mortality rate was 10% (4/40 patients). Significant risk factors for NCs and therefore seizures were HAT (P = 0.020), total surgery time (P = 0.009), retransplantation (P < 0.001), period of catecholamine therapy (P = 0.024), period of mechanical ventilation (P = 0.014), and period of sedation (P = 0.010). Our study is the first to provide detailed information on NCs after pLT in children under 24 months of age. The incidence of NCs in this particular group of very young patients was not increased compared to previously published data of children of all ages. Main NC was new-onset seizure. In the surviving infants, prognosis of seizure was excellent and the risk of developing epilepsy was low. Even more, the occurrence of NCs did not significantly affect mortality or survival in this particular age group.

Acute, Chronic, and Humoral Rejection: Pathologic Features Under Current Immunosuppressive Regimes

Under current immunosuppressive regimes, T-cell-mediated acute and chronic rejection remain common and important posttransplant complications. The definition of humoral (antibody-mediated) rejection has been greatly expanded in recent years. The histopathologic assessment of allograft biopsies continues to serve an important role in the diagnosis of rejection and to facilitate patient management. The diagnosis of both acute and chronic antibody-mediated rejection requires integration of the results of donor-specific antibody testing and C4d immunostaining, as well as exclusion of other potential etiologies of allograft dysfunction. Chronic antibody-mediated rejection should also be included in the differential diagnosis for unexplained allograft fibrosis.