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Lal BB, Khanna R, Sood V, Alam S, Nagral A, Ravindranath A, Kumar A, Deep A, Gopan A, Srivastava A, Maria A, Pawaria A, Bavdekar A, Sindwani G, Panda K, Kumar K, Sathiyasekaran M, Dhaliwal M, Samyn M, Peethambaran M, Sarma MS, Desai MS, Mohan N, Dheivamani N, Upadhyay P, Kale P, Maiwall R, Malik R, Koul RL, Pandey S, Ramakrishna SH, Yachha SK, Lal S, Shankar S, Agarwal S, Deswal S, Malhotra S, Borkar V, Gautam V, Sivaramakrishnan VM, Dhawan A, Rela M, Sarin SK. Diagnosis and management of pediatric acute liver failure: consensus recommendations of the Indian Society of Pediatric Gastroenterology, Hepatology, and Nutrition (ISPGHAN). Hepatol Int 2024; 18:1343-1381. [PMID: 39212863 DOI: 10.1007/s12072-024-10720-3] [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: 05/23/2024] [Accepted: 08/08/2024] [Indexed: 09/04/2024]
Abstract
Timely diagnosis and management of pediatric acute liver failure (PALF) is of paramount importance to improve survival. The Indian Society of Pediatric Gastroenterology, Hepatology, and Nutrition invited national and international experts to identify and review important management and research questions. These covered the definition, age appropriate stepwise workup for the etiology, non-invasive diagnosis and management of cerebral edema, prognostic scores, criteria for listing for liver transplantation (LT) and bridging therapies in PALF. Statements and recommendations based on evidences assessed using the modified Grading of Recommendations Assessment, Development and Evaluation (GRADE) system were developed, deliberated and critically reappraised by circulation. The final consensus recommendations along with relevant published background information are presented here. We expect that these recommendations would be followed by the pediatric and adult medical fraternity to improve the outcomes of PALF patients.
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Affiliation(s)
- Bikrant Bihari Lal
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
| | - Rajeev Khanna
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
| | - Vikrant Sood
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
| | - Seema Alam
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India.
| | - Aabha Nagral
- Department of Gastroenterology, Jaslok Hospital and Research Center, Mumbai, India
- Apollo Hospital, Navi Mumbai, India
| | - Aathira Ravindranath
- Department of Pediatric Gastroenterology, Apollo BGS Hospital, Mysuru, Karnataka, India
| | - Aditi Kumar
- Department of Pediatrics, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Akash Deep
- Department of Pediatric Intensive Care, King's College Hospital, London, UK
| | - Amrit Gopan
- Department of Pediatric Gastroenterology and Hepatology, Sir H.N Reliance Foundation Hospital, Mumbai, India
| | - Anshu Srivastava
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Arjun Maria
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Institute of Child Health, Sir Ganga Ram Hospital, New Delhi, India
| | - Arti Pawaria
- Department of Pediatric Hepatology and Gastroenterology, Amrita Institute of Medical Sciences, Faridabad, India
| | - Ashish Bavdekar
- Department of Pediatrics, KEM Hospital and Research Centre, Pune, India
| | - Gaurav Sindwani
- Department of Organ Transplant Anesthesia and Critical Care, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Kalpana Panda
- Department of Pediatrics, Institute of Medical Sciences & SUM Hospital, Bhubaneshwar, India
| | - Karunesh Kumar
- Department of Pediatric Gastroenterology and Liver Transplantation, Indraprastha Apollo Hospitals, New Delhi, India
| | | | - Maninder Dhaliwal
- Department of Pediatric Intensive Care, Amrita Institute of Medical Sciences, Faridabad, India
| | - Marianne Samyn
- Department of Pediatric Hepatology, King's College Hospital, London, UK
| | - Maya Peethambaran
- Department of Pediatric Gastroenterology and Hepatology, VPS Lakeshore Hospital, Kochi, Kerala, India
| | - Moinak Sen Sarma
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Moreshwar S Desai
- Department of Paediatric Critical Care and Liver ICU, Baylor College of Medicine &Texas Children's Hospital, Houston, TX, USA
| | - Neelam Mohan
- Department of Pediatric Gastroenterology and Hepatology, Medanta the Medicity Hospital, Gurugram, India
| | - Nirmala Dheivamani
- Department of Paediatric Gastroenterology, Institute of Child Health and Hospital for Children, Egmore, Chennai, India
| | - Piyush Upadhyay
- Department of Pediatrics, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India
| | - Pratibha Kale
- Department of Microbiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Rakhi Maiwall
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Rohan Malik
- Department of Pediatric Gastroenterology and Hepatology, All India Institute of Medical Sciences, New Delhi, India
| | - Roshan Lal Koul
- Department of Neurology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Snehavardhan Pandey
- Department of Pediatric Hepatology and Liver Transplantation, Sahyadri Superspeciality Hospital Pvt Ltd Pune, Pune, India
| | | | - Surender Kumar Yachha
- Department of Pediatric Gastroenterology, Hepatology and Liver Transplantation, Sakra World Hospital, Bangalore, India
| | - Sadhna Lal
- Division of Pediatric Gastroenterology and Hepatology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sahana Shankar
- Division of Pediatric Gastroenterology and Hepatology, Department of Pediatrics, Mazumdar Shaw Medical Centre, Narayana Health City, Bangalore, India
| | - Sajan Agarwal
- Department of Pediatric Gastroenterology and Hepatology, Gujarat Gastro Hospital, Surat, Gujarat, India
| | - Shivani Deswal
- Department of Pediatric Gastroenterology, Hepatology and Liver Transplant, Narayana Health, DLF Phase 3, Gurugram, India
| | - Smita Malhotra
- Department of Pediatric Gastroenterology and Hepatology, Indraprastha Apollo Hospitals, New Delhi, India
| | - Vibhor Borkar
- Department of Paediatric Hepatology and Gastroenterology, Nanavati Max Super Speciality Hospital, Mumbai, Maharashtra, India
| | - Vipul Gautam
- Department of Pediatric Gastroenterology, Hepatology and Liver Transplantation, Max Superspeciality Hospital, New Delhi, India
| | | | - Anil Dhawan
- Department of Pediatric Hepatology, King's College Hospital, London, UK
| | - Mohamed Rela
- Department of Liver Transplantation and HPB (Hepato-Pancreatico-Biliary) Surgery, Dr. Rela Institute & Medical Center, Chennai, India
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
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Zhou Y, Qian Y, Zhang X, Chen F, Ren X, Xu R, Xia Q. Nutrition and Epstein-Barr viremia in children underwent liver transplantation: A retrospective, cross-sectional study. Clin Nutr ESPEN 2024; 61:22-27. [PMID: 38777437 DOI: 10.1016/j.clnesp.2024.03.010] [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: 11/02/2023] [Revised: 12/25/2023] [Accepted: 03/05/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND AND AIMS We aimed to examine the association between nutritional status, assessed by height/length and body weight for age and sex, and Epstein-Barr virus (EBV) viremia in children underwent liver transplantation. METHODS Nutritional status was determined by total score of age- and sex-specific height/length and body weight: < (-2 SD) as "2 points", (-2 SD to -1 SD) as "1 point", and ≥ (-1SD) as "0 point". Children were further classified into three groups: malnutrition (4 points), risk of malnutrition (1-3 points), and normal (0 point). EBV viremia were confirmed by real time quantitative PCR method if EBV burden was ≥400 copies/ml. RESULTS A total number of 896 children (414 boys and 482 girls, medium age 8 months) were included in the study. The medium height was 65.0 cm while medium body weight was 7.0 kg. The prevalence of EBV viremia was 54.6% during follow up. Comparing with children with normal nutritional status, the adjusted odds ratios for the risk of EBV viremia was 2.14 (95% CI: 1.44, 3.19) in children with risk of malnutrition, and 2.29 (95% CI: 1.54, 3.40) in children with malnutrition. Each point increase of nutritional score was associated with a 21% higher risk of EBV viremia (odd ratios = 1.21; 95% CI: 1.10, 1.34) in fully adjusted model. CONCLUSIONS Nutritional score was associated with EBV viremia in children underwent liver transplantation.
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Affiliation(s)
- Yiquan Zhou
- Department of Clinical Nutrition, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Yongbing Qian
- Department of Liver Surgery, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Xiaomin Zhang
- Department of Clinical Nutrition, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Fang Chen
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Xuefei Ren
- Department of Liver Surgery, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Renying Xu
- Department of Clinical Nutrition, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Department of Nutrition, College of Health Science and Technology, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Qiang Xia
- Department of Liver Surgery, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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Zhang LY, Huang LS, Yue YH, Fawaz R, Lim JK, Fan JG. Acute Hepatitis of Unknown Origin in Children: Early Observations from the 2022 Outbreak. J Clin Transl Hepatol 2022; 10:522-530. [PMID: 35836761 PMCID: PMC9240245 DOI: 10.14218/jcth.2022.00281] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 06/15/2022] [Accepted: 06/15/2022] [Indexed: 12/14/2022] Open
Abstract
Recent reports of acute hepatitis of unknown origin in previously healthy children have been increasing worldwide. The main characteristics of the affected children were jaundice and gastrointestinal symptoms. Their serum aminotransaminase levels were above 500 IU/L, with negative tests for hepatitis viruses A-E. By 31 May 2022, the outbreak had affected over 800 children under the age of 16 years in more than 40 countries, resulting in acute liver failure in approximately 10%, including at least 21 deaths and 38 patients requiring liver transplantation. There was still no confirmed cause or causes, although there were several different working hypotheses, such as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), adenovirus serotype 41, or SARS-CoV-2 superantigen-mediated immune cell activation. Here, we review early observations of the 2022 outbreak which may inform diagnosis, treatment, and prevention in the context of an overlapping COVID-19 pandemic.
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Affiliation(s)
- Li-Ya Zhang
- Department of Infectious Disease, Xinhua Children’s Hospital, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Li-Su Huang
- Department of Infectious Disease, Xinhua Children’s Hospital, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yu-Hang Yue
- Department of Infectious Disease, Xinhua Children’s Hospital, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Rima Fawaz
- Section of Pediatric Gastroenterology and Hepatology, Yale University School of Medicine, New Haven, CT, USA
| | - Joseph K. Lim
- Section of Digestive Diseases and Yale Liver Center, Yale University School of Medicine, New Haven, CT, USA
| | - Jian-Gao Fan
- Department of Gastroenterology, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Key Lab of Pediatric Gastroenterology and Nutrition, Shanghai, China
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Zhou YJ, Gu HY, Tang QQ, Li F, Zhu J, Ai T, Zhu K, Xu BY, Wang Q, Huang AL, Chen J, Zhang ZZ. Case report: A case of severe acute hepatitis of unknown origin. Front Pediatr 2022; 10:975628. [PMID: 36275068 PMCID: PMC9579323 DOI: 10.3389/fped.2022.975628] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 09/12/2022] [Indexed: 11/13/2022] Open
Abstract
According to analyses of etiology, clinical features, diagnostic methods, and treatment strategies by summarizing a case of unexplained acute hepatitis recently experienced, we are aiming to provide some information to enrich the clinical experience in diagnosis and treatment of severe acute hepatitis of unknown etiology in young children. A boy, aged 10 years and 6 months old, was admitted to the hospital due to acute abdominal pain, jaundice, and exceptionally high levels of ALT and AST. A range of measures, including patient history, physical examination, and routine laboratory testing, were performed. Furthermore, strategies such as trio-based next-generation sequencing (Trio-NGS) and liver biopsy, as well as metagenomic NGS (mNGS) of blood and liver samples were also performed. In summary, this case was an acute severe non-A-E hepatitis that is a probable case with hepatitis of unknown origin. Immunohistochemical analysis showed an immune injury in liver tissues. Torque teno virus (TTV) sequences were detected by mNGS assay. As for treatment strategies, in addition to general treatment, this patient also underwent plasmapheresis and methylprednisolone treatment due to disease deterioration. The patient's liver function was improved afterward and discharged after one month of treatment. Taken together, this work reported the clinical feature and treatment of severe acute hepatitis with non-A-E hepatitis in detail. The potential mechanism of liver damage might be due to an immune attack in which TTV might play a role as a co-factor.
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Affiliation(s)
- Yu-Jiao Zhou
- The Key Laboratory of Molecular Biology of Infectious Diseases Designated by the Chinese Ministry of Education, Chongqing Medical University, Chongqing, China
| | - Hui-Ying Gu
- The Key Laboratory of Molecular Biology of Infectious Diseases Designated by the Chinese Ministry of Education, Chongqing Medical University, Chongqing, China
| | - Qi-Qin Tang
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Child Infection and Immunity, Department of Infectious Disease, National Clinical Research Center for Child Health and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Fan Li
- Department of Endocrine and Breast Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jin Zhu
- Department of Pathology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Ting Ai
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Child Infection and Immunity, Department of Infectious Disease, National Clinical Research Center for Child Health and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Kun Zhu
- Department of Radiology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Bin-Yue Xu
- Chongqing Municipal Center for Disease Control and Prevention, Chongqing, China
| | - Qing Wang
- Chongqing Municipal Center for Disease Control and Prevention, Chongqing, China
| | - Ai-Long Huang
- The Key Laboratory of Molecular Biology of Infectious Diseases Designated by the Chinese Ministry of Education, Chongqing Medical University, Chongqing, China
| | - Juan Chen
- The Key Laboratory of Molecular Biology of Infectious Diseases Designated by the Chinese Ministry of Education, Chongqing Medical University, Chongqing, China.,Key Laboratory of Laboratory Medical Diagnostics, Chinese Ministry of Education, Chongqing Medical University, Chongqing, China
| | - Zhen-Zhen Zhang
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Child Infection and Immunity, Department of Infectious Disease, National Clinical Research Center for Child Health and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
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