Current status of pediatric transplantation in Japan

Pediatric and adult liver transplantation in Bahrain: The experiences in a country with no available liver transplant facilities

BACKGROUND

Liver transplantation (LT) is a life-saving procedure for patients with end-stage liver disease and has become the standard and most effective treatment method for these patients. There are many indications for LT that vary between countries and settings. The outcome of LT depends on the available facilities and surgical expertise, as well as the types of liver graft donors available.

AIM

To assess the clinical characteristics of patients from Bahrain who underwent LT overseas, and analyze factors affecting their survival.

METHODS

In this retrospective cohort study, we reviewed the medical records and overseas committee registry information of all pediatric and adult patients who were sent overseas to undergo LT by the Pediatric and Medical Departments of Salmaniya Medical Complex and Bahrain Defence Force Hospital via the Overseas Treatment Office, Ministry of Health, Kingdom of Bahrain, between 1997 and 2023. Demo graphic data, LT indication, donor-recipient relationship, overseas LT center, graft type, post-LT medications, and LT complications, were collected. Outcomes measured included the overall and 5-year LT survival rate. Fisher's exact, Pearson χ2, and Mann-Whitney U tests were used to compare the pediatric and the adults' group in terms of clinical characteristics, donor-recipient relationship, medication, complications, and outcome. Survival analysis was estimated via the Kaplan-Meier's method. Univariate and multivariate analyses were used to detect predictors of survival.

RESULTS

Of the 208 eligible patients, 170 (81.7%) were sent overseas to undergo LT while 38 (18.3%) remained on the waiting list. Of the 170 patients, 167 (80.3%) underwent LT and were included in the study. The majority of the patients were Bahraini (91.0%), and most were males (57.5%). One-hundred-and-twenty (71.8%) were adults and 47 (28.3%) were children. The median age at transplant was 50.0 [interquartile range (IQR): 14.9-58.4] years. The main indication for pediatric LT was biliary atresia (31.9%), while that of adult LT was hepatitis C-related cirrhosis (35.0%). Six (3.6%) patients required re-transplantation. Most patients received a living-related liver graft (82%). Pediatric patients received more living and related grafts than adults (P = 0.038 and P = 0.041, respectively), while adult patients received more cadaveric and unrelated grafts. Most patients required long-term immunosuppressive therapy after LT (94.7%), of which tacrolimus was the most prescribed (84.0%), followed by prednisolone (50.7%), which was prescribed more frequently for pediatric patients (P = 0.001). Most patients developed complications (62.4%) with infectious episodes being the most common (38.9%), followed by biliary stricture (19.5%). Tonsilitis and sepsis (n = 12, 8.1% for each) were the most frequent infections. Pediatric patients experienced higher rates of infection, rejection, and early poor graft function than adult patients (P < 0.001, P = 0.003, and P = 0.025, respectively). The median follow-up time was 6.5 (IQR: 2.6-10.6) years. The overall survival rate was 84.4%, the 5-year survival rate, 86.2%, and the mortality rate, 15.6%. Younger patients had significantly better odds of survival (P = 0.019) and patients who survived had significantly longer follow-up periods (P < 0.001).

CONCLUSION

Patients with end-stage liver disease in Bahrain shared characteristics with those from other countries. Since LT facilities are not available, an overseas LT has offered them great hope.

Outcomes of pediatric patients supported with ventricular assist devices single center experience

BACKGROUND

There has been a remarkable increase in the number of pediatric ventricular assist device (VAD) implanted over the past decade. Asian pediatric heart centers had not participated in the multicenter registries among the Western countries. This article aimed to report the outcomes of pediatric VAD in our hospital.

METHODS

The study enrolled all patients aged <18 years at the time of VAD implantation in our institution between 2008 and 2021.

RESULTS

There were 33 patients with diagnosis of acute fulminant myocarditis (n = 9), congenital heart disease (n = 5), dilated cardiomyopathy (n = 16), and others. Paracorporeal continuous-flow pump was the most frequently implanted (n = 27). Most of the devices were implanted in patients with INTERMACS profile 1 (n = 24). The median duration on VAD was 22 days (range 2-254). The proportion of patients attaining positive outcomes (alive on device, bridge to transplantation or recovery) was 72.7% at 1 month, 67.7% at 3 months, and 67.7% at 6 months. Most of the deaths on device occurred within the first month post-implant (n = 9), with neurological complications being the most frequent cause of death. All recovered cases were successfully weaned off the device within the first month of implantation.

CONCLUSION

We demonstrated a favorable outcome in pediatric patients supported with VAD at our institution.

Spontaneous and reflex movements after diagnosis of clinical brain death: A lesson from acute encephalopathy

BACKGROUND

Organ transplantation after brain death (BD) of the donor has been promoted in many countries as an established medical treatment. However, some problems with brain-dead organ transplantation have been reported. For example, there is no evidence as to the optimal observation period for a diagnosis and no evidence to support the interpretation of the various body movements observed after the determination of BD.

CASE REPORT

A previously healthy 17-month-old girl with severe febrile convulsive status was transferred to our intensive care unit. The convulsions were refractory and the patient required respiratory management due to whole brain edema on head CT. Later she was diagnosed with acute encephalopathy. The patient showed a flat EEG, no responses on auditory brainstem responses (ABR), and loss of brainstem reflexes on repeated daily examinations. No apnea test was performed. Based on the diagnosis of clinical BD, coordinator of Japan Organ Transplant Network explained about organ donation on the 17th day of the disease. Subsequently, the family responded that they could not consent to organ donation, and the patient did not proceed to the legal BD determination. Around five weeks after the onset, spontaneous body movements began to appear, as not only the spinal reflexes but also the brainstem involvement.

CONCLUSION

The pathophysiology of acute encephalopathy is largely unknown, and it is difficult to determine the observation period necessary for BD determination. What we have learned from this case is that clinical BD remains ambiguous and cannot be confirmed even with a thorough neurological examination, EEG, and ABR.

The current status of kidney transplantation in Nigerian children: still awaiting light at the end of the tunnel

BACKGROUND

Kidney transplantation (KT) is the gold standard treatment for children with chronic kidney disease stage 5 (CKD5). It is easily accessible in well-resourced countries, but not in low/middle-income countries (LMICs). We present, a multicentre experience of paediatric KT of children domiciled in Nigeria. We aim to highlight the challenges and ethical dilemmas that children, their parents or guardians and health care staff face on a daily basis.

METHODS

A multicentre survey of Nigerian children who received KTs within or outside Nigeria from 1986 to 2019 was undertaken using a questionnaire emailed to all paediatric and adult consultants who are responsible for the care of children with kidney diseases in Nigeria. Demographic data, causes of CKD5, sources of funding, donor organs and graft and patient outcome were analysed. Using Kaplan-Meier survival analysis, we compared graft and patient survival.

RESULTS

Twenty-two children, aged 4-18 years, received 23 KTs, of which 12 were performed in Nigeria. The male-to-female ratio was 3.4:1. Duration of pre-transplant haemodialysis was 4-48 months (median 7 months). Sixteen KTs were self-funded. State governments funded 3 philanthropists 4 KTs. Overall differences in graft and patient survival between the two groups, log rank test P = 0.68 and 0.40, respectively were not statistically significant.

CONCLUSIONS

The transplant access rate for Nigerian children is dismal at < 0.2%. Poor funding is a major challenge. There is an urgent need for the federal government to fund health care and particularly KTs. Graphical Abstract.

Donor considerations in pediatric kidney transplantation

This article reviews kidney transplant donor options for children with end-stage kidney disease (ESKD). Global access to kidney transplantation is variable. Well-established national policies, organizations for organ procurement and allocation, and donor management policies may account for higher deceased donor (DD transplants) in some countries. Living donor kidney transplantation (LD) predominates in countries where organ donation has limited national priority. In addition, social, cultural, religious and medical factors play a major role in both LD and DD kidney transplant donation. Most children with ESKD receive adult-sized kidneys. The transplanted kidney has a finite survival and the expectation is that children who require renal replacement therapy from early childhood will probably have 2 or 3 kidney transplants in their lifetime. LD transplant provides better long-term graft survival and is a better option for children. When a living related donor is incompatible with the intended recipient, paired kidney exchange with a compatible unrelated donor may be considered. When the choice is a DD kidney, the decision-making process in accepting a donor offer requires careful consideration of donor history, kidney donor profile index, HLA matching, cold ischemia time, and recipient's time on the waiting list. Accepting or declining a DD offer in a timely manner can be challenging when there are undesirable facts in the donor's history which need to be balanced against prolonging dialysis in a child. An ongoing global challenge is the significant gap between organ supply and demand, which has increased the need to improve organ preservation techniques and awareness for organ donation.

Pediatric patient with restrictive cardiomyopathy on staged biventricular assist device support with Berlin Heart EXCOR® underwent heart transplantation successfully: the first case in Japan

Pure restrictive cardiomyopathy is a strong risk factor for poor outcomes in children with cardiomyopathy on ventricular assist devices. Owing to concomitant right heart failure, children with end-staged restrictive cardiomyopathy who are supported with a ventricular assist device often require a biventricular assist device, which is another risk factor for waitlist mortality in heart transplantation candidates. Herein, we report the case of a 3-year-old boy with pure restrictive cardiomyopathy who successfully underwent heart transplantation after 12 months of support with staged biventricular assist devices. Owing to the progression of diastolic dysfunction, the left ventricular assist device could not provide adequate circulation support. Despite the provision of biventricular assist device support, the patient required a complex management strategy that involved balancing the left and right ventricular assist device supports. We were able to stabilize the patient by careful synchronization of the supports and proceeded to heart transplantation. TRIAL REGISTRATION: Clinical Registration No.: Institutional Review Board of Osaka University Hospital, approval no. 16105.

Clinical and molecular basis of hepatocerebral mitochondrial DNA depletion syndrome in Japan: evaluation of outcomes after liver transplantation

BACKGROUND

Hepatocerebral mitochondrial DNA depletion syndrome (MTDPS) is a disease caused by defects in mitochondrial DNA maintenance and leads to liver failure and neurological complications during infancy. Liver transplantation (LT) remains controversial due to poor outcomes associated with extrahepatic symptoms. The purposes of this study were to clarify the current clinical and molecular features of hepatocerebral MTDPS and to evaluate the outcomes of LT in MTDPS patients in Japan.

RESULTS

We retrospectively assessed the clinical and genetic findings, as well as the clinical courses, of 23 hepatocerebral MTDPS patients from a pool of 999 patients who were diagnosed with mitochondrial diseases between 2007 and 2019. Causative genes were identified in 18 of 23 patients: MPV17 (n = 13), DGUOK (n = 3), POLG (n = 1), and MICOS13 (n = 1). Eight MPV17-deficient patients harbored c.451dupC and all three DGUOK-deficient patients harbored c.143-307_170del335. The most common initial manifestation was failure to thrive (n = 13, 56.5%). The most frequent liver symptom was cholestasis (n = 21, 91.3%). LT was performed on 12 patients, including nine MPV17-deficient and two DGUOK-deficient patients. Among the 12 transplanted patients, five, including one with mild intellectual disability, survived; while seven who had remarkable neurological symptoms before LT died. Five of the MPV17-deficient survivors had either c.149G > A or c.293C > T.

CONCLUSIONS

MPV17 was the most common genetic cause of hepatocerebral MTDPS. The outcome of LT for MTDPS was not favorable, as previously reported, however, patients harboring MPV17 mutations associated with mild phenotypes such as c.149G > A or c.293C > T, and exhibiting no marked neurologic manifestations before LT, had a better prognosis after LT.

Hepatic Artery Thrombosis in Liver Transplantation in Adult Recipients Using Pediatric Deceased Donors

INTRODUCTION

Routinely, pediatric donor (PD) grafts are allocated to pediatric liver transplantation (LT) recipients; however, occasionally they can be allocated for adult recipients (ARs). Some authors reported decreased patient/graft survival and higher vascular complications, such as hepatic artery thrombosis (HAT), in LT in ARs using PDs.

METHODS

It is a retrospective study enrolling 1202 ARs undergoing LT using whole liver grafts during the period of January 2002 to April 2019. The patients were categorized according to donor age in 2 groups: PDs and adult donors (ADs). The variables were collected from the database including the graft to recipient weight ratio (GWRW) and the incidence of HAT and graft primary nonfunction (PNF).

RESULTS

The AD group had 1152 patients, and the PD group had 50 patients. PNF occurred in 68 (5.66%) patients, and the distribution between the 2 groups were similar: 65 (5.64%) in the AD group, and 3 (6%) in the PD group (P = .915). HAT was diagnosed in 30 (2.6%) patients in the AD group and in 6 (12%) patients in the PD group. HAT was significantly higher in the PD group (P = .001). In the PD group, the GWRWs among patients diagnosed with HAT were similar (P = .152).

CONCLUSION

HAT is higher in PDs, although it is a viable alternative with satisfactory results. Serial Doppler in the first week and early introduction of platelet antiaggregants and/or anticoagulants may be beneficial, albeit it is not clear if it could reduce the incidence of HAT.

Posttransplant Lymphoproliferative Disorder in Children: A 360-degree Perspective

An earlier incorrect version of this article appeared online. This article was corrected on December 17, 2019.

Pediatric heart transplantation in the current era

PURPOSE OF REVIEW

To provide an international perspective and current review of pediatric heart transplantation (PHTx).

RECENT FINDINGS

Waitlist survival and long-term outcomes in PHTx continue to improve. Strategies to maximize donor pool utilization include ABO incompatible listing for infants and expanded donor-to-recipient weight ranges. However, there is a high degree of practice variation internationally, from listing strategies and donor acceptance practices to chronic immunosuppression regimens, long-term graft surveillance, and consideration for retransplantation.

SUMMARY

Common indications for PHTx include end-stage congenital heart disease and cardiomyopathy. Current median graft survival among PHTx recipients ranges from 13 to 22 years. Common morbidities include infection, rejection, renal dysfunction, coronary allograft vasculopathy, and posttransplant lymphoproliferative disease. International registry data, collaborative initiatives to standardize management, and multicenter studies continue to improve knowledge and advancement of the field.

Utility of neonatal donors in pediatric liver transplantation: A single-center experience

BACKGROUND

The lack of age- and size-matched organs result in higher waiting list mortality in pediatric recipients than adults. Organs from deceased newborns and infants are a valuable source to increase donor pool in pediatric liver transplantation. However, the feasibility and safety of using neonatal donors have not been well evaluated.

METHODS

From 2014 to 2016, 48 deceased donor pediatric liver transplantations with donor age younger than 1 year old in our center were enrolled in this study. The recipients were divided into three groups based on the donor age (<1 month, 1 month ≤ to <3 months, and 3 months ≤ to <1 year). Recipient's characteristics, perioperative data, and postoperative complications were compared.

RESULTS

Two-year patient survival rates were 87.5%, 94.4%, and 95.5%, and 2-year graft survival rates were 75%, 94.4%, and 95.5%, respectively, without significant difference. The liver grafts from donors younger than 3 months were more advantageous in terms of acute rejection and virus infection, while the young grafts were related to slight higher incidence of hepatic artery thrombosis and SFSS. Those complications could be effectively prevented or treated by our perioperative care strategies. In addition, eight recipients who received neonatal livers achieved comparable outcomes with recipients with older livers.

CONCLUSION

Our data revealed that the application of liver grafts from donors younger than 1 year old could achieve excellent outcome. In particular, neonatal donors could be safely used in well-selected patients.

Long-stay pediatric patients in Japanese intensive care units: their significant presence and a newly developed, simple predictive score

Background

The length of stay (LOS) in intensive care units (ICUs) has been used as a good indicator not only for resource consumption but also for health outcomes of patients. However, data regarding pediatric LOS in Japanese ICUs are limited. The primary aim of this study was to characterize the Japanese pediatric ICU patients based on their LOS. Second, we aimed to develop a simple scoring system to predict long-stay pediatric ICU patients on admission.

Methods

We performed a retrospective cohort study using consecutive pediatric data (aged < 16 years) registered in the Japanese Registry of Pediatric Acute Care (JaRPAC) from October 2013 to September 2016, which consisted of descriptive and diagnostic information. The factors for long-stay patients (LSPs; LOS > 14 days) were identified using multiple regression analysis, and subsequently, a simple predictive scoring system was developed based on the results. The validity of the score was prospectively tested using data from the JaRPAC registration from October 2016 to September 2017.

Results

Overall, 4107 patients were included. Although LSPs were few (8.0% [n = 330]), they consumed 38.0% of ICU bed days (9750 for LSPs versus 25,659 overall). Mortality was seven times higher in LSPs than in short-stay patients (9.1% versus 1.3%). An 11-variable simple predictive scoring system was constructed, including Pediatric Index of Mortality 2 ≥ 1 (2 points), liver dysfunction (non-post operation) (2 points), post-cardiopulmonary resuscitation (1 point), circulatory disorder (1 point), post-operative management of liver transplantation (1 point), encephalitis/encephalopathy (1 point), myocarditis/cardiomyopathy (1 point), congenital heart disease (non-post operation) (1 point), lung tissue disease (1 point), Pediatric Cerebral Performance Category scores ≥ 2 (1 point), and age < 2 years (1 point). A score of ≥ 3 points yielded an area under the receiver operating characteristic curve (AUC) of 0.79, sensitivity of 87.0%, and specificity of 59.4% in the original dataset. Reproducibility was confirmed with the internal validation dataset (AUC 0.80, sensitivity 92.6%, and specificity 60.2%).

Conclusions

Pediatric LSPs possess a significant presence in Japanese ICUs with high rates of bed utilization and mortality. The newly developed predictive scoring system may identify pediatric LSPs on admission.

Electronic supplementary material

The online version of this article (10.1186/s40560-019-0392-2) contains supplementary material, which is available to authorized users.

Postoperative Risk Factors and Outcome of Patients With Liver Transplantation Who Were Admitted to Pediatric Intensive Care Unit: A 10-Year Single-Center Review in China

INTRODUCTION

The aim of this study was to present our 10-year experience of pediatric intensive care unit (PICU) management with pediatric liver recipients and to understand the importance of close interdisciplinary cooperation in 2 hospitals.

METHODS

A retrospective chart review study was performed according to our hospital's medical records and the pediatric liver transplant database of Renji hospital.

RESULTS

A total of 767 patients received liver transplantation (LT) performed in Renji hospital between October 2006 and December 2016, of which 97 of them were admitted to PICU in our center for various complications developed after transplantation. 8.8% (16/208) and 14.4% (81/559) of patients were transferred to PICU in stages I and II, respectively, and was comparable in the 2 stages (P = .017). The majority of patients was late postoperative children (median 185 post-LT days) in stage I. More patients were transferred to PICU directly in stage II. PICU admitted more younger (median 8.2 months) and early postoperative patients in stage II. The median length of PICU stay was 11.0 (6.0-20.5) days. The median length of mechanical ventilation was 5.0 (0.0-12.0) days. The most frequent complications were pulmonary complications (52 [53.6%] patients), surgical complications (22 [22.7%] patients), sepsis (7 [7.2%]), and other miscellaneous complications (16 [16.5%] patients). The overall 28-day PICU mortality was 25.8% (n = 25) and 64.0% (n = 16) of the deaths happened in the early postoperative period. There was significant difference concerning mortality in children with surgical complications and medical problems (54.5% [12/22] vs 17.3% [13/75], P = .001). Multivariate analysis by regression showed that the pediatric risk of mortality III score was the only independent prognostic factor (P = .031).

CONCLUSIONS

Multiple complications occur in children with LT. Although challenging, interdisciplinary cooperation between different hospitals is an effective mean to enable children to maximize the benefit gained from LT in China.

Aggressive prevention and preemptive management of vascular complications after pediatric liver transplantation: A major impact on graft survival and long-term outcome

Vascular complications are a major cause of patient and graft loss after LTs. The aim of this study was to evaluate the effect of a multimodal perioperative strategy aimed at reducing the incidence of vascular complications. A total of 126 first isolated LTs-performed between November 2008 and December 2015-were retrospectively analyzed. A minimum follow-up period of 24 months was analyzable for 124/126 patients (98.4%). The aggressive preemptive strategy consisted of identifying and immediately managing any problem and any abnormality in the vascular flow, in any of the hepatic vessels, and at any time after the liver graft revascularization. As a result, with a median follow-up of 57 months (3-112 months), not a single graft has been lost from vascular or biliary problems. The actuarial 8-year graft survival is 96.5%. These results have shown that a combination of technical attention, medical prevention, an early diagnosis, and rapid interventions reduced the negative impact of vascular problems on the outcome of both grafts and patients.

Outcomes of Pediatric Liver Transplantation: Deceased Donor Liver Transplantation vs Living Donor Liver Transplantation

BACKGROUND

The use of pediatric donor liver for pediatric liver transplantation (LT) remains controversial and few studies have focused on pediatric deceased donors. To address this issue, we decided to perform a retrospective research, trying to compare the clinical effects between deceased donor LTs (DDLTs) and living donor LTs (LDLTs).

METHODS

A retrospective review of pediatric LTs using grafts from deceased donors and living donors from June 2013 to August 2016 was performed. The children were divided into a DDLT group and a LDLT group based on their donor styles. The incidence of early vascular complications (VC), biliary complications, and graft and patient survival rates were observed between the 2 groups.

RESULTS

There were 217 cases of pediatric LTs performed in our hospital from June 2013 to August 2016 (83 DDLTs and 134 LDLTs). The 1-year cumulative survival rates of grafts and recipients were 89.16% and 91.57% in DDLTs, and 95.47% and 95.52% in LDLTs, respectively (P > .05). The incidence of early VC was lower in LDLTs than that in DDLTs (3.7% vs 19.3%, P < .001). The incidence of HAT in children aged less than 1 year was significantly higher in the DDLT group (P < .001) and can be up to 31.82%. The incidence of biliary complications was similar in the 2 groups (8.4% vs 13.5%, P = .285).

CONCLUSIONS

Pediatric DDLTs have similar graft and patient survival rates with LDLT. The incidence of early VC was higher in DDLTs, and children aged less than 1 year are at a higher risk of developing HAT.