Pediatric living donor liver transplantation decade progress in Shanghai: Characteristics and risks factors of mortality

Nomogram for predicting myocardial injury in pediatric patients undergoing living donor liver transplantation for biliary atresia

BACKGROUND

Myocardial injury is common during liver transplantation and is associated with poor outcomes. The development of a reliable prediction system for this type of injury is crucial for reducing the incidence of cardiac complications in children receiving living donor liver transplantation (LDLT). However, establishing a practical myocardial injury prediction system for children with biliary atresia remains a considerable challenge.

AIM

To create and validate a nomogram model for predicting myocardial injury in children with biliary atresia who received LDLT.

METHODS

Clinical data from pediatric patients who received LDLT for biliary atresia between November, 2019 and January, 2022 were retrospectively analyzed. The complete dataset was randomly partitioned into a training set and a validation set at a ratio of 7:3. Least absolute shrinkage and selection operator regression was used to preliminarily screen out the predictors of myocardial injury. The prediction model was established via multivariable logistic regression and presented in the form of a nomogram.

RESULTS

This study included 321 patients, 150 (46.7%) of whom had myocardial injury. The participants were randomly allocated into two groups: A training group consisting of 225 patients and a validation group comprising 96 patients. The predictors in this nomogram included the preoperative neutrophil-to-lymphocyte ratio, high sensitivity C-reactive protein level, pediatric end-stage liver disease score and postreperfusion syndrome. The area under the curve for predicting myocardial injury was 0.865 in the training set and 0.856 in the validation set. The calibration curve revealed that the predicted values were very close to the actual values in the two sets. Decision curve analysis revealed that the prediction model offered a favorable net benefit.

CONCLUSION

The nomogram developed in this study effectively predicts myocardial injury in pediatric LDLT patients, showing good accuracy and potential for clinical application.

Cerebral tissue oxygen saturation and its potential relationship with neurodevelopmental delay in pediatric liver transplant recipients

Objective

To discover the potential association between diminished intraoperative average SctO2 levels and postoperative neurodevelopmental delays among patients after pediatric living-donor liver transplantation.

Study design

Patients undergoing living-donor liver transplantation were recruited for this trial. The neurodevelopment status of patients was assessed using the Ages Stages Questionnaires. The primary outcome was the occurrence of neurodevelopmental delay among patients at different intervals following pediatric liver transplantation. Secondary outcomes included the duration of mechanical ventilation, rates of re-intubation, length of ICU stay, postoperative hospitalization, and intraoperative comparisons of mean arterial pressure (MAP), arterial partial pressure of oxygen (PaO2), arterial partial pressure of carbon dioxide (PaCO2), and hemoglobin (Hb) concentration.

Results

A total of 119 patients were included in the statistical analysis and assigned to high saturation group (HS) and low saturation group (LS) according to the average intraoperative cerebral tissue oxygen saturation values. Following adjustment for PELD scores, significant differences between the two groups were observed for the incidence of neurodevelopmental delay in communication at 1 and 3 months follow-up (P = 0.019 and P = 0.020, respectively), fine motor at six months follow-up (P = 0.014), and problem-solving abilities at one year follow-up (P = 0.047). Moverover, the length of ICU stay (P = 0.009) and postoperative hospitalization (P = 0.029) in LS group were also significant prolonged.

Conclusion

This prospective observational study revealed that the patients with low average SctO2 values were more predisposed to experiencing postoperative neurodevelopment delays, suggesting a potential association between decreased average SctO2 and neurodevelopmental delay.

Reducing Hospital Length of Stay and Hepatic Artery Thrombosis Rates for Children Receiving a Liver Transplant: A Single-Center Experience From 2000 to 2021

BACKGROUND

Pediatric liver transplantation is a very resource-intensive therapy. This study aimed to identify the changes made between two epochs of management and analyze their influence on length of stay (LOS).

METHODS

Data from a single center were obtained from the liver transplant and Pediatric Intensive Care Unit (PICU) databases for 336 transplants (282 children) performed between 2000 and 2021. Transplants were analyzed in two epochs, before and after July 2012, representing a change in postoperative anticoagulation management. Differences in graft recipient demographics and perioperative management factors were compared between epochs. Multivariate regression was performed to identify the complications that correlated most strongly with hospital LOS.

RESULTS

There was a difference in hospital LOS between Epoch 1 (Median = 31.7 days) and Epoch 2 (Median = 26.3 days) (p < 0.001), but not in PICU LOS (E1 Median = 7.3 days, E2 Median = 7.4 days; p = 0.792). Epoch 2 saw increased use of split grafts (60.6% of total), decreased pediatric end-stage liver disease (PELD) score at transplant (Average = 16.7; p < 0.001), decreased invasive ventilation time (Average = 4.48 days; p < 0.001), and decreased hepatic artery thrombosis (HAT) rates (E1 = 14.4%, E2 = 4.3%; p < 0.001) without an associated increase in bleeding rates.

CONCLUSIONS

Hospital LOS has reduced in Epoch 2 due to refinements in intraoperative and postoperative management. There is increased emphasis on early extubation and increased use of noninvasive ventilatory techniques in Epoch 2. Split grafts have effectively expanded our graft donor pool and reduced transplant waitlist times.

Nutrition and Epstein-Barr viremia in children underwent liver transplantation: A retrospective, cross-sectional study

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.

A 7-month-old girl with a suspected air embolism complication during a living-donor liver transplantation procedure: a case report

Background

Pediatric liver transplantation is an important modality for treating biliary atresia. The overall survival rate of pediatric liver transplantation has significantly improved. The incidence of perioperative cardiac events was evaluated, and risk factors were also investigated in adult patients undergoing liver transplantation in previous studies. To the best of our knowledge, this is the first case of a cardiac event during a pediatric living-donor liver transplantation.

Case summary

Our report describes the management of cardiac events during a liver transplantation in a 7-month-old girl. The ST segment began to increase to 3.0 mm immediately after reperfusion, with peak ST-segment elevation reaching 13.2 mm after 45 min. The procedure ended uneventfully after continuous symptomatic and etiological treatment. It was considered to be the occurrence of an acute air embolism complication during the procedure based on the electrocardiograph and biomarkers. An echocardiogram during follow-up showed a patent foramen ovale with a left-to-right shunt tract width of 2.7 mm.

Discussion

Pediatric liver transplantation has become a state-of-the-art treatment for children with end-stage liver disease and can improve the quality of life to some extent. These children may be complicated with congenital heart disease, which increases the risk of surgery. Application of echocardiogram, close monitoring, and appropriate management may reduce the incidence of perioperative cardiac events.

Disseminated Intravascular Coagulation as a Risk Factor for Clinical Outcome After Liver Transplantation in Pediatric Patients With Kasai Portoenterostomy Failure

BACKGROUND

Disseminated intravascular coagulation (DIC) is a serious complication in critically ill pediatric patients. This study aimed to evaluate the association between pretransplant DIC and perioperative clinical outcomes of liver transplantation (LT) in pediatric patients with Kasai portoenterostomy (KPE) failure.

METHODS

We enrolled pediatric patients who received LT after KPE failure between January 2005 and April 2021. We retrospectively reviewed the electronic medical records of included patients and evaluated the presence of DIC using the International Society on Thrombosis and Hemostasis (ISTH) criteria and association with perioperative clinical outcome.

RESULTS

The study included 106 patients. Their median age and body weight at the time of pediatric intensive care unit (PICU) admission were 28.7 months and 9.25 kg, respectively. Of these patients, 23 had undergone pretransplant DIC (22%). Patients with pretransplant DIC required significantly more blood transfusions during operation. They had significantly higher serum lactate levels, pediatric end-stage liver disease scores, pediatric risk for mortality III (PRISM III) scores, longer durations of mechanical ventilator support, and longer PICU stays (all P < .05).

CONCLUSIONS

The presence of pretransplant DIC in pediatric patients requiring LT after KPE failure was associated with poor clinical outcomes, which required more intensive and meticulous supportive management in the perioperative period of LT. DIC would be a promising prognostic factor in these patients.

Development and validation of a multivariable prediction model in pediatric liver transplant patients for predicting intensive care unit length of stay

BACKGROUND

Liver transplantation is the life-saving treatment for many end-stage pediatric liver diseases. The perioperative course, including surgical and anesthetic factors, have an important influence on the trajectory of this high-risk population. Given the complexity and variability of the immediate postoperative course, there would be utility in identifying risk factors that allow prediction of adverse outcomes and intensive care unit trajectories.

AIMS

The aim of this study was to develop and validate a risk prediction model of prolonged intensive care unit length of stay in the pediatric liver transplant population.

METHODS

This is a retrospective analysis of consecutive pediatric isolated liver transplant recipients at a single institution between April 1, 2013 and April 30, 2020. All patients under the age of 18 years receiving a liver transplant were included in the study (n = 186). The primary outcome was intensive care unit length of stay greater than 7 days.

RESULTS

Recipient and donor characteristics were used to develop a multivariable logistic regression model. A total of 186 patients were included in the study. Using multivariable logistic regression, we found that age < 12 months (odds ratio 4.02, 95% confidence interval 1.20-13.51, p = .024), metabolic or cholestatic disease (odds ratio 2.66, 95% confidence interval 1.01-7.07, p = .049), 30-day pretransplant hospital admission (odds ratio 8.59, 95% confidence interval 2.27-32.54, p = .002), intraoperative red blood cells transfusion >40 mL/kg (odds ratio 3.32, 95% confidence interval 1.12-9.81, p = .030), posttransplant return to the operating room (odds ratio 11.45, 95% confidence interval 3.04-43.16, p = .004), and major postoperative respiratory event (odds ratio 32.14, 95% confidence interval 3.00-343.90, p < .001) were associated with prolonged intensive care unit length of stay. The model demonstrates a good discriminative ability with an area under the receiver operative curve of 0.888 (95% confidence interval, 0.824-0.951).

CONCLUSIONS

We develop and validate a model to predict prolonged intensive care unit length of stay in pediatric liver transplant patients using risk factors from all phases of the perioperative period.

The Role of Pretransplant Infections in Pediatric Receiving LDLT in Indonesia: A 7-y Retrospective Study

Liver transplantation is the definitive treatment for pediatric end-stage liver disease. Infections posttransplantation might significantly affect the outcome of the surgery. This study aimed to identify the role of pretransplant infection among children who underwent living donor liver transplantation (LDLT) in Indonesia.

Methods

This is an observational, retrospective cohort study. A total of 56 children were recruited between April 2015 and May 2022. Patients were categorized into 2 according to the presence of pretransplantation infections requiring hospitalization before the surgery. Diagnosis of posttransplantation infection was observed for up to 1 y based on the clinical features and laboratory parameters.

Results

The most common indication for LDLT was biliary atresia (82.1%). Fifteen of 56 patients (26.7%) had a pretransplant infection, whereas 73.2% of patients were diagnosed with a posttransplant infection. There was no significant association between pretransplant and posttransplant infection in all 3-time points (≤1 mo, 2-6 mo, and 6-12 mo). The most common organ involvement posttransplantation was respiratory infections (50%). The pretransplant infection did not significantly affect posttransplant bacteremia, length of stay, duration of mechanical ventilation, initiation of enteral feeding, hospitalization cost, and graft rejection.

Conclusions

Our data showed that pretransplant infections did not significantly affect clinical outcomes in post-LDLT procedures. A prompt and sufficient diagnosis and treatment before and after the LDLT procedure is the best way to obtain an optimal outcome.

Association of different central venous pressure levels with outcome of living-donor liver transplantation in children under 12 years

BACKGROUND

Pediatric liver transplantation is an important modality for treating biliary atresia. The overall survival (OS) rate of pediatric liver transplantation has significantly improved compared with that of 20 years ago, but it is still unsatisfactory. The anesthesia strategy of maintaining low central venous pressure (CVP) has shown a positive effect on prognosis in adult liver transplantation. However, this relationship remains unclear in pediatric liver transplantation. Thus, this study was conducted to review the data of pediatric living-donor liver transplantation to analyze the associations of different CVP levels with the prognosis of recipients.

METHODS

This was a retrospective study and the patients were divided into two groups according to CVP levels after abdominal closure: low CVP (LCVP) (≤ 10 cmH2O, n = 470) and high CVP (HCVP) (> 10 cmH2O, n = 242). The primary outcome measured in the study was the overall survival rate. The secondary outcomes included the duration of mechanical ventilation in the intensive care unit (ICU), length of stay in the ICU, and postoperative stay in the hospital. Patient demographic and perioperative data were collected and compared between the two groups. Kaplan-Meier curves were constructed to determine the associations of different CVP levels with the survival rate.

RESULTS

In the study, 712 patients, including 470 in the LCVP group and 242 in the HCVP group, were enrolled. After propensity score matching, 212 pairs remained in the group. The LCVP group showed a higher overall survival rate than the HCVP group in the Kaplan-Meier curves and multivariate Cox regression analyses (P = 0.018), and the HCVP group had a hazard ratio of 2.445 (95% confidence interval, 1.163-5.140).

CONCLUSION

This study confirmed that a low-CVP level at the end of surgery is associated with improved overall survival and a shorter length of hospital stay.

Performance assessment of medical service for organ transplant department based on diagnosis-related groups: A programme incorporating ischemia-free liver transplantation in China

Background

In July 2017, the first affiliated hospital of Sun Yat-sen university carried out the world's first case of ischemia-free liver transplantation (IFLT). This study aimed to evaluate the performance of medical services pre- and post-IFLT implementation in the organ transplant department of this hospital based on diagnosis-related groups, so as to provide a data basis for the clinical practice of the organ transplant specialty.

Methods

The first pages of medical records of inpatients in the organ transplant department from 2016 to 2019 were collected. The China version Diagnosis-related groups (DRGs) were used as a risk adjustment tool to compare the income structure, service availability, service efficiency and service safety of the organ transplant department between the pre- and post-IFLT implementation periods.

Results

Income structure of the organ transplant department was more optimized in the post-IFLT period compared with that in the pre-IFLT period. Medical service performance parameters of the organ transplant department in the post-IFLT period were better than those in the pre-IFLT period. Specifically, case mix index values were 2.65 and 2.89 in the pre- and post-IFLT periods, respectively (p = 0.173). Proportions of organ transplantation cases were 14.16 and 18.27%, respectively (p < 0.001). Compared with that in the pre-IFLT period, the average postoperative hospital stay of liver transplants decreased by 11.40% (30.17 vs. 26.73 days, p = 0.006), and the average postoperative hospital stay of renal transplants decreased by 7.61% (25.23 vs.23.31 days, p = 0.092). Cost efficiency index decreased significantly compared with that in the pre-IFLT period (p < 0.001), while time efficiency index fluctuated around 0.83 in the pre- and post-IFLT periods (p = 0.725). Moreover, the average postoperative hospital stay of IFLT cases was significantly shorter than that of conventional liver transplant cases (p = 0.001).

Conclusion

The application of IFLT technology could contribute to improving the medical service performance of the organ transplant department. Meanwhile, the DRGs tool may help transplant departments to coordinate the future delivery planning of medical service.

Meta-analysis of donor-recipient gender profile in paediatric living donor liver transplantation

OBJECTIVE

Paediatric living donor liver transplantation (LDLT) has gained popularity due to limited deceased donor organ supply. Some studies report inequalities in donor and recipient gender profiles, but data are sparse. We evaluated LDLT donor-recipient gender profiles, comparing country income categories and gender disparity level.

DESIGN

We performed a systematic review, searching PubMed, Embase and Cochrane databases for publications dated January 2006-September 2021. We included full-text English articles reporting gender in ≥40 universally sampled donor-recipient pairs. Search terms were permutations of 'liver transplant', 'living donor' and 'paediatric'. Countries were grouped as high/middle/low-income economies based on World Bank criteria and into groups based on deviation from gender parity in Gender Development Index (GDI) values (group 1 indicating closest to gender parity, group 5 indicating furthest). Proportions analysis with corresponding 95% CI were used for analysis of dichotomous variables, with significance when 95% CI did not cross 0.5. Data are reported as female proportion (%) and 95% CI.

RESULTS

Of 12 525 studies identified, 14 retrospective studies (12 countries; 6152 recipients and 6138 donors) fulfilled study inclusion criteria. Male recipient preponderance was seen in lower middle-income countries (all were also GDI group 5) (39.3 (95% CI 34.7 to 44.0)) and female recipient preponderance in GDI groups 1 and 3. Female donor preponderance was seen overall (57.4% (95% CI 55.1 to 59.6)), in middle income countries and in three of four GDI groups represented.

CONCLUSION

There are significant imbalances in recipient-donor gender profiles in paediatric LDLT that are not well explained. The reasons for overall female donor preponderance across income tiers must be scrutinised.

Pediatric living donor liver transplantation (LDLT): Short- and long-term outcomes during sixteen years period at a single centre- A retrospective cohort study

Background and objectives

Pediatric living donor liver transplantation (LDLT) is an effective tool for managing pediatric patients with end-stage liver disease (ESLD) with good long-term graft and patient survival, especially after improvement in peri-operative care, surgical tools and techniques; however, the morbidity and mortality after such a procedure are still a challenging matter. The study aimed to analyze short-and long-term outcomes after pediatric LDLT in a single centre.

Methods

We retrospectively analyzed 67 pediatric patients who underwent LDLT in the period from April 2003 to July 2018. The overall male/female ratio was 40/27.

Results

Forty-one (61.2%) of patients had ≥1 early and/or late morbidities; the early (less than 3months) and late (≥3months) ones affected 36(53.7%) and 12(17.9%) of them respectively. The 16-year graft and patient survivals were 35(52.2%) while early and late mortalities were 23(34.3%) and 9(13.4%) respectively. Sepsis and chronic rejection were the most frequent causes of early and late mortalities respectively. Moreover, more packed RBCs transfusion units, bacterial infections, and pulmonary complications were independent predictors of poor patient survival.

Conclusions

More packed RBCs transfusion units intra-operatively, and post-liver transplant (LT) bacterial infection, sepsis, chronic rejection, as well as pulmonary complications had a negative insult on our patients' outcomes, so proper management of them is mandatory for improving outcomes after pediatric LDLT.

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More packed RBCs transfusion units intra-operatively had a negative insult on outcomes after paediatric LDLT.

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Bacterial infection and pulmonary complications led to poor outcomes after paediatric LDLT.

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Sepsis and chronic rejection led to post paediatric LDLT poor patient outcomes.

Recent Improvement in Survival Outcomes and Reappraisal of Prognostic Factors in Pediatric Living Donor Liver Transplantation

Living donor liver transplantation (LDLT) is a significant advancement for the treatment of children with end-stage liver disease given the shortage of deceased donors. The ultimate goal of pediatric LDLT is to achieve complete donor safety and zero recipient mortality. We conducted a retrospective, single-center assessment of the outcomes as well as the clinical factors that may influence graft and patient survival after primary LDLTs performed between 1994 and 2020. A Cox proportional hazards model was used for multivariate analyses. The trends for independent prognostic factors were analyzed according to the following treatment eras: 1, 1994 to 2002; 2, 2003 to 2011; and 3, 2012 to 2020. Primary LDLTs were performed on 287 children during the study period. Biliary atresia (BA; 52%), acute liver failure (ALF; 26%), and monogenic liver disease (11%) were the leading indications. There were 45 graft losses (16%) and 27 patient deaths (7%) in this population during the study period. During era 1 (n = 81), the cumulative survival rates at 1 and 5 years after LDLT were 90.1% and 81.5% for patients and 86.4% and 77.8% for grafts, respectively. During era 2 (n = 113), the corresponding rates were 92.9% and 92% for patients and 89.4% and 86.7% for grafts, respectively. During era 3 (n = 93), the corresponding rates were 100% and 98.6% for patients and 98.9% and 95.4% for grafts, respectively. In the multivariate analyses, primary diagnosis ALF, bloodstream infection, posttransplant lymphoproliferative disease, and chronic rejection were found to be negative prognostic indicators for patient survival. Based on generalized care guidelines and center-oriented experiences, comprehensive advances in appropriate donor selection, refinement of surgical techniques, and meticulous medical management may eventually realize a zero-mortality rate in pediatric LDLT.

A Bibliometric Analysis of the Landscape of Pediatric Liver Transplantation

Background

Nowadays, pediatric liver transplantation (PLT) has become an effective strategy for treating various acute or chronic end-stage liver diseases and inherited metabolic diseases. Many experts have already concluded the current challenges and future directions of PLT. However, no detailed analysis of the publication landscape has substantiated these proposed opinions.

Methods

This study presents a bibliometric review of the articles related to PLT between 1997 and 2020. A total of 3,084 publications were analyzed mainly by CiteSpace and VOSviewer.

Results

The field of PLT has evolved gradually in the past two decades. Articles increased at an average rate of 97 articles every 4 years. University of Pittsburgh (PITT) is the most prolific institution. The three most productive regions are North America, Europe, and East Asia. Currently, interdisciplinary studies on PLT are scarce. The main goal of PLT has shifted from survival rates to long-term outcome. The quality of life, living donor liver transplantation (LDLT), immunological biomarkers, perioperative hemodynamic management, expanding the indications of PLT, etc. are parts of the emerging research fronts. In the past two decades, articles that contain potentials that may lead to transformative discoveries are scarce, and obvious deficits can be seen in the field of new therapies.

Conclusions

Long-term outcome and good quality of life represent the principal direction of work concerning PLT. Deficits in new therapies align with the shortage of intellectual milestones, which indicate possible subsequent intellectual milestones may occur as innovations in therapies such as new immunosuppression therapies or liver cell transplantation.

Assessment of pathogens and risk factors associated with bloodstream infection in the year after pediatric liver transplantation

BACKGROUND

Bloodstream infection (BSI) is one of the most significantly adverse events that can occur after liver transplantation (LT) in children.

AIM

To analyze the profile of BSI according to the postoperative periods and assess the risk factors after pediatric LT.

METHODS

Clinical data, collected from medical charts of children (n = 378) who underwent primary LT, were retrospectively reviewed. The primary outcome considered was BSI in the first year after LT. Univariate and multivariate analyses were performed to identify risk factors for BSI and respective odds ratios (ORs).

RESULTS

Of the examined patients, 106 (28%) experienced 162 episodes of pathogen-confirmed BSI during the first year after LT. There were 1.53 ± 0.95 episodes per children (mean ± SD) among BSI-complicated patients with a median onset of 0.4 mo post-LT. The most common pathogenic organisms identified were Coagulase-negative staphylococci, followed by Enterococcus spp. and Streptococcus spp. About half (53%) of the BSIs were of unknown origin. Multivariate analysis demonstrated that young age (≤ 1.3 year; OR = 2.1, P = 0.011), growth failure (OR = 2.1, P = 0.045), liver support system (OR = 4.2, P = 0.008), and hospital stay of > 44 d (OR = 2.3, P = 0.002) were independently associated with BSI in the year after LT.

CONCLUSION

BSI was frequently observed in patients after pediatric LT, affecting survival outcomes. The profile of BSI may inform clinical treatment and management in high-risk children after LT.

Over 30 Years of Pediatric Liver Transplantation at the Charité-Universitätsmedizin Berlin

Background: Pediatric liver transplantation (LT) is the treatment of choice for children with end-stage liver disease and in certain cases of hepatic malignancies. Due to low case numbers, a technically demanding procedure, the need for highly specialized perioperative intensive care, and immunological, as well as infectious, challenges, the highest level of interdisciplinary cooperation is required. The aim of our study was to analyze short- and long-term outcomes of pediatric LT in our center. Methods: We conducted a retrospective single-center analysis of all liver transplantations in pediatric patients (≤16 years) performed at the Department of Surgery, Charité – Universitätsmedizin Berlin between 1991 and 2021. Three historic cohorts (1991–2004, 2005–2014 and 2015–2021) were defined. Graft- and patient survival, as well as perioperative parameters were analyzed. The study was approved by the institutional ethics board. Results: Over the course of the 30-year study period, 212 pediatric LTs were performed at our center. The median patient age was 2 years (IQR 11 years). Gender was equally distributed (52% female patients). The main indications for liver transplantation were biliary atresia (34%), acute hepatic necrosis (27%) and metabolic diseases (13%). The rate of living donor LT was 25%. The median cold ischemia time for donation after brain death (DBD) LT was 9 h and 33 min (IQR 3 h and 46 min). The overall donor age was 15 years for DBD donors and 32 years for living donors. Overall, respective 1, 5, 10 and 30-year patient and graft survivals were 86%, 82%, 78% and 65%, and 78%, 74%, 69% and 55%. One-year patient survival was 85%, 84% and 93% in the first, second and third cohort, respectively (p = 0.14). The overall re-transplantation rate was 12% (n = 26), with 5 patients (2%) requiring re-transplantation within the first 30 days. Conclusion: The excellent long-term survival over 30 years showcases the effectiveness of liver transplantation in pediatric patients. Despite a decrease in DBD organ donation, patient survival improved, attributed, besides refinements in surgical technique, mainly to improved interdisciplinary collaboration and management of perioperative complications.

Lactated Ringer's solution versus normal saline in pediatric living-donor liver transplantation: A matched retrospective cohort study

BACKGROUND

In pediatric living-donor liver transplantation, lactated Ringer's solution and normal saline are commonly used for intraoperative fluid management, but the comparative clinical outcomes remain uncertain.

AIMS

To compare the effect between lactated Ringer's solution and normal saline for intraoperative volume replacement on clinical outcomes among pediatric living-donor liver transplantation patients.

METHODS

This single-center, retrospective trial study enrolled children who received either lactated Ringer's solution or normal saline during living-donor liver transplantation between January 2010 and August 2016. The groups with comparable clinical characteristics were balanced by propensity score matching. The primary outcome was 90-day all-cause mortality, and the secondary outcomes included early allograft dysfunction, primary nonfunction, acute renal injury, and hospital-free days (days alive postdischarge within 30 days of liver transplantation).

RESULTS

We included 333 pediatric patients who met the entry criteria for analysis. Propensity score matching identified 61 patients in each group. After matching, the lactated Ringer's solution group had a higher 90-day mortality rate than the normal saline group (11.5% vs. 0.0%). Early allograft dysfunction and primary nonfunction incidences were also more frequent in the lactated Ringer's solution group (19.7% and 11.5%, respectively) than in the normal saline group (3.3% and 0.0%, respectively). In the lactated Ringer's solution group, four (6.6%) recipients developed acute renal injury within 7 days postoperatively compared with three (4.9%) recipients in the normal saline group. Hospital-free days did not differ between groups (9 days [1-13] vs. 9 days [0-12]).

CONCLUSIONS

For intraoperative fluid management in pediatric living-donor liver transplantation patients, lactated Ringer's solution administration was associated with a higher 90-day mortality rate than normal saline. This finding has important implications for selecting crystalloid in pediatric living-donor liver transplantation. Further randomized clinical trials in larger cohort are necessary to confirm this finding.

Comment on pediatric living donor liver transplantation decade progress in Shanghai: Characteristics and risks factors of mortality

Since the first successful liver transplantation was performed five decades ago, pediatric liver transplantation has become the gold standard treatment choice for pediatric liver disease, including metabolic diseases, liver tumors, and some acute liver failure. With improvements in immunosuppression, surgical techniques, and postoperative medical care, long-term outcomes of patients after liver transplantation have markedly improved, especially in pediatric patients.