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Kehler T, Grothues D, Evert K, Wahlenmayer J, Knoppke B, Melter M. Elastography-The New Standard in the Assessment of Fibrosis After Pediatric Liver Transplantation? Pediatr Transplant 2024; 28:e14832. [PMID: 39075333 DOI: 10.1111/petr.14832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 06/21/2024] [Accepted: 07/12/2024] [Indexed: 07/31/2024]
Abstract
BACKGROUND The development of graft fibrosis after pediatric liver transplantation (PLT) remains a major concern as it can lead to graft failure and ultimately graft loss. Elastography is a non-invasive method to assess liver fibrosis, but its role in the posttransplant setting is unclear. The aim of our study was to evaluate shear wave elastography (SWE) in the assessment of liver fibrosis after PLT, including split-liver recipients. METHODS We retrospectively analyzed data from PLT recipients who underwent surveillance liver biopsy and concurrent 2D-SWE during the study period from April 2018 to July 2021. Spearman's correlation was used to compare histologic fibrosis stages with liver stiffness measurements (LSM) by 2D-SWE. AUROC analysis was performed to evaluate the performance. One sample t-test was used to compare results with reference values of healthy children. RESULTS 62 cases were included. 29% showed histologic fibrosis. LSM by 2D-SWE were feasible in all children regardless of age or graft type. There was a significant correlation between LSM and fibrosis stage for all three scoring systems used (Ishak, p = 0.003; METAVIR, p = 0.005; LAF Score, p = 0.003). Patients with a history of biliary complications had increased liver stiffness (p = 0.015). The AUROC of 2D-SWE for predicting significant liver graft fibrosis was 0.81. Liver stiffness after PLT without graft fibrosis was higher than in healthy subjects, but comparable to that in children with chronic liver disease without fibrosis. CONCLUSION 2D-SWE can reliably detect children with significant liver graft fibrosis, even in split-liver recipients. This study demonstrates the value of a non-invasive tool for fibrosis staging after PLT. 2D-SWE has the potential to improve long-term outcomes after PLT and to reduce the number of surveillance liver biopsies. But elastography is not a substitute for liver biopsy.
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Affiliation(s)
- Thomas Kehler
- University Children's Hospital Regensburg (KUNO), University Hospital Regensburg, Regensburg, Germany
| | - Dirk Grothues
- University Children's Hospital Regensburg (KUNO), University Hospital Regensburg, Regensburg, Germany
| | - Katja Evert
- Institute of Pathology, University Hospital Regensburg, Regensburg, Germany
| | - Janka Wahlenmayer
- University Children's Hospital Regensburg (KUNO), University Hospital Regensburg, Regensburg, Germany
| | - Birgit Knoppke
- University Children's Hospital Regensburg (KUNO), University Hospital Regensburg, Regensburg, Germany
| | - Michael Melter
- University Children's Hospital Regensburg (KUNO), University Hospital Regensburg, Regensburg, Germany
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Bruns N, Hauschild J, Lainka E, Dohna-Schwake C. Surgical Site Infections After Pediatric Liver Transplantation-Impact of a Change in Perioperative Prophylactic Antibiotic Protocol. Pediatr Transplant 2024; 28:e14830. [PMID: 39030994 DOI: 10.1111/petr.14830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 06/21/2024] [Accepted: 07/08/2024] [Indexed: 07/22/2024]
Abstract
BACKGROUND In spite of improved survival rates after pediatric liver transplantation, infections remain major contributors to perioperative morbidity and mortality. This study aimed to understand the impact of type and duration of perioperative antibiotic prophylaxis (PAP) on the occurrence of surgical site infections (SSIs). METHODS In total, 125 patients who underwent liver transplantation between 2014 and 2020 were retrospectively included. Patients were categorized into two periods based on changes in the standard PAP regimen. Risk factors for SSIs were investigated, including the influence of PAP duration, antibiotic substances used, and abdominal patch placement using multivariable regression models. RESULTS SSIs occurred in 23 (19%) of 119 analyzed patients and were not impacted by changes in the PAP regimen. The placement of an abdominal patch was a relevant risk factor for SSIs (odds ratio 3.81; 95% confidence interval [CI] 1.15-12.68). Longer PAP duration reduced the occurrence of SSIs by up to 4.6 percentage points (95% CI 0.0-9.1) per day, with its effect diminishing with longer duration. The choice of antibiotic substances for PAP changed after implementation of the new protocol, with a decline in vancomycin usage from 14% to 3%. CONCLUSION The results of this study emphasize the need for evidence-based PAP regimens tailored to the unique needs of pediatric liver transplant recipients. The occurrence of SSIs remains complex and is influenced by various factors beyond the PAP regimen. Multicentric efforts to develop effective prevention strategies against SSIs in this vulnerable population are warranted.
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Affiliation(s)
- Nora Bruns
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care Medicine, and Pediatric Neurology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- TNBS, Centre for Translational Neuro- and Behavioural Sciences, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Juliane Hauschild
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care Medicine, and Pediatric Neurology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Elke Lainka
- Department of Pediatrics II, Pediatric Gastroenterology, Hepatology and Liver Transplantation, University Children's Hospital, Essen, Germany
| | - Christian Dohna-Schwake
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care Medicine, and Pediatric Neurology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- TNBS, Centre for Translational Neuro- and Behavioural Sciences, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- West German Centre of Infectious Diseases, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
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Abraham RR, Zameer MM, Vinay C, Rao S, D’Cruz A. Transplanting Livers in Young Children - Looking Back at 100 Cases. J Indian Assoc Pediatr Surg 2024; 29:192-198. [PMID: 38912017 PMCID: PMC11192256 DOI: 10.4103/jiaps.jiaps_229_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 11/14/2023] [Accepted: 12/05/2023] [Indexed: 06/25/2024] Open
Abstract
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.
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Affiliation(s)
- Reya Rachel Abraham
- Department of Paediatric Surgery, Narayana Health City, Bengaluru, Karnataka, India
| | - M. M. Zameer
- Department of Paediatric Surgery, Narayana Health City, Bengaluru, Karnataka, India
| | - C. Vinay
- Department of Paediatric Surgery, Narayana Health City, Bengaluru, Karnataka, India
| | - Sanjay Rao
- Department of Paediatric Surgery, Narayana Health City, Bengaluru, Karnataka, India
| | - Ashley D’Cruz
- Department of Paediatric Surgery, Narayana Health City, Bengaluru, Karnataka, India
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Jieyang J, Mei L, Kunying L, Tao W, Ling J, Yang Y, Shuhong Y, Yan L, Jie R. A new method to predict venous complications in pediatric liver transplantation: Evaluation of splenic parameters by ultrasonography. Pediatr Transplant 2024; 28:e14737. [PMID: 38602290 DOI: 10.1111/petr.14737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 12/14/2023] [Accepted: 02/22/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Venous complications after pediatric liver transplantation seriously affect the survival rate of patients and grafts. At present, the diagnostic indicators have not been unified. Venous complications may cause portal hypertension, which may lead to splenomegaly and splenic vein dilatation. Therefore, the changes in spleen may be closely related to the venous complications. The purpose of this study was to explore the relationship between ultrasonic splenic parameters and venous complications and to study whether these splenic parameters can be used for the diagnosis of venous complications. METHODS We retrospectively included pediatric patients who underwent liver transplantation and collected ultrasonic spleen parameters before, and then 1-3 days, 1-3 weeks, 1-3 months, and 4-12 months after liver transplantation. We observed whether there were portal vein or hepatic vein complications within 1 year after liver transplantation. RESULTS Among 109 pediatric patients after liver transplantation included in our study, 11 of them suffered from portal vein complications and nine hepatic vein complications. Spleen transverse diameter, spleen longitudinal diameter, spleen portal vein diameter, spleen index, spleen transverse diameter ratio, spleen longitudinal diameter ratio, and spleen index ratio were independent risk factors of venous complications. The accuracy of spleen transverse diameter (AUROC: 0.73), spleen index (AUROC: 0.70), spleen transverse diameter ratio (AUROC: 0.71), and spleen index ratio (AUROC: 0.72) in predicting venous complications were higher than other ones. CONCLUSIONS Ultrasonic examination is a common follow-up method for pediatric patients after liver transplantation and the application of ultrasonic spleen parameters may be helpful to monitor venous complications.
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Affiliation(s)
- Jin Jieyang
- Department of Ultrasound, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- GuangDong Key Laboratory of Liver Disease Research, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Liao Mei
- Department of Ultrasound, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- GuangDong Key Laboratory of Liver Disease Research, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Liu Kunying
- Department of Ultrasound, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- GuangDong Key Laboratory of Liver Disease Research, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Wu Tao
- Department of Ultrasound, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- GuangDong Key Laboratory of Liver Disease Research, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Jin Ling
- State Key Laboratory of Ophthalmology Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, China
| | - Yang Yang
- GuangDong Key Laboratory of Liver Disease Research, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- Department of Hepatic Surgery and Liver transplantation Center, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- Organ Transplantation Institute, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- Organ Transplantation Research Center of Guangdong Province, Guangzhou, China
- Guangdong Province Engineering Laboratory for Transplantation Medicine, Guangzhou, China
| | - Yi Shuhong
- GuangDong Key Laboratory of Liver Disease Research, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- Department of Hepatic Surgery and Liver transplantation Center, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- Organ Transplantation Institute, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- Organ Transplantation Research Center of Guangdong Province, Guangzhou, China
- Guangdong Province Engineering Laboratory for Transplantation Medicine, Guangzhou, China
| | - Lv Yan
- Department of Ultrasound, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- GuangDong Key Laboratory of Liver Disease Research, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Ren Jie
- Department of Ultrasound, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- GuangDong Key Laboratory of Liver Disease Research, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
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Feldman K, Heble DE, Hendrickson RJ, Fischer RT. Hepatic artery thrombosis and use of anticoagulants and antiplatelet agents in pediatric liver transplantation. Pediatr Transplant 2024; 28:e14516. [PMID: 37550273 DOI: 10.1111/petr.14516] [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: 08/19/2022] [Revised: 01/18/2023] [Accepted: 02/06/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND Hepatic artery thrombosis (HAT) is a reported complication of 5%-10% of pediatric liver transplantations, rates 3-4 times that seen in adults. Early HAT (seen within 14 days after transplant) can lead to severe allograft damage and possible urgent re-transplantation. In this report, we present our analysis of HAT in pediatric liver transplant from a national clinical database and examine the association of HAT with anticoagulant or antiplatelet medication administered in the post-operative period. METHODS Data were obtained from the Pediatric Health Information System database maintained by the Children's Hospital Association. For each liver transplant recipient identified in a 10-year period, diagnosis, demographic, and medication data were collected and analyzed. RESULTS Our findings showed an average rate of HAT of 6.3% across 31 centers. Anticoagulant and antiplatelet medication strategies varied distinctly among and even within centers, likely due to the fact there are no consensus guidelines. Notably, in centers with similar medication usage, HAT rates continue to vary. At the patient level, use of aspirin within the first 72 h of transplantation was associated with a decreased risk of HAT, consistent with other reports in the literature. CONCLUSION We suggest that concerted efforts to standardize anticoagulation approaches in pediatric liver transplant may be of benefit in the prevention of HAT. A prospective multi-institutional study of regimen-possibly including aspirin-following transplantation could have significant value.
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Affiliation(s)
- Keith Feldman
- Health Outcomes and Health Services Research, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Daniel E Heble
- Department of Pharmacy, Children's Mercy Kansas City, University of Missouri-Kansas City School of Pharmacy, Kansas City, Missouri, USA
| | - Richard J Hendrickson
- Department of Surgery, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Ryan T Fischer
- Division of Gastroenterology, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
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Sihaklang B, Getsuwan S, Pattanaprateep O, Butsriphum N, Lertudomphonwanit C, Tanpowpong P, Thirapattaraphan C, Treepongkaruna S. Cost-effectiveness analysis of liver transplantation in biliary atresia according to the severity of end-stage liver disease. BMC Pediatr 2023; 23:439. [PMID: 37660000 PMCID: PMC10474723 DOI: 10.1186/s12887-023-04270-0] [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: 05/30/2023] [Accepted: 08/24/2023] [Indexed: 09/04/2023] Open
Abstract
BACKGROUND Timing for liver transplantation (LT) in biliary atresia (BA) children with end-stage liver disease (ESLD) is associated with all-cause mortality. The cut-off value of pediatric end-stage liver disease (PELD) score for LT consideration varies across institutions. We aimed to determine the cost-effectiveness of LT to prevent death among BA children registered on the waiting list with different severities of ESLD. METHODS Subjects were BA children aged < 12 years at a transplant center between 2010 and 2021. A decision tree was developed for cost-effectiveness analysis from a hospital perspective to compare all-cause death between patients initially registered with a low PELD score (< 15) and a high PELD score (≥ 15). Each patient's direct medical cost was retrieved from the beginning of registration until 5 years after LT, adjusted with an inflation rate to 2022 Thai Baht (THB). RESULTS Among 176 children, 138 (78.4%) were initially registered with the high PELD score. The cost and mortality rate of the low PELD score group (THB1,413,424 or USD41,904 per patient and 31.6% mortality) were less than the high PELD score group (THB1,781,180 or USD52,807 per patient and 47.9% mortality), demonstrating the incremental cost-effectiveness ratio (ICER) of THB2,259,717 or USD66,994 per death prevented. The cost of early post-operative admission had the highest effect on the ICER. Considering the break-even analysis, cost among children initially registered at the low PELD score was also less expensive over time. CONCLUSIONS Registration for LT at PELD score < 15 was more cost-effective to prevent death among BA children with ESLD.
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Affiliation(s)
- Boonyanurak Sihaklang
- Division of Gastroenterology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Thung Phayathai, Ratchathewi, Bangkok, Thailand
- Department of Pediatrics, Institute of Medicine, Suranaree University of Technology, Nakhon Ratchasima, Thailand
| | - Songpon Getsuwan
- Division of Gastroenterology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Thung Phayathai, Ratchathewi, Bangkok, Thailand.
- Ramathibodi Excellence Center in Organ Transplantation, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
| | - Oraluck Pattanaprateep
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Napapat Butsriphum
- Division of Gastroenterology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Thung Phayathai, Ratchathewi, Bangkok, Thailand
- Ramathibodi Excellence Center in Organ Transplantation, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chatmanee Lertudomphonwanit
- Division of Gastroenterology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Thung Phayathai, Ratchathewi, Bangkok, Thailand
- Ramathibodi Excellence Center in Organ Transplantation, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pornthep Tanpowpong
- Division of Gastroenterology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Thung Phayathai, Ratchathewi, Bangkok, Thailand
- Ramathibodi Excellence Center in Organ Transplantation, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chollasak Thirapattaraphan
- Ramathibodi Excellence Center in Organ Transplantation, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- Division of Pediatric Surgery, Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Suporn Treepongkaruna
- Division of Gastroenterology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Thung Phayathai, Ratchathewi, Bangkok, Thailand
- Ramathibodi Excellence Center in Organ Transplantation, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Riemersma NL, Kremer D, Knobbe TJ, Gan CT, Nolte S, Gomes-Neto AW, Blokzijl H, de Meijer VE, Damman K, Eisenga MF, Drost G, Elting JWJ, Touw DJ, Berger SP, Bakker SJL, van der Stouwe AMM. Tremor, Daily Functioning, and Health-Related Quality of Life in Solid Organ Transplant Recipients. Transpl Int 2023; 36:10951. [PMID: 37008718 PMCID: PMC10062599 DOI: 10.3389/ti.2023.10951] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 02/23/2023] [Indexed: 04/04/2023]
Abstract
Solid organ transplant recipients (SOTR) frequently report tremor. Data concerning tremor-related impairment and its potential impact on health-related quality of life (HRQoL) are lacking. This cross-sectional study assesses impact of tremor on activities of daily living and HRQoL using validated questionnaires among SOTR enrolled in the TransplantLines Biobank and Cohort Study. We included 689 SOTR (38.5% female, mean [±SD] age 58 [±14] years) at median [interquartile range] 3 [1-9] years after transplantation, of which 287 (41.7%) reported mild or severe tremor. In multinomial logistic regression analyses, whole blood tacrolimus trough concentration was an independent determinant of mild tremor (OR per µg/L increase: 1.11, 95% CI: 1.02 to 1.21, p = 0.019). Furthermore, in linear regression analyses, severe tremor was strongly and independently associated with lower physical and mental HRQoL (β = -16.10, 95% CI: -22.23 to -9.98, p < 0.001 and β = -12.68, 95% CI: -18.23 to -7.14, p < 0.001 resp.). SOTR frequently report tremor-related impairment of activities of daily living. Tacrolimus trough concentrations appeared as a main determinant of tremor among SOTR. The strong and independent association of tremor-related impairment with lower HRQoL warrants further studies into the effects of tacrolimus on tremor. Clinical Trial Registration: ClinicalTrials.gov, Identifier NCT03272841.
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Affiliation(s)
- Niels L. Riemersma
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
- *Correspondence: Niels L. Riemersma,
| | - Daan Kremer
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Tim J. Knobbe
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - C. Tji Gan
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
- Department of Pulmonary Diseases and Lung Transplantation, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Svea Nolte
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - António W. Gomes-Neto
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Hans Blokzijl
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Vincent E. de Meijer
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Kevin Damman
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Michele F. Eisenga
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Gea Drost
- Department of Neurology and Clinical Neurophysiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Jan Willem J. Elting
- Department of Neurology and Clinical Neurophysiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Daan J. Touw
- Department of Pharmaceutical Analysis, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, Netherlands
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Stefan P. Berger
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Stephan J. L. Bakker
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - A. M. Madelein van der Stouwe
- Department of Neurology and Clinical Neurophysiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
- Expertise Center Movement Disorders Groningen, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
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Bhushan S, Noble C, Balouch F, Lewindon P, Lampe G, Hodgkinson P, McGill J, Ee L. Hepatocellular carcinoma requiring liver transplantation in hereditary tyrosinemia type 1 despite nitisinone therapy and α1-fetoprotein normalization. Pediatr Transplant 2022; 26:e14334. [PMID: 35698261 DOI: 10.1111/petr.14334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 05/23/2022] [Accepted: 05/26/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Hereditary tyrosinemia type 1 is a rare metabolic condition associated with an increased risk of hepatocellular carcinoma. Nitisinone (2-[2-nitro-4-trifluoromethylbenzoyl]-1,3-cyclohexanedione, NTBC) treatment has reduced but not eliminated the risk. The delayed initiation of nitisinone treatment, and persistently abnormal α1-fetoprotein (AFP) levels are recognized to be risk factors for late-onset hepatocellular carcinoma. We report three children diagnosed and treated with nitisinone since infancy who developed hepatocellular carcinoma despite long-term normalization of AFP. METHODS A retrospective review of all patients with tyrosinemia on nitisinone managed at our center was undertaken. Patient demographics, age at diagnosis, duration of therapy, timing of AFP normalization, and radiographic imaging findings were noted. RESULTS Three patients at our center with tyrosinemia type 1 developed hepatocellular carcinoma 9-13 years after diagnosis despite long-term nitisinone therapy and normalization of AFP. Two patients developed new nodules on imaging with an elevation of AFP leading to the diagnosis and subsequent liver transplant. The third patient proceeded with liver transplant because of a very nodular liver and increasing splenomegaly despite normal AFP and no change in surveillance gadoxetate magnetic resonance imaging. Early hepatocellular carcinoma was found in her liver explant. All three patients were cirrhotic at diagnosis. CONCLUSIONS Patients with hereditary tyrosinemia type 1, especially those already cirrhotic at diagnosis, remain at high risk of developing hepatocellular carcinoma despite long-term nitisinone therapy and AFP normalization, and warrant close monitoring and surveillance.
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Affiliation(s)
- Shreya Bhushan
- Department of Gastroenterology, Hepatology and Liver Transplantation, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Charlton Noble
- Department of Gastroenterology, Hepatology and Liver Transplantation, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Fariha Balouch
- Department of Gastroenterology, Hepatology and Liver Transplantation, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Peter Lewindon
- Department of Gastroenterology, Hepatology and Liver Transplantation, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Guy Lampe
- Department of Anatomical Pathology, Central Laboratory Pathology Queensland, Herston, Queensland, Australia
| | - Peter Hodgkinson
- Queensland Liver Transplant Service, Princess Alexandra Hospital and Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Jim McGill
- Department of Chemical Pathology, Central Laboratory Pathology Queensland, Herston, Queensland, Australia
| | - Looi Ee
- Department of Gastroenterology, Hepatology and Liver Transplantation, Queensland Children's Hospital, Brisbane, Queensland, Australia
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Ghelichi-Ghojogh M, Javanian M, Amiri S, Vali M, Sedighi S, Rajabi A, Shojaie L, Moftakhar L, Khezri R, Mohammadi M, Nikbakht HA. The survival rate of liver transplantation in children: a systematic review and meta-analysis. Pediatr Surg Int 2022; 38:1177-1186. [PMID: 35870002 DOI: 10.1007/s00383-022-05179-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/06/2022] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
| | - Mostafa Javanian
- Infectious Diseases and Tropical Medicine Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
| | - Sanaz Amiri
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohebat Vali
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Saman Sedighi
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Abdolhalim Rajabi
- Department of Health Management and Social Development Research Center, Faculty of Health, Golestan University of Medical Sciences, Gorgan, Iran
| | - Layla Shojaie
- Division of GI/Liver, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Leila Moftakhar
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Rokhan Khezri
- Student Research Committee, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Masoud Mohammadi
- Research Center of Gastroenterology and Hepatology, Golestan University of Medical Sciences, Gorgan, Iran
| | - Hossein-Ali Nikbakht
- Social Determinants of Health Research Center, Health Research Institute, Department of Biostatistics and Epidemiology, School of Public Health, Babol University of Medical Sciences, Babol, Iran.
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10
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Shifman HP, Rasnick E, Huang CY, Beck AF, Bucuvalas J, Lai JC, Wadhwani SI. Association of Primary Care Shortage Areas with Adverse Outcomes after Pediatric Liver Transplant. J Pediatr 2022; 246:103-109.e2. [PMID: 35301019 PMCID: PMC9987637 DOI: 10.1016/j.jpeds.2022.03.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 03/02/2022] [Accepted: 03/09/2022] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To characterize associations between living in primary care shortage areas and graft failure/death for children after liver transplantation. STUDY DESIGN This was an observational study of all pediatric patients (aged <19 years) who received a liver transplant between January 1, 2005, and December 31, 2015 in the US, with follow-up through January 2019 (N = 5964). One hundred ninety-five patients whose home ZIP code could not be matched to primary care shortage area status were excluded. The primary outcome was a composite endpoint of graft failure or death. We used Cox proportional hazards to model the associations between health professional shortage area (HPSA) and graft failure/death. RESULTS Children living in HPSAs had lower estimated graft survival rates at 10 years compared with those not in HPSAs (76% vs 80%; P < .001). In univariable analysis, residence in an HPSA was associated with a 22% higher hazard of graft failure/death than non-residence in an HPSA (hazard ratio [HR], 1.22; 95% CI, 1.09-1.36; P < .001). Black children from HPSAs had a 67% higher hazard of graft failure/death compared with those not in HPSAs (HR, 1.67; 95% CI, 1.29 to 2.16; P = .006); the effect of HPSA status was less pronounced for White children (HR, 1.11; 95% CI, 0.98-1.27; P = .10). CONCLUSIONS Children living in primary care shortage areas are at increased risk of graft failure and death after liver transplant, and this risk is particularly salient for Black children. Future work to understand how living in these regions contributes to adverse outcomes may enable teams to mitigate this risk for all children with chronic illness.
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Affiliation(s)
- Holly P Shifman
- School of Medicine, Oakland University William Beaumont, Rochester, MI
| | - Erika Rasnick
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Chiung-Yu Huang
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA
| | - Andrew F Beck
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, OH
| | - John Bucuvalas
- Division of Hepatology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY; Division of Hepatology, Department of Pediatrics, Kravis Children's Hospital, New York, NY
| | - Jennifer C Lai
- Division of Gastroenterology, Hepatology & Nutrition, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Sharad I Wadhwani
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, University of California San Francisco, San Francisco, CA.
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11
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Mullapudi B, Hendrickson R. Pediatric liver transplantation. Semin Pediatr Surg 2022; 31:151191. [PMID: 35725050 DOI: 10.1016/j.sempedsurg.2022.151191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Bhargava Mullapudi
- Department of Surgery, Section of Transplant Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA.
| | - Richard Hendrickson
- Department of Surgery, Section of Transplant Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA
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12
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Bellini MI, Lauro A, D'Andrea V, Marino IR. Pediatric Liver Transplantation: Long-Term Follow-Up Issues. EXP CLIN TRANSPLANT 2022; 20:27-35. [PMID: 35570596 DOI: 10.6002/ect.pediatricsymp2022.l16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Pediatric liver transplant is an established life-saving procedure for children with end-stage liver diseases, achieving excellent graft and patient survival but with effects on quality of life and psychological welfare in the long-term. With the natural increase in the number of pediatric transplant patients becoming adults, it is essential to successfully plan and manage issues affecting late outcomes in the vulnerable pediatric transplant population. This study offers an overview of the long-term surgical complications, the consequences of immunosuppression (such as posttransplant diabetes, hypertension, cardiovascular disease, and renal dysfunction), and the infection and malignancy risks. Finally, because quality of life is now an inclusive measurement of patient satisfaction, guidance on how to facilitate the transition to adulthood, empowering transplant recipients, is also provided.
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13
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Bakhtiyar S, Batra A, Malik T, Cotton R, Galvan NT, O'Mahony C, Goss J, Rana A. Three decades' analysis of pediatric liver transplantation outcomes reveals limited long-term improvements. Pediatr Transplant 2022; 26:e14158. [PMID: 34698432 DOI: 10.1111/petr.14158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 08/06/2021] [Accepted: 09/18/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The aim of this study was to assess improvements in long-term survival of pediatric patients after liver transplantation by analyzing outcomes in transplant recipients who survived beyond 1 year after transplantation. There has been a marked increase in the 1-year survival of pediatric patients, from 78% in transplant recipients between 1987 and 1990 to 95% in transplant recipients between 2011 and 2017. The long-term outcomes have not seen a similar trend, creating a disparity that warrants analysis. METHODS We analyzed 13 753 pediatric patients who survived for 1 year after receiving orthotopic liver transplantation between 1987 and 2017. The study period was divided into six eras. Outcomes were analyzed using the Kaplan-Meier method for time-to-event analysis, and multivariable Cox regression. RESULTS There were no significant gains in long-term outcomes among 1-year survivors over the past three decades. Log-rank tests for equality of survivor functions between each era and 1987-1990 were not statistically significant. Cause of death analysis revealed that although infections caused 20.6% of deaths in patients transplanted between 1987 and 1990, this number dropped to 5.6% in those transplanted between 2011 and 2017 (p = .01). Malignancy caused 10.6% of deaths in 1987-1990 but caused 22.2% of the deaths in 2011-2017 (p = .04). CONCLUSION Despite the gratifying gains in short-term survival of pediatric patients, 1-year survivors have no significant improvements in long-term survival after undergoing a liver transplantation. Long-term sequelae of immunosuppression, such as malignancy and infection, continue to be the most common causes of death. This study highlights the necessity for better long-term management of immunosuppression.
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Affiliation(s)
- Syed Bakhtiyar
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Anjay Batra
- School of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Tahir Malik
- School of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Ronald Cotton
- Department of Surgery, Division of Abdominal Transplantation and Hepatobiliary Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - N Thao Galvan
- Department of Surgery, Division of Abdominal Transplantation and Hepatobiliary Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Christine O'Mahony
- Department of Surgery, Division of Abdominal Transplantation and Hepatobiliary Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - John Goss
- Department of Surgery, Division of Abdominal Transplantation and Hepatobiliary Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Abbas Rana
- Department of Surgery, Division of Abdominal Transplantation and Hepatobiliary Surgery, Baylor College of Medicine, Houston, Texas, USA
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14
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Effect of Music on Fatigue, Comfort, and Vital Signs in Patients After Liver Transplant Surgery: A Randomized Controlled Trial. Holist Nurs Pract 2021; 35:150-157. [PMID: 33853099 DOI: 10.1097/hnp.0000000000000444] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
This randomized controlled clinical trial was conducted to determine the effect of music therapy on fatigue, comfort and vital signs of the liver transplant patients. The study sample comprised 120 adult patients (60 in the experimental and 60 in the control group) who met the inclusion criteria and agreed to participate in the study. In the experimental group, the researcher performed music therapy. After applying music therapy once to patients for 30 minutes, their fatigue, comfort, and vital signs were evaluated. No treatment was performed in the control group. According to music therapy follow-ups after liver transplantation, mean scores of fatigue levels were lower, comfort levels were higher, and vital signs were normal, with a statistical significance in the experimental group compared with the control group in all measurements before and after music therapy (P < .001). The study should be repeated using different parameters.
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15
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Duvant P, Fillat M, Garaix F, Roquelaure B, Ovaert C, Fouilloux V, Tsimaratos M, Auquier P, Fabre A, Baumstarck K. Quality of life of transplanted children and their parents: a cross-sectional study. Orphanet J Rare Dis 2021; 16:364. [PMID: 34404428 PMCID: PMC8369793 DOI: 10.1186/s13023-021-01987-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 07/25/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Transplantation is a saving therapeutic that has heavy consequences. The quality of life (QoL) of transplanted children and their parents has been little studied and should help physicians better manage these patients. The objectives of the study were to assess: (1) the QoL of transplanted children and parents and compare it with that of children with other chronic conditions associated with long-term consequences, and (2) potential variables modulating the QoL. METHODS This cross-sectional study was performed in a multidisciplinary paediatric unit (Timone Hospital, Marseille, France). Children were less than 18 years old; had a liver, kidney or heart transplant; and had a time since transplantation of 1-10 years. Socio-demographics and clinical data were recorded from medical forms. The QoL was assessed using the VSP-A (Vécu et Santé Perçue de l'Adolescent et de l'Enfant) and the WhoQoL self-reported questionnaires. RESULTS Forty-five families were included (response rate: 76%). The transplanted organs were the liver for 20 children, the kidney for 15 children, and the heart for 10 children. The QoL of transplanted children reported by their parents was better than that of children with inborn errors of metabolism and similar to that of childhood leukaemia survivors. The QoL of parents of transplanted children was better than that of parents of children with inborn errors of metabolism and did not differ from French norms. The QoL did not differ according to the nature of the transplanted organ, sex or the main sociodemographic data. The main modulators decreasing QoL were residual treatment level, medications switch and the presence of another regular treatment. CONCLUSION Transplanted children and their families reported a fairly preserved QoL compared to children with other chronic health conditions. Special attention should be given to QoL modulators related to therapeutic management (medication switches, regular treatments) that might be amenable to improve the QoL. Trial registration Ethics committee of Aix-Marseille University, France (reference number: 2014-08-04-03, 24/4/2015; https://www.univ-amu.fr/fr/public/comite-dethique ).
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Affiliation(s)
- Pauline Duvant
- Service de pédiatrie multidisciplinaire, Hôpital de la Timone, Marseille, France
| | - Magali Fillat
- Service de pédiatrie multidisciplinaire, Hôpital de la Timone, Marseille, France
| | - Florentine Garaix
- Service de pédiatrie multidisciplinaire, Hôpital de la Timone, Marseille, France
| | - Bertrand Roquelaure
- Service de pédiatrie multidisciplinaire, Hôpital de la Timone, Marseille, France
| | - Caroline Ovaert
- Service médico-chirurgical de cardiologie pédiatrique et congénitale, Hôpital de la Timone, Marseille, France
| | - Virginie Fouilloux
- Service médico-chirurgical de cardiologie pédiatrique et congénitale, Hôpital de la Timone, Marseille, France
| | - Michel Tsimaratos
- Service de pédiatrie multidisciplinaire, Hôpital de la Timone, Marseille, France
| | - Pascal Auquier
- EA 3279 CEReSS - Health Service Research and Quality of Life Center, Aix-Marseille Univ, 27 bd Jean Moulin, 13385, Marseille Cedex 05, France
| | - Alexandre Fabre
- Service de pédiatrie multidisciplinaire, Hôpital de la Timone, Marseille, France
| | - Karine Baumstarck
- EA 3279 CEReSS - Health Service Research and Quality of Life Center, Aix-Marseille Univ, 27 bd Jean Moulin, 13385, Marseille Cedex 05, France.
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16
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Vimalesvaran S, Souza LN, Deheragoda M, Samyn M, Day J, Verma A, Vilca-Melendez H, Rela M, Heaton N, Dhawan A. Outcomes of adults who received liver transplant as young children. EClinicalMedicine 2021; 38:100987. [PMID: 34505022 PMCID: PMC8413260 DOI: 10.1016/j.eclinm.2021.100987] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 06/06/2021] [Accepted: 06/10/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Patient and graft survival 20-years after pediatric liver transplantation (pLT) are excellent. In children, attainment of normal growth, education and social adaptation to be an independent adult are equally important. This is particularly relevant for children who receive liver transplant at a young age, where infantile-onset liver disease, surgery and immunosuppression can adversely affect growth and neurodevelopment. The aim of this study was to evaluate the long-term physical and psychosocial outcomes of pLT recipients with normal graft function. We coin the term 'meaningful survival'. METHODS We performed a cross-sectional study of pLT recipients who received transplants between 1985 and 2004. A 20-year evaluation of physical health (growth, renal function), mental wellbeing and social outcomes (substance abuse, adherence, education, employment) was performed. All patients included were considered to have normal graft function. FINDINGS Eighty-four patients met study criteria. Median age at transplantation was 1.3 years (IQR 0·7-3·3 years), with median duration of follow-up of 20.2 years (18·0-23·5). At median of 20-years, 19 patients (23%) had chronic renal dysfunction and 3 patients (4%) had a BMI of >30 (mean 20·4). Evaluation of long-term psychosocial outcomes demonstrated 22 patients (26%) with mental health disorders. Substance abuse was lower than national average. 62 patients (74%) were in education, employment or training. Overall, only 26% of our cohort achieved a composite outcome of 'meaningful survival'. INTERPRETATION This is the largest reported long-term study of biopsychosocial outcomes of pLT recipients with normal liver biochemistry, with follow-up upon completion of physical growth and senior school education. Importantly, despite normal liver function, many patients did not demonstrate 'meaningful survival'. We must refocus our efforts towards better understanding the long-term outcomes of children. A 'meaningful survival' rather than mere survival should be our goal. FUNDING None.
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Key Words
- ALP, alkaline phosphatase
- AST, aspartate aminotransferase
- BA, biliary atresia
- BMI, body mass index
- GGT, gamma-glutamyl transferase
- IMPARTS, Integrating Mental and Physical Healthcare: Research, Training and Services
- IQR, interquartile range
- Liver transplantation
- SD, standard deviation
- biopsychosocial
- eGFR, estimated glomerular filtration rate
- long-term
- outcomes
- pLT, pediatric liver transplantation
- pediatric
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Affiliation(s)
- Sunitha Vimalesvaran
- Paediatric Liver, GI and Nutrition Center and Mowat Labs, King's College Hospital, Denmark Hill, London SE5 9RS, United Kingdom
| | - Lara Neves Souza
- Liver Histopathology Laboratory, Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Maesha Deheragoda
- Liver Histopathology Laboratory, Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Marianne Samyn
- Paediatric Liver, GI and Nutrition Center and Mowat Labs, King's College Hospital, Denmark Hill, London SE5 9RS, United Kingdom
| | - Jemma Day
- Paediatric Liver, GI and Nutrition Center and Mowat Labs, King's College Hospital, Denmark Hill, London SE5 9RS, United Kingdom
| | - Anita Verma
- Paediatric Liver, GI and Nutrition Center and Mowat Labs, King's College Hospital, Denmark Hill, London SE5 9RS, United Kingdom
| | - Hector Vilca-Melendez
- Liver and Intestinal Transplant Surgical Service, King's College Hospital, London, United Kingdom
| | - Mohamed Rela
- Institute of Liver disease and Transplantation, Dr Rela Institute and Medical Center, Bharat Institute of Higher Education and Research, Chennai, India
| | - Nigel Heaton
- Liver Histopathology Laboratory, Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Anil Dhawan
- Paediatric Liver, GI and Nutrition Center and Mowat Labs, King's College Hospital, Denmark Hill, London SE5 9RS, United Kingdom
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Rock NM, Anghileri E, Cousin VL, Petit LM, McLin VA. Vitamin D Insufficiency Prior to Paediatric Liver Transplantation Is Associated with Early T-Cell Mediated Rejection. CHILDREN-BASEL 2021; 8:children8070612. [PMID: 34356591 PMCID: PMC8306001 DOI: 10.3390/children8070612] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 07/09/2021] [Accepted: 07/14/2021] [Indexed: 12/19/2022]
Abstract
Objectives: T-cell mediated rejection (TCMR) can compromise long-term liver allograft survival. The immunomodulatory properties of vitamin D are increasingly recognized. We investigated whether perturbations in vitamin D metabolism prior to LT may predispose to TCMR in a representative cohort of paediatric LT recipients. Methods: In this retrospective single-center study of children who underwent liver transplantation between 2005 and 2017, we collected serum 25(OH) vitamin D levels and other parameters related to vitamin D metabolism. Post-transplant variables were collected from medical records during the first year following LT. Results: Eighty-two patients were included. Twenty-six (32%) developed TCMR, 52 (65%) presented at least one event of 25(OH) D insufficiency during the year before the transplant, while 23 (32%) had at least one documented elevated plasma parathyroid hormone level. Forty-six patients benefited from nutritional support (56%). The development of TCMR was associated with vitamin D insufficiency pre-LT (p = 0.01). No significant correlations were identified between PTH levels and incidence of TCMR. The association was stronger in patients transplanted for cholestatic diseases (p = 0.004). Conclusions: Vitamin D insufficiency before a liver transplant may be associated with TCMR during the first year post-LT. These findings warrant further investigation.
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Affiliation(s)
- Nathalie M. Rock
- Swiss Paediatric Liver Center, Paediatric Gastroenterology, Hepatology and Nutrition Unit, Division of Paediatric Specialties, Department of Paediatrics, Gynecology and Obstetrics, Geneva University Hospitals, University of Geneva, 6, Rue Willy-Donzé, 1211 Geneva, Switzerland; (E.A.); (V.L.C.); (L.-M.P.); (V.A.M.)
- Correspondence: ; Tel.: +41-22-3724545; Fax: +41-22-3725489
| | - Elisa Anghileri
- Swiss Paediatric Liver Center, Paediatric Gastroenterology, Hepatology and Nutrition Unit, Division of Paediatric Specialties, Department of Paediatrics, Gynecology and Obstetrics, Geneva University Hospitals, University of Geneva, 6, Rue Willy-Donzé, 1211 Geneva, Switzerland; (E.A.); (V.L.C.); (L.-M.P.); (V.A.M.)
- School for General Medicine, Polis Lombardia, via Taramelli 12, 20124 Milano, Italy
| | - Vladimir L. Cousin
- Swiss Paediatric Liver Center, Paediatric Gastroenterology, Hepatology and Nutrition Unit, Division of Paediatric Specialties, Department of Paediatrics, Gynecology and Obstetrics, Geneva University Hospitals, University of Geneva, 6, Rue Willy-Donzé, 1211 Geneva, Switzerland; (E.A.); (V.L.C.); (L.-M.P.); (V.A.M.)
- Division of Intensive Care, Department of Acute Medicine, Geneva University Hospitals, University of Geneva, Rue Gabriel-Perret Gentil 4, 1211 Geneva, Switzerland
| | - Laetitia-Marie Petit
- Swiss Paediatric Liver Center, Paediatric Gastroenterology, Hepatology and Nutrition Unit, Division of Paediatric Specialties, Department of Paediatrics, Gynecology and Obstetrics, Geneva University Hospitals, University of Geneva, 6, Rue Willy-Donzé, 1211 Geneva, Switzerland; (E.A.); (V.L.C.); (L.-M.P.); (V.A.M.)
| | - Valérie A. McLin
- Swiss Paediatric Liver Center, Paediatric Gastroenterology, Hepatology and Nutrition Unit, Division of Paediatric Specialties, Department of Paediatrics, Gynecology and Obstetrics, Geneva University Hospitals, University of Geneva, 6, Rue Willy-Donzé, 1211 Geneva, Switzerland; (E.A.); (V.L.C.); (L.-M.P.); (V.A.M.)
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18
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Proli F, Metou-Lopes A, Ayachi A, Rossi M, D'Arcangelo G, Faragalli A, Lambe C, Talbotec C, Goulet O, Chardot C, Lacaille F. Quality of life in long term survivors of pediatric intestinal transplantation compared with liver transplantation and home parenteral nutrition: A prospective single-center pilot study. Pediatr Transplant 2021; 25:e13982. [PMID: 33590643 DOI: 10.1111/petr.13982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 01/11/2021] [Accepted: 01/18/2021] [Indexed: 11/30/2022]
Abstract
Health-related quality of life (HRQOL) after intestinal transplantation (IT) is important, as many psychological troubles have been reported in these patients on the long term. Our aim was to assess and compare HRQOL of patients after IT to patients after liver transplantation (LT) or on home parenteral nutrition (HPN) for intestinal failure. A cross-sectional study included patients and their parents between 10 and 18 years of age, on HPN for more than 2 years, or who underwent IT or LT, with a graft survival longer than 2 years. Quality of life was explored by Child Health Questionnaire. Thirteen children-parents dyads after IT, 10 after LT, and eight children on HPN completed the survey. Patients were a median age of 14 years old, a median of 10 years post-transplantation or on HPN. Patients after IT scored lower than patients after LT or on HPN in "social limitations due to behavioral difficulties" and in "behavior." They scored higher than those on HPN in "global health." Parents of children after IT scored lower than those after LT in many domains. No relevant correlation with clinical data was found. Our study showed the multi-level impact of IT on quality of life of patients and their parents. It highlights the importance of a regular psychological follow-up for patients, but also of a psychological support for families. Helping the patients to overcome the difficulties at adolescence may improve their mental health in adulthood.
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Affiliation(s)
- Francesco Proli
- Gastroenterology-Hepatology-Nutrition Unit, Hôpital Necker-Enfants Malades, Paris, France.,Department of Pediatrics, Department of Woman and Child Health and Public Health, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Adamadia Metou-Lopes
- Gastroenterology-Hepatology-Nutrition Unit, Hôpital Necker-Enfants Malades, Paris, France
| | - Amel Ayachi
- Gastroenterology-Hepatology-Nutrition Unit, Hôpital Necker-Enfants Malades, Paris, France
| | - Matilde Rossi
- Gastroenterology-Hepatology-Nutrition Unit, Hôpital Necker-Enfants Malades, Paris, France
| | - Giulia D'Arcangelo
- Gastroenterology-Hepatology-Nutrition Unit, Hôpital Necker-Enfants Malades, Paris, France
| | - Andrea Faragalli
- Centre of Epidemiology, Biostatistics and Medical Information Technology, Marche Polytechnic University, Ancona, Italy
| | - Cécile Lambe
- Gastroenterology-Hepatology-Nutrition Unit, Hôpital Necker-Enfants Malades, Paris, France
| | - Cécile Talbotec
- Gastroenterology-Hepatology-Nutrition Unit, Hôpital Necker-Enfants Malades, Paris, France
| | - Olivier Goulet
- Gastroenterology-Hepatology-Nutrition Unit, Hôpital Necker-Enfants Malades, Paris, France
| | | | - Florence Lacaille
- Gastroenterology-Hepatology-Nutrition Unit, Hôpital Necker-Enfants Malades, Paris, France
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Gordon K, Figueira ERR, Rocha-Filho JA, Mondadori LA, Joaquim EHG, Seda-Neto J, da Fonseca EA, Pugliese RPS, Vintimilla AM, Auler Jr JOC, Carmona MJC, D'Alburquerque LAC. Perioperative blood transfusion decreases long-term survival in pediatric living donor liver transplantation. World J Gastroenterol 2021; 27:1161-1181. [PMID: 33828392 PMCID: PMC8006094 DOI: 10.3748/wjg.v27.i12.1161] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/20/2021] [Accepted: 03/13/2021] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Karina Gordon
- Division of Anesthesiology, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo 05403-000, Brazil
- Department of Anesthesiology, AC Camargo Cancer Center, São Paulo 01509-010, Brazil
| | - Estela Regina Ramos Figueira
- Department of Gastroenterology, Discipline of Liver and Gastrointestinal Transplantation, Laboratory of Medical Investigations LIM37 Hospital das Clinicas, University of São Paulo School of Medicine, São Paulo 05402-000, Brazil
| | - Joel Avancini Rocha-Filho
- Division of Anesthesiology, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo 05403-000, Brazil
| | | | | | - Joao Seda-Neto
- Department of Liver Transplantation, AC Camargo Cancer Center, São Paulo 01525-901, Brazil
| | | | | | - Agustin Moscoso Vintimilla
- Department of Gastroenterology, Division of Liver and Gastrointestinal Transplant, Hospital das Clinicas, University of São Paulo School of Medicine, São Paulo 05402-000, Brazil
| | - Jose Otavio Costa Auler Jr
- Division of Anesthesiology, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo 05403-000, Brazil
| | - Maria Jose Carvalho Carmona
- Division of Anesthesiology, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo 05403-000, Brazil
| | - Luiz Augusto Carneiro D'Alburquerque
- Department of Gastroenterology, Division of Liver and Gastrointestinal Transplant, Hospital das Clinicas, University of São Paulo School of Medicine, São Paulo 05402-000, Brazil
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20
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Jain AK, Anand R, Lerret S, Yanni G, Chen JY, Mohammad S, Doyle M, Telega G, Horslen S. Outcomes following liver transplantation in young infants: Data from the SPLIT registry. Am J Transplant 2021; 21:1113-1127. [PMID: 32767649 PMCID: PMC7867666 DOI: 10.1111/ajt.16236] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 07/20/2020] [Accepted: 07/20/2020] [Indexed: 02/06/2023]
Abstract
Liver transplantation (LT) in young patients is being performed with greater frequency. We hypothesized that objective analysis of pre-, intra-, and postoperative events would help understand contributors to successful outcomes and guide transplant decision processes. We queried SPLIT registry for pediatric transplants between 2011 and 2018. Outcomes were compared for age groups: 0-<3, 3-<6, 6-<12 months, and 1-<3 years (Groups A, B, C, D respectively) and by weight categories: <5, 5-10, >10 kg; 1033 patients were available for analysis. Cholestatic disease and fulminant failure were highest in group A and those <5 kg; and biliary atresia in group C (72.8%). Group A had significantly higher life support dependence (34.6%; P < .001), listing as United Network for Organ Sharing status 1a/1b (70.4%; P < .001), and shortest wait times (P < .001). The median (interquartile range) for international normalized ratio and bilirubin were highest in group A (3.0 [2.1-3.9] and 16.7 [6.8-29.7] mg/dL) and those <5 kg (2.6 [1.8-3.4] and 13.5 [3.0-28.4] mg/dL). A pediatric end -stage liver disease score ≥40, postoperative hospital stays, rejection, and nonanastomotic biliary strictures were highest in group A with lowest survival at 93.1%. Infants 0 to <3 months and those <5 kg need more intensive care with lower survival and higher complications. Importantly, potential LT before reaching status 1a/1b and aggressive postoperative management may positively influence their outcomes.
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Affiliation(s)
- Ajay K. Jain
- Saint Louis University, Saint Louis, Missouri, USA
| | | | - Stacee Lerret
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Pediatric Gastroenterology, Hepatology and Nutrition, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - George Yanni
- Pediatrics, Children’s Hospital of Los Angeles, Los Angeles, California, USA
| | | | - Saeed Mohammad
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Majella Doyle
- Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Greg Telega
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Pediatric Gastroenterology, Hepatology and Nutrition, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Simon Horslen
- Liver and Small Bowel Transplantation, Seattle Children’s Hospital, Seattle, Washington, USA
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21
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Bobrowski AE. School and sports participation post-transplant. Pediatr Transplant 2021; 25:e13791. [PMID: 33202076 DOI: 10.1111/petr.13791] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 06/07/2020] [Accepted: 06/17/2020] [Indexed: 12/15/2022]
Abstract
Pediatric recipients of life-saving organ transplants are living longer, with improved graft and overall survivals. After successful transplant, children are encouraged to return to "normal life," with school attendance and participation in age-appropriate physical activities. This transition may cause stress to the recipients, parents, teachers, and other participating caregivers and staff. Planning for school reentry and assuring education for and open lines of communication with the school staff can help alleviate some of this discomfort and ease the process for the patient and the family. Cardiovascular disease has emerged as the leading cause of death in survivors of pediatric transplantation and is contributed to by modifiable risk factors such as obesity, hypertension, and the MS. Physical activity is a proven tool in decreasing surrogate markers of this risk. Sports participation is an important way to promote an enjoyment of physical activity that can ideally persist into adulthood, but conflicting advice and opinions exist regarding type and participation in physical activity. Moreover, specific recommendations are likely not applicable to all recipients, as certain degrees of rehabilitation may be needed depending on degree and length of illness. In general, a program of rehabilitation and increased physical activity has been shown to be safe and effective for most pediatric transplant recipients. Focusing on optimizing the "normal" childhood activities of going to school and participating in sports can improve the physical, social, cognitive, and mental health outcomes of this population after transplant and should be prioritized.
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Affiliation(s)
- Amy E Bobrowski
- Division of Pediatric Kidney Diseases, Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois, USA
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22
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Evaluation of Graft Fibrosis, Inflammation and Donor-specific Antibodies at Protocol Liver Biopsies in Pediatric Liver Transplant Patients: a Single Center Experience. Transplantation 2021; 106:85-95. [PMID: 33496554 DOI: 10.1097/tp.0000000000003649] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND The impact of graft fibrosis and inflammation on the natural history of pediatric liver transplants (LT) is still debated. Our objectives were to evaluate the evolution of posttransplant fibrosis and inflammation over time at protocol liver biopsies (PLBs), risk factors for fibrosis, presence of donor-specific antibodies (DSAs) and/or their correlation with graft and recipient factors. METHODS A single-center, retrospective (2000-2019) cross-sectional study on pediatric LT recipients who had at least one PLB, followed by a longitudinal evaluation in those who had at least two PLBs, was conducted. Fibrosis was assessed by the Liver Allograft Fibrosis Semiquantitative score, inflammation by the Rejection Activity Index, DSAs by Luminex®. RESULTS A total of 134 PLBs from 94 patients were included. Fibrosis was detected in 87% (30% mild, 45% moderate, 12% severe), 80% in the portal tracts. There was an increase in fibrosis between the 1-3 and the 4-6 year group (p=0.01), then it was stable. Inflammation was observed in 44% (30% mild, 13% moderate, 1% severe), 90% in the portal tracts. Anti-HLA II (IgG) DSAs were detected in 14/40 (35%). Portal fibrosis was associated with portal inflammation in the 1-3 year group (p=0.04). Low immunosuppression levels were correlated with sinusoidal fibrosis (p=0.04) and DSA positivity (p-value=0.006). There was no statistically significant correlation between DSA positivity and the presence of graft fibrosis or inflammation. CONCLUSIONS This study corroborates the concept of an early evolution of silent graft fibrosis. Suboptimal immunosuppression may play a role in the development of fibrosis and DSAs.
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23
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Acun A, Oganesyan R, Uygun K, Yeh H, Yarmush ML, Uygun BE. Liver donor age affects hepatocyte function through age-dependent changes in decellularized liver matrix. Biomaterials 2021; 270:120689. [PMID: 33524812 DOI: 10.1016/j.biomaterials.2021.120689] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 12/19/2020] [Accepted: 01/18/2021] [Indexed: 02/08/2023]
Abstract
The only treatment available for end stage liver diseases is orthotopic liver transplantation. Although there is a big donor scarcity, many donor livers are discarded as they do not qualify for transplantation. Alternatively, decellularization of discarded livers can potentially render them transplantable upon recellularization and functional testing. The success of this approach will heavily depend on the quality of decellularized scaffolds which might show variability due to factors including age. Here we assessed the age-dependent differences in liver extracellular matrix (ECM) using rat and human livers. We show that the liver matrix has higher collagen and glycosaminoglycan content and a lower growth factor content with age. Importantly, these changes lead to deterioration in primary hepatocyte function potentially due to ECM stiffening and integrin-dependent signal transduction. Overall, we show that ECM changes with age and these changes significantly affect cell function thus donor age should be considered as an important factor for bioengineering liver substitutes.
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Affiliation(s)
- Aylin Acun
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Shriners Hospitals for Children, Boston, MA, USA; Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Ruben Oganesyan
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Shriners Hospitals for Children, Boston, MA, USA; Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Korkut Uygun
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Shriners Hospitals for Children, Boston, MA, USA; Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Heidi Yeh
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Martin L Yarmush
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Shriners Hospitals for Children, Boston, MA, USA; Department of Surgery, Massachusetts General Hospital, Boston, MA, USA; Department of Biomedical Engineering, Rutgers University, Piscataway, NJ, USA
| | - Basak E Uygun
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Shriners Hospitals for Children, Boston, MA, USA; Department of Surgery, Massachusetts General Hospital, Boston, MA, USA.
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24
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Burkhardt JA, Rapport MJK. Quality of Life and Functional Mobility After Progressive Resistance Exercise in an Adolescent With a Liver Transplant. Pediatr Phys Ther 2020; 32:E70-E75. [PMID: 32925815 DOI: 10.1097/pep.0000000000000751] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE This case report describes physical therapy intervention using progressive resistance exercise (PRE) with the recipient of a liver transplant to improve physical fitness, quality of life, and functional mobility. SUMMARY OF KEY POINTS Outpatient physical therapy intervention included 2 phases, 10 weeks each, focused on functional training and PRE-based power training and functional tasks. Secondary conditions included excessive weight gain, adjustment disorder, and intensive scarring. STATEMENT OF CONCLUSIONS PRE-based power training appears to be effective in an adolescent with decreased strength and endurance following liver transplant. Improvements in 1 repetition maximum, functional mobility, aerobic/anaerobic fitness, patient-directed goals, and quality of life were measurable. RECOMMENDATIONS FOR CLINICAL PRACTICE A PRE-based program may be useful in physical therapy with adolescents after liver transplant. Choice of musculature for training should be relevant to functional limitations and dosing of exercises must be sufficient for muscular hypertrophy.
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Affiliation(s)
- Julie A Burkhardt
- Children's Hospital of Colorado (Dr Burkhardt), Aurora, Colorado; University of Colorado Anschutz Medical Campus (Dr Rapport), Aurora, Colorado
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25
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Executive Functioning in Pediatric Solid Organ Transplant Recipients: A Meta-analytic Review. Transplantation 2020; 104:357-366. [PMID: 31517786 DOI: 10.1097/tp.0000000000002954] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Examining executive functioning (EF) posttransplant has become increasingly prevalent, as EF deficits are associated with poor disease-related outcomes and psychosocial functioning. The purpose of the current meta-analysis was to compare overall and domain-specific EF between healthy youth and those with a kidney, heart, or liver transplant, and identify moderating variables related to EF differences between these 2 groups. METHODS A literature search of PsycINFO, Pubmed, and Medline was conducted for eligible articles published until January 2019. Twenty studies met eligibility criteria and were included in the present meta-analysis. RESULTS Results from the random-effects model indicated a significant standardized mean difference in overall EF skills with transplant recipients demonstrating worse EF (g = 0.40; 95% confidence interval [CI], 0.29-0.50) than healthy youth. Specifically, transplanted youth had worse working memory (g = 0.33; 95% CI, 0.01-0.66), processing speed (g = 0.41; 95% CI, 0.19-0.62), attentional control (g = 0.53; 95% CI, 0.33-0.73), and metacognitive skills (g = 0.36; 95% CI, 0.18-0.54). Assessment type and time since transplantation were not significant moderators. CONCLUSIONS Pediatric solid organ transplant recipients demonstrate worse overall EF skills and deficits in working memory, processing speed, attentional control, and metacognitive skills. Many children who have undergone solid organ transplantation will require additional support in medical and academic settings because of deficits in various EF domains.
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26
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Ueno T, Kodama T, Noguchi Y, Deguchi K, Nomura M, Saka R, Watanabe M, Tazuke Y, Bessho K, Okuyama H. Safety and Efficacy of Everolimus Rescue Treatment After Pediatric Living Donor Liver Transplantation. Transplant Proc 2020; 52:1829-1832. [PMID: 32571711 DOI: 10.1016/j.transproceed.2020.01.159] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 01/26/2020] [Indexed: 01/01/2023]
Abstract
PURPOSE Everolimus (EVR) is a derivative of sirolimus with a similar mechanism of action. The safety and efficacy of EVR after pediatric living donor liver transplantation (LDLT) are currently unknown. The purpose of this study was to examine the safety and efficacy of EVR as rescue therapy after pediatric LDLT. METHODS This study included patients younger than 19 years of age who received EVR after LDLT at our institution. EVR was administered as rescue treatment in addition to tacrolimus. In 21 patients, EVR dose, trough level, outcomes, and adverse effects were assessed. RESULTS Original diseases of patients consisted of biliary atresia (n = 11), Alagille syndrome (n = 3), fulminant hepatitis (n = 3), hepatoblastoma (n = 2), and other (n = 2). Mean age at transplant was 2.0 years (range 0.6-6.2 years). Mean age at initial EVR administration was 8.0 years (range 0.9-18.9 years). Indications for EVR use were graft fibrosis (n = 8), refractory acute cellular rejection (n = 5), renal sparing (n = 4), hepatoblastoma (n = 2), and chronic rejection (CR) (n = 2). Mean duration of administration was 17.1 months (range 2.1-60.4 months). Mean dose was 0.5 mg/m2 twice daily. Mean EVR trough level was 2.5 ng/mL (range 1.5-5.0 ng/mL). Liver function improved and fibrosis did not progress in all patients with CR. However, 14 patients (67%) experienced adverse effects that required EVR dose reduction or discontinuation. CONCLUSION EVR is tolerable for pediatric patients after LDLT with dose adjustment. EVR had a certain effect to relieve progression on CR. Further follow-up is required.
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Affiliation(s)
- Takehisa Ueno
- Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan.
| | - Tasuku Kodama
- Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yuki Noguchi
- Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Koichi Deguchi
- Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Motonari Nomura
- Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Ryuta Saka
- Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Miho Watanabe
- Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yuko Tazuke
- Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Kazuhiko Bessho
- Pediatrics, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Hiroomi Okuyama
- Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
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27
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Glinka J, de Santibañes M, Biagiola D, D Agostino D, Ardiles V, Ciardullo M, Mattera J, Pekolj J, de Santibañes E. Biliary reconstruction before clamp removal to avoid portal vein thrombosis in pediatric living-donor liver transplantation using hyper-reduced left lateral segment grafts: A novel technical strategy. Pediatr Transplant 2019; 23:e13516. [PMID: 31215179 DOI: 10.1111/petr.13516] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/26/2019] [Indexed: 01/10/2023]
Abstract
LT has become the treatment of choice for children with end-stage liver disease. The scarcity of donors and the considerable mortality on waiting lists have propelled the related living-donor techniques, especially in small children. This population need smaller and good quality grafts and are usually candidates to receive a LLS from a related donor. Many times this grafts are still large and do not fit in the receptor's abdomen, so a further hyper-reduction may be required. Despite all advances in LT field, vascular complications still occur in a considerable proportion remaining as a significant cause of morbidity, graft loss, and mortality. Technical issues currently play an essential role in its genesis. The widely spread technique for biliary and vascular reconstruction in living donor LT (LDLT) nowadays implies removal of the portal vein (PV) clamp after the venous anastomosis, then the arterial reconstruction is done, followed by the biliary reconstruction. However, due to the posterior location of the LLS bile duct, for its reconstruction, a rotation of the liver is required risking a potential transient PV occlusion leading to thrombosis afterward. We describe a new technique that involves performing biliary reconstruction after the PV anastomosis and before removing the vascular clamp, thus allowing to freely rotate the liver with less risk of PV occlusion and thrombosis.
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Affiliation(s)
- Juan Glinka
- Department of General Surgery, Hepato-bilio-pancreatic & Liver Transplantation Unit Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Martin de Santibañes
- Department of General Surgery, Hepato-bilio-pancreatic & Liver Transplantation Unit Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - David Biagiola
- Department of General Surgery, Hepato-bilio-pancreatic & Liver Transplantation Unit Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Daniel D Agostino
- Pediatric Gastroenterology-Hepatology Division, Liver-Intestinal Transplantation Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Victoria Ardiles
- Department of General Surgery, Hepato-bilio-pancreatic & Liver Transplantation Unit Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Miguel Ciardullo
- Department of General Surgery, Hepato-bilio-pancreatic & Liver Transplantation Unit Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Juan Mattera
- Department of General Surgery, Hepato-bilio-pancreatic & Liver Transplantation Unit Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Juan Pekolj
- Department of General Surgery, Hepato-bilio-pancreatic & Liver Transplantation Unit Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Eduardo de Santibañes
- Department of General Surgery, Hepato-bilio-pancreatic & Liver Transplantation Unit Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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28
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Sun Y, Jia L, Yu H, Zhu M, Sheng M, Yu W. The Effect of Pediatric Living Donor Liver Transplantation on Neurocognitive Outcomes in Children. Ann Transplant 2019; 24:446-453. [PMID: 31371696 PMCID: PMC6690216 DOI: 10.12659/aot.914164] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background Neurocognitive dysfunction commonly occurs after solid organ transplantation and affects 15–30% of liver transplant recipients. The aim of this study was to evaluate the neurocognitive changes pre- and post-operation and the relative factors affecting those changes. Material/Methods Children with biliary atresia who underwent pediatric living donor-related liver transplantation before the age of 2 years were given Bayley Scale of Infant Development-II test (BSID-II), including Mental Development Index (MDI) and Psychomotor Development Index (PDI) the week before and again half a year after transplantation to assess the effect of transplantation on neurocognition. According to the test outcome, the children were divided into a normal group and an abnormal group. The association of clinical data with neurocognitive development between the 2 groups was analyzed by logistic regression analysis. Results There was a certain degree of improvement in neurocognition half a year after surgery compared with preoperative. The BSID-II subscales were significantly lower than expected before and after transplantation. Preoperative blood ammonia and bilirubin levels were independent risk factors for MDI half a year after transplantation, and preoperative albumin and bilirubin levels were risk factors for PDI. Conclusions Liver transplantation clearly improves children’s neurocognitive function. The postoperative neurocognition is closely related to pre-operation nutritional development.
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Affiliation(s)
- Ying Sun
- Department of Anesthesiology, Tianjin First Center Hospital, Tianjin, China (mainland)
| | - Lili Jia
- Department of Anesthesiology, Tianjin First Center Hospital, Tianjin, China (mainland)
| | - Hongli Yu
- Department of Anesthesiology, Tianjin First Center Hospital, Tianjin, China (mainland)
| | - Min Zhu
- Department of Anesthesiology, Tianjin First Center Hospital, Tianjin, China (mainland)
| | - Mingwei Sheng
- Department of Anesthesiology, Tianjin First Center Hospital, Tianjin, China (mainland)
| | - Wenli Yu
- Department of Anesthesiology, Tianjin First Center Hospital, Tianjin, China (mainland)
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29
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Feldman AG, Sokol RJ. Neonatal cholestasis: emerging molecular diagnostics and potential novel therapeutics. Nat Rev Gastroenterol Hepatol 2019; 16:346-360. [PMID: 30903105 DOI: 10.1038/s41575-019-0132-z] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Neonatal cholestasis is a group of rare disorders of impaired bile flow characterized by conjugated hyperbilirubinaemia in the newborn and young infant. Neonatal cholestasis is never physiological but rather is a sign of hepatobiliary and/or metabolic disorders, some of which might be fatal if not identified and treated rapidly. A step-wise timely evaluation is essential to quickly identify those causes amenable to treatment and to offer accurate prognosis. The aetiology of neonatal cholestasis now includes an expanding group of molecularly defined entities with overlapping clinical presentations. In the past two decades, our understanding of the molecular basis of many of these cholestatic diseases has improved markedly. Simultaneous next-generation sequencing for multiple genes and whole-exome or whole-genome sequencing now enable rapid and affordable molecular diagnosis for many of these disorders that cannot be directly diagnosed from standard blood tests or liver biopsy. Unfortunately, despite these advances, the aetiology and optimal therapeutic approach of the most common of these disorders, biliary atresia, remain unclear. The goals of this Review are to discuss the aetiologies, algorithms for evaluation and current and emerging therapeutic options for neonatal cholestasis.
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Affiliation(s)
- Amy G Feldman
- Pediatric Liver Center, Digestive Health Institute, Children's Hospital Colorado, Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ronald J Sokol
- Pediatric Liver Center, Digestive Health Institute, Children's Hospital Colorado, Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine, Aurora, CO, USA. .,Colorado Clinical and Translational Sciences Institute, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
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30
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Zhang Y, Wang J, Jin S, Xiang B, Yang J, Li K, Huang B, Lai W, Yan L, Zhao J. Post-traumatic stress disorder in living donors after pediatric liver transplantation: A cross-sectional investigation study. Medicine (Baltimore) 2019; 98:e15565. [PMID: 31096459 PMCID: PMC6531068 DOI: 10.1097/md.0000000000015565] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Liver transplantation can lead to post-traumatic stress disorder (PTSD) in recipients, but the risk factors associated with PTSD in living donors are unknown. To investigate this progression in pediatric living donors, a cross-sectional investigation was carried out.All participants completed 2 questionnaires: a PTSD self-rating scale (PTSD-SS) and a validated Chinese version of the Medical Outcomes Study Short Form-36 (SF-36). Clinical and demographic data were collected from medical records and self-report questionnaires. Univariate analysis was conducted to identify statistical differences.The prevalence of full PTSD (all symptom clusters) and partial PTSD (2 out of 3 symptom clusters) was 12.1% and 31.1%, respectively. Those with an educational status of elementary school (P = .001), who were donors to their children (P = .008), who were in the first 6 months after transplant (P < .001), or were involved in transplants where the recipients had severe complications (P = .02) were more likely to have higher PTSD-SS scores than other groups. The non-PTSD group had a higher health-related quality-of-life score compared with the full and partial PTSD groups in the domains of physical function, role-physical, bodily pain, general health, vitality, social functioning, role-emotional, and mental health. In addition, the occurrence of PTSD was related to a poorer quality of life.The occurrence of PTSD was common in living donors after pediatric liver transplantation. Those with a lower educational status, who were donors to their children, were in the first 6 months after transplant, or were involved in transplants where the recipients had severe complications were most likely to experience PTSD. Post-traumatic stress symptom severity was significantly associated with a poorer quality of life after transplant.
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Affiliation(s)
| | | | | | | | | | | | | | - Wei Lai
- Department of Intensive Care Unit, West China Hospital of Sichuan University, Chengdu City, Sichuan Province, China
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Pediatric living donor liver transplantation: A single center experiences. JOURNAL OF SURGERY AND MEDICINE 2019. [DOI: 10.28982/josam.542279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Hsu CT, Chang MH, Ho MC, Chang HH, Lu MY, Jou ST, Ni YH, Chen HL, Hsu HY, Wu JF. Post-transplantation lymphoproliferative disease in pediatric liver recipients in Taiwan. J Formos Med Assoc 2019; 118:1537-1545. [PMID: 30630698 DOI: 10.1016/j.jfma.2018.12.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 09/15/2018] [Accepted: 12/24/2018] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Post-transplantation lymphoproliferative disorder (PTLD) is a heterogeneous, potentially life-threatening complication after liver transplantation in children. In this study, the disease characteristics, outcomes, and prognostic factors of PTLD were investigated. METHODS A retrospective, observational study was conducted on 16 pediatric liver transplant (LT) recipients who developed PTLD between February 2001 and December 2013 at a tertiary referral center in Taiwan. The disease characteristics and treatment outcomes of the patients were analyzed. RESULTS The median time from liver transplantation to the development of PTLD was 8 months. Early onset (<1 year post-transplantation) PTLD constituted 62.5% of the cases. PTLD location was frequently extranodal (81.3%) and mostly involved the gastrointestinal tract (68.8%). Histopathologic findings showed polymorphic PTLD in six cases (37.5%), diffuse large B-cell lymphoma in five cases (31.3%), and Burkitt's PTLD in two cases (12.5%). Early lesions in PTLD, T-cell lymphoma, and Hodgkin's lymphoma were observed in one case each (6.3%). Overall survival at 1- and 5-years post-PTLD diagnosis was 87.5% and 79.5%, respectively. St Jude's classification stage IV disease was associated with poor survival (hazard ratio [HR] = 13.37, P = 0.037). Two patients (12.5%) had chronic rejection after the treatment for PTLD and one patient (6.3%) developed graft failure. CONCLUSION PTLD is a major complication in pediatric LT recipients, but long-term survival is possible in most cases with an adequate treatment strategy. Stage IV disease is a major risk factor for poor survival in pediatric PTLD patients. During the management of PTLD, the possibility of chronic rejection and even graft failure should be considered.
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Affiliation(s)
- Chien-Ting Hsu
- Department of Pediatrics, National Taiwan University Hospital, No. 8, Chung-Shan S. Rd., Taipei, Taiwan.
| | - Mei-Hwei Chang
- Department of Pediatrics, National Taiwan University Hospital, No. 8, Chung-Shan S. Rd., Taipei, Taiwan.
| | - Ming-Chih Ho
- Department of Surgery, National Taiwan University Hospital, No. 7, Chung-Shan S. Rd., Taipei, Taiwan.
| | - Hsiu-Hao Chang
- Department of Pediatrics, National Taiwan University Hospital, No. 8, Chung-Shan S. Rd., Taipei, Taiwan.
| | - Meng-Yao Lu
- Department of Pediatrics, National Taiwan University Hospital, No. 8, Chung-Shan S. Rd., Taipei, Taiwan.
| | - Shiann-Tarng Jou
- Department of Pediatrics, National Taiwan University Hospital, No. 8, Chung-Shan S. Rd., Taipei, Taiwan.
| | - Yen-Hsuan Ni
- Department of Pediatrics, National Taiwan University Hospital, No. 8, Chung-Shan S. Rd., Taipei, Taiwan.
| | - Huey-Ling Chen
- Department of Pediatrics, National Taiwan University Hospital, No. 8, Chung-Shan S. Rd., Taipei, Taiwan.
| | - Hong-Yuan Hsu
- Department of Pediatrics, National Taiwan University Hospital, No. 8, Chung-Shan S. Rd., Taipei, Taiwan.
| | - Jia-Feng Wu
- Department of Pediatrics, National Taiwan University Hospital, No. 8, Chung-Shan S. Rd., Taipei, Taiwan.
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Alanzi A, Alkheder M, Qudeimat M. Oral Health Status of Kuwaiti Children with a History of Chronic Liver Disease. Med Princ Pract 2019; 28:341-346. [PMID: 30870835 PMCID: PMC6639567 DOI: 10.1159/000499594] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Accepted: 03/14/2019] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE To investigate the oral health status and dental manifestations of children with a history of chronic liver disease (CLD) compared to healthy children. SUBJECTS AND METHODS Twenty children (15 boys and 5 girls) with a history of CLD were compared to 20 healthy controls matched for age and gender. The clinical examination was carried out by the same dentist. Caries prevalence, using the decayed, missing, and filled primary and permanent teeth indices (dmft/DMFT), was recorded. Developmental enamel defects, plaque scores, and gingival overgrowth were also investigated. RESULTS No statistically significant differences were found in mean dmft scores for children with a history of CLD (4.9 ± 5.4) and for healthy individuals (3.9 ± 4.5). However, the mean DMFT score was significantly higher (p =0.025) in children with CLD (4.2 ± 4.6) compared to controls (1.7 ± 1.6). The mean decayed teeth parameter (DT) was also significantly higher in children with CLD (p =0.004). All patients with CLD exhibited enamel defects compared to only 33% in the control group (p< 0.05). A higher mean plaque index was observed in children with a history of CLD (p< 0.001). Also, a positive correlation for gingival overgrowth was noted in patients with a history of CLD (p< 0.05). Green staining was evident only in the permanent dentition of 1 child with CLD. CONCLUSION Children with a history of CLD exhibited a high caries prevalence, high plaque scores, and more enamel defects compared to healthy subjects. Gingival overgrowth is less prevalent among pediatric liver transplant patients on tacrolimus therapy.
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Affiliation(s)
- Abrar Alanzi
- Department of Developmental and Preventive Sciences, Faculty of Dentistry, Kuwait University, Kuwait, Kuwait,
| | - Mariam Alkheder
- Department of Developmental and Preventive Sciences, Faculty of Dentistry, Kuwait University, Kuwait, Kuwait
| | - Muawia Qudeimat
- Department of Developmental and Preventive Sciences, Faculty of Dentistry, Kuwait University, Kuwait, Kuwait
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The changes of intraoperative body temperature in adult liver transplantation: A retrospective study. Hepatobiliary Pancreat Dis Int 2018; 17:496-501. [PMID: 30205926 DOI: 10.1016/j.hbpd.2018.08.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 08/08/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND Body temperature is poorly regulated in patients with end-stage liver disease. Due to the prolonged surgery time and anhepatic time as well as the complex surgical procedures performed in liver transplantation, the body temperature fluctuates greatly. This study investigated the effect of intraoperative body temperature fluctuations on the prognosis of liver recipients. METHODS The body temperatures of liver recipients recorded from the induction of anesthesia (T0) until the end of surgery (T14) were retrieved. The patients were divided into two groups: the hypothermia group (< 35 °C and ≥ 5 min) and the normothermia group (≥ 35 °C or < 35 °C but < 5 min). Intraoperative and postoperative variables were compared between the two groups, and the correlations between the duration of hypothermia and the medical variables were analyzed. RESULTS Of the 107 patients, 67 patients were in the normothermia group, and 40 in the hypothermia group. The lowest body temperature was at 5 min after reperfusion for the whole cohort. Compared with the normothermia group, patients in the hypothermia group were more prone to bleeding, had a longer intubation time and increased rates of bacterial infection and acute pulmonary edema after liver transplantation (P < 0.05). Hypothermia time was positively correlated with bleeding volume, intubation time, units of blood transfusions and intensive care stay, but negatively correlated with urine output. CONCLUSIONS The intraoperative body temperature exhibited a graphical "V" trend, and the lowest temperature was at 5 min after reperfusion. The longer the duration of hypothermia, the more unfavourable the prognosis.
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The Health Care Transition of Youth With Liver Disease Into the Adult Health System: Position Paper From ESPGHAN and EASL. J Pediatr Gastroenterol Nutr 2018; 66:976-990. [PMID: 29570559 DOI: 10.1097/mpg.0000000000001965] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Medical advances have dramatically improved the long-term prognosis of children and adolescents with once-fatal hepatobiliary diseases. However, there is no generally accepted optimal pathway of care for the transition from paediatric care to the adult health system. AIM The purpose of this position paper is to propose a transition process for young people with paediatric onset hepatobiliary diseases from child-centred to adult-centred healthcare services. METHODS Seventeen ESPGHAN/EASL physicians from 13 countries (Austria, Belgium, France, Germany, Hungary, Italy, the Netherlands, Norway, Poland, Spain, Sweden, Switzerland, and United Kingdom) formulated and answered questions after examining the currently published literature on transition from childhood to adulthood. PubMed and Google Scholar were systematically searched between 1980 and January 2018. Quality of evidence was assessed by the Grading of Recommendation Assessment, Development and Evaluation (GRADE) system. Expert opinions were used to support recommendations whenever the evidence was graded weak. All authors voted on each recommendation, using the nominal voting technique. RESULTS We reviewed the literature regarding the optimal timing for the initiation of the transition process and the transfer of the patient to adult services, principal documents, transition multi-professional team components, main barriers, and goals of the general transition process. A transition plan based on available evidence was agreed focusing on the individual young people's readiness and on coordinated teamwork, with transition monitoring continuing until the first year of adult services.We further agreed on selected features of transitioning processes inherent to the most frequent paediatric-onset hepatobiliary diseases. The discussion highlights specific clinical issues that will probably present to adult gastrointestinal specialists and that should be considered, according to published evidence, in the long-term tracking of patients. CONCLUSIONS Transfer of medical care of individuals with paediatric onset hepatobiliary chronic diseases to adult facilities is a complex task requiring multiple involvements of patients and both paediatric and adult care providers.
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Haafiz AB. A mechanism based approach to management of children with end-stage liver disease. Expert Rev Gastroenterol Hepatol 2017; 11:1085-1094. [PMID: 28803487 DOI: 10.1080/17474124.2017.1367662] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Due to parallel advances in surgical and acute care disciplines, liver transplantation (LT) has revolutionized the outlook for children with end-stage liver disease (ESLD). Contrary to advances in technical aspects of LT and the peri-operative care, pre-transplant management of ESLD remains quite a formidable challenge. Areas covered: This review provides mechanisms based management strategies to address common complications of ESLD including malnutrition, amended metabolic pathways, gastrointestinal dysfunction, and development of ascites. Clinically relevant discussion of each paradigm is followed by an account of high impact therapeutic interventions which can be used as guides for formulating management plans. A tabulated summary of the suggested interventions is also provided. Indeed, execution of a dynamic plan tailored to the evolution of pathophysiologic derangements can further enhance outcomes of pediatric LT. Expert commentary: LT has evolved as a dependable therapeutic option for a variety of fatal pediatric liver diseases. However, relative organ shortage remains a formidable challenge. Similarly, consumer expectations continue to grow for sustained improvement of graft and patient survival after LT. In this environment, the level of sophistication applied to the management ESLD before LT stands out as a major opportunity with lasting impact on the future of pediatric LT.
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Affiliation(s)
- Allah B Haafiz
- a Pediatric Transplant Hepatology, Organ Transplant and Hepatobiliary Surgery , King Abdullah Specialized Children Hospital , Riyadh , KSA
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Ganschow R, Ericzon BG, Dhawan A, Sharif K, Martzloff ED, Rauer B, Ng J, Lopez P. Everolimus and reduced calcineurin inhibitor therapy in pediatric liver transplant recipients: Results from a multicenter, prospective study. Pediatr Transplant 2017; 21. [PMID: 28714558 DOI: 10.1111/petr.13024] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/08/2017] [Indexed: 12/31/2022]
Abstract
In a 24-month, multicenter, single-arm, prospective study, 56 pediatric liver transplant patients with or without basiliximab induction were converted at 1-6 months post-transplant from standard calcineurin inhibitor (CN) therapy (± mycophenolic acid), to everolimus with reduced exposure to CNI (tacrolimus n=50, cyclosporine n=6). Steroid therapy was optional. Recruitment was stopped prematurely due to high rates of PTLD, treatment-related serious infections leading to hospitalization and premature study drug discontinuation. Subsequently, patients aged <7 years reverted to local standard-of-care immunosuppression. Mean tacrolimus concentration was above or near the upper end of the maintenance target range (2-5 ng/mL) until after month 6 post-enrollment. The primary variable, mean (SD) change in eGFR from baseline to month 12 (last observation carried forward), was +6.2 (19.5) mL/min/1.73 m2 . Two patients experienced treated biopsy-proven acute rejection. No graft losses or deaths occurred. PTLD occurred in five patients (8.9%) (3/25 [12.0%] patients <2 years, 2/31 aged 2-18 years [6.5%]). Adverse events, serious adverse events, and discontinuation due to adverse events were reported in 100.0%, 76.8%, and 44.6% of patients, respectively. In conclusion, everolimus with reduced CNI improved renal function while maintaining antirejection potency in pediatric liver transplant patients but safety outcomes suggest that patients were overimmunosuppressed.
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Affiliation(s)
- Rainer Ganschow
- Department of Pediatrics, University Medical Center, Bonn, Germany
| | - Bo-Goran Ericzon
- Division of Transplantation Surgery, CLINTEC, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
| | - Anil Dhawan
- Paediatric Liver, Gastrointestinal and Nutrition Center, King's College Hospital, London, UK
| | - Khalid Sharif
- Liver Unit, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
| | | | | | - Jennifer Ng
- Biometrics and Statistical Science, Novartis Pharmaceuticals, East Hanover, NJ, USA
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Cardarelli-Leite L, Fornazari VAV, Peres RR, Salzedas-Neto AA, Gonzalez AM, Szejnfeld D, Goldman SM. The value of percutaneous transhepatic treatment of biliary strictures following pediatric liver transplantation. Radiol Bras 2017; 50:308-313. [PMID: 29085164 PMCID: PMC5656071 DOI: 10.1590/0100-3984.2016.0087] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE To evaluate the percutaneous transhepatic approach to the treatment of biliary strictures in pediatric patients undergoing liver transplantation. MATERIALS AND METHODS This was a retrospective study of data obtained from the medical records, laboratory reports, and imaging examination reports of pediatric liver transplant recipients who underwent percutaneous transhepatic cholangiography, because of clinical suspicion of biliary strictures, between 1st September 2012 and 31 May 2015. Data were collected for 12 patients, 7 of whom were found to have biliary strictures. RESULTS In the 7 patients with biliary strictures, a total of 21 procedures were carried out: 2 patients (28.6%) underwent the procedure twice; 3 (42.8%) underwent the procedure three times; and 2 (28.6%) underwent the procedure four times. Therefore, the mean number of procedures per patient was 3 (range, 2-4), and the average interval between them was 2.9 months (range, 0.8-9.1 months). The drainage tube remained in place for a mean of 5.8 months (range, 3.1-12.6 months). One patient presented with a major complication, hemobilia, which was treated with endovascular embolization. Clinical success was achieved in all 7 patients, and the mean follow-up after drain removal was 15.4 months (range, 5.3-26.7 months). CONCLUSION The percutaneous transhepatic approach to treating biliary strictures in pediatric liver transplant recipients proved safe, with high rates of technical and clinical success, as well as a low rate of complications.
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Affiliation(s)
- Leandro Cardarelli-Leite
- MD, Interventional Radiologist, Department of Diagnostic Imaging, Escola Paulista de Medicina da Universidade Federal de São Paulo (EPM-Unifesp), São Paulo, SP, Brazil
| | - Vinicius Adami Vayego Fornazari
- PhD, Interventional Radiologist, Department of Diagnostic Imaging, Escola Paulista de Medicina da Universidade Federal de São Paulo (EPM-Unifesp), São Paulo, SP, Brazil
| | - Rogério Renato Peres
- MD, Surgeon, Department of Surgery, Escola Paulista de Medicina da Universidade Federal de São Paulo (EPM-Unifesp), São Paulo, SP, Brazil
| | - Alcides Augusto Salzedas-Neto
- PhD, Professor, Department of Surgery, Escola Paulista de Medicina da Universidade Federal de São Paulo (EPM-Unifesp), São Paulo, SP, Brazil
| | - Adriano Miziara Gonzalez
- PhD, Professor, Department of Surgery, Escola Paulista de Medicina da Universidade Federal de São Paulo (EPM-Unifesp), São Paulo, SP, Brazil
| | - Denis Szejnfeld
- PhD, Professor, Department of Diagnostic Imaging, Escola Paulista de Medicina da Universidade Federal de São Paulo (EPM-Unifesp), São Paulo, SP, Brazil
| | - Suzan Menasce Goldman
- PhD, Professor, Department of Diagnostic Imaging, Escola Paulista de Medicina da Universidade Federal de São Paulo (EPM-Unifesp), São Paulo, SP, Brazil
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Abstract
Considerable strides have been made over the last several decades toward improving outcomes in pediatric liver transplantation. Refinements in surgical technique has allowed for the use of living donor and deceased donor split-liver grafts, thus expanding the pool of available organs and reducing waitlist mortality. The use of a multidisciplinary team continues to be paramount in the care of the transplant recipient. With improvements in overall graft and survival, indications for liver transplantation have also broadened. Currently, pediatric transplant patients have a 5-year survival of over 85%. Long-term morbidity is mainly associated with complications from immunosuppression and chronic rejection. Here we review indications for liver transplantation in children, surgical considerations, post-operative complications, and long-term outcomes.
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Affiliation(s)
- Alex G Cuenca
- Department of Surgery, Boston Children's Hospital, 300 Longwood Ave, Fegan 3, Boston 02115, MA
| | - Heung Bae Kim
- Department of Surgery, Pediatric Transplant Center, Boston Children's Hospital, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Khashayar Vakili
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA.
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Abstract
Excellent outcomes over the last 3 decades have made liver transplantation the treatment of choice for many advanced liver disorders. This success also opened liver transplantation to new indications such as liver tumors and metabolic disorders. The emergence of such new indications for liver transplantation is bringing a new stream of patients along with disease-specific challenges. The cumulative number of liver transplant recipients is peaking, requiring novel systems of health care delivery that meet the needs of this special patient population. This article reviews updates and new development in pediatric liver transplantation.
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Affiliation(s)
- Nidhi Rawal
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Maryland Medical Center, 22 South Green Street, Baltimore, MD 21201, USA
| | - Nada Yazigi
- Pediatric Transplant Hepatology, Department of Transplantation, MedStar Georgetown University Hospital, MedStar Georgetown Transplant Institute, PHC#2, 3800 Reservoir Road, Northwest, Washington, DC 20007, USA.
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The intensive care medicine clinical research agenda in paediatrics. Intensive Care Med 2017; 43:1210-1224. [PMID: 28315043 DOI: 10.1007/s00134-017-4729-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Accepted: 02/16/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Intensive Care Medicine set us the task of outlining a global clinical research agenda for paediatric intensive care (PIC). In line with the clinical focus of this journal, we have limited this to research that may directly influence patient care. METHODS Clinician researchers from PIC research networks of varying degrees of formality from around the world were invited to answer two main questions: (1) What have been the major recent advances in paediatric critical care research? (2) What are the top 10 studies for the next 10 years? RESULTS (1) Inclusive databases are well established in many countries. These registries allow detailed observational studies and feasibility testing of clinical trial protocols. Recent trials are larger and more valuable, and (2) most common interventions in PIC are not evidenced-based. Clinical studies for the next 10 years should address this deficit, including: ventilation techniques and interfaces; fluid, transfusion and feeding strategies; optimal targets for vital signs; multiple organ failure definitions, mechanisms and treatments; trauma, prevention and treatment; improving safety; comfort of the patient and their family; appropriate care in the face of medical complexity; defining post-PICU outcomes; and improving knowledge generation and adoption, with novel trial design and implementation strategies. The group specifically highlighted the need for research in resource-limited environments wherein mortality remains often tenfold higher than in well-resourced settings. CONCLUSION Paediatric intensive care research has never been healthier, but many gaps in knowledge remain. We need to close these urgently. The impact of new knowledge will be greatest in resource-limited environments.
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Parmar A, Vandriel SM, Ng VL. Health-related quality of life after pediatric liver transplantation: A systematic review. Liver Transpl 2017; 23:361-374. [PMID: 28006876 DOI: 10.1002/lt.24696] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 11/26/2016] [Indexed: 12/15/2022]
Abstract
With improved survival rates after pediatric liver transplantation (LT), attention is targeting improving the health-related quality of life (HRQOL) as an outcome metric. We conducted a systematic review of the literature to examine HRQOL after pediatric LT, focusing on assessment tools and factors associated with HRQOL. A literature search was conducted through PubMed, Web of Science, Ovid, and Google Scholar for all studies matching the eligibility criteria between January 2004 and September 2016. Titles and abstracts were screened independently by 2 authors and consensus for included studies was achieved through discussion. A total of 25 (2 longitudinal, 23 cross-sectional) studies were reviewed. HRQOL in pediatric LT recipients is lower than healthy controls, but it is comparable to children with chronic diseases or other pediatric solid organ transplant recipients. Domain scores were lowest in school functioning on the Pediatric Quality of Life Inventory (PedsQL) Generic Core Scale 4.0 and general health perception on the Child Health Questionnaire, the 2 most commonly used generic HRQOL instruments. Identified predictors of poor HRQOL include sleep disturbances, medication adherence, and older age at transplantation. Two recently validated disease-specific HRQOL tools, Pediatric Liver Transplant Quality of Life tool and the Pediatric Quality of Life Inventory 3.0 Transplant Module, have enabled enhanced representation of patient HRQOL, when used in conjugation with generic tools. Heterogeneity in study design and instruments prevented a quantitative, meta-analysis of the data. In conclusion, continued optimization of durable outcomes for this population mandates prioritization of research focusing on the gap of targeted intervention studies aimed at specific HRQOL subdomains and longitudinal studies to predict the trajectory of HRQOL over time. Liver Transplantation 23 361-374 2017 AASLD.
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Affiliation(s)
- Arpita Parmar
- Division of Paediatric Gastroenterology, Hepatology and Nutrition, Transplant and Regenerative Medicine Center, The Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - Shannon Marie Vandriel
- Division of Paediatric Gastroenterology, Hepatology and Nutrition, Transplant and Regenerative Medicine Center, The Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - Vicky Lee Ng
- Division of Paediatric Gastroenterology, Hepatology and Nutrition, Transplant and Regenerative Medicine Center, The Hospital for Sick Children, University of Toronto, Ontario, Canada
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Basturk A, Yılmaz A, Sayar E, Dinçkan A, Aliosmanoğlu İ, Erbiş H, Aydınlı B, Artan R. Pediatric Liver Transplantation: Our Experiences. Eurasian J Med 2017; 48:209-212. [PMID: 28149148 DOI: 10.5152/eurasianjmed.2016.0147] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE The aim of our study was to evaluate our liver transplant pediatric patients and to report our experience in the complications and the long-term follow-up results. MATERIALS AND METHODS Patients between the ages of 0 and 18 years, who had liver transplantation in the organ transplantation center of our university hospital between 1997 and 2016, were included in the study. The age, sex, indications for the liver transplantation, complications after the transplantation, and long-term follow-up findings were retrospectively evaluated. The obtained results were analyzed with statistical methods. RESULTS In our organ transplantation center, 62 pediatric liver transplantations were carried out since 1997. The mean age of our patients was 7.3 years (6.5 months-17 years). The 4 most common reasons for liver transplantation were: Wilson's disease (n=10; 16.3%), biliary atresia (n=9; 14.5%), progressive familial intrahepatic cholestasis (n=8; 12.9%), and cryptogenic cirrhosis (n=7; 11.3%). The mortality rate after transplantation was 19.6% (12 of the total 62 patients). The observed acute and chronic rejection rates were 34% and 4.9%, respectively. Thrombosis (9.6%) was observed in the hepatic artery (4.8%) and portal vein (4.8%). Bile leakage and biliary stricture rates were 31% and 11%, respectively. 1-year and 5-year survival rates of our patients were 87% and 84%, respectively. CONCLUSION The morbidity and mortality rates in our organ transplantation center, regarding pediatric liver transplantations, are consistent with the literature.
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Affiliation(s)
- Ahmet Basturk
- Department of Pediatric Gastroenterology, Akdeniz University School of Medicine, Antalya, Turkey
| | - Aygen Yılmaz
- Department of Pediatric Gastroenterology, Akdeniz University School of Medicine, Antalya, Turkey
| | - Ersin Sayar
- Clinic of Pediatrics, Konya Training and Research Hospital, Konya, Turkey
| | - Ayhan Dinçkan
- Department of General Surgery, İstanbul Yeni Yüzyil University School of Medicine, İstanbul, Turkey
| | - İbrahim Aliosmanoğlu
- Department of General Surgery, Akdeniz University School of Medicine, Antalya, Turkey
| | - Halil Erbiş
- Department of General Surgery, Akdeniz University School of Medicine, Antalya, Turkey
| | - Bülent Aydınlı
- Department of General Surgery, Akdeniz University School of Medicine, Antalya, Turkey
| | - Reha Artan
- Department of Pediatric Gastroenterology, Akdeniz University School of Medicine, Antalya, Turkey
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Calinescu AM, McLin V, Spahni S, Boggini T, Randriambelonoro M, Jaquier-Grant R, Steiner M, Geissbuhler A, Wildhaber BE. [KidsETransplant: a serious game for liver transplanted children]. Med Sci (Paris) 2017; 32:1120-1126. [PMID: 28044976 DOI: 10.1051/medsci/20163212016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Serious games are increasingly used in pediatric care, especially to educate young patients with chronic diseases, to improve their understanding of the disease and develop independence in disease management, as it can ultimately improve clinical results. This is also true for liver transplanted children and adolescents, who are not only challenged by their therapeutic burden, but who need to face transition to adult care, often without remembering their transplantation, which was performed, most of the time, very early in their life. KidsETransplant aims to improve long term outcomes of liver transplanted patients, using the principle of a serious game in 3D.
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Affiliation(s)
- Ana-Maria Calinescu
- Centre universitaire romand de chirurgie pédiatrique, Service de chirurgie pédiatrique, Hôpitaux Universitaires de Genève, Rue Willy Donzé 6, 1211 Genève, Suisse
| | - Valérie McLin
- Unité de gastroentérologie et hépatologie pédiatrique, Hôpitaux Universitaires de Genève, Rue Willy Donzé 6, 1211 Genève, Suisse
| | - Stéphane Spahni
- Service de cyber-santé et télémédecine, Hôpitaux Universitaires de Genève, Rue Willy Donzé 6, 1211 Genève, Suisse
| | - Thomas Boggini
- Service de cyber-santé et télémédecine, Hôpitaux Universitaires de Genève, Rue Willy Donzé 6, 1211 Genève, Suisse
| | - Mirana Randriambelonoro
- Service de cyber-santé et télémédecine, Hôpitaux Universitaires de Genève, Rue Willy Donzé 6, 1211 Genève, Suisse
| | - Roxane Jaquier-Grant
- Centre universitaire romand de chirurgie pédiatrique, Service de chirurgie pédiatrique, Hôpitaux Universitaires de Genève, Rue Willy Donzé 6, 1211 Genève, Suisse
| | - Michèle Steiner
- Unité de gastroentérologie et hépatologie pédiatrique, Hôpitaux Universitaires de Genève, Rue Willy Donzé 6, 1211 Genève, Suisse
| | - Antoine Geissbuhler
- Service de cyber-santé et télémédecine, Hôpitaux Universitaires de Genève, Rue Willy Donzé 6, 1211 Genève, Suisse
| | - Barbara E Wildhaber
- Centre universitaire romand de chirurgie pédiatrique, Service de chirurgie pédiatrique, Hôpitaux Universitaires de Genève, Rue Willy Donzé 6, 1211 Genève, Suisse
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van Ginkel WG, Pennings JP, van Spronsen FJ. Liver Cancer in Tyrosinemia Type 1. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2017; 959:101-109. [PMID: 28755188 DOI: 10.1007/978-3-319-55780-9_9] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hereditary Tyrosinemia type I (HT1) is clinically mainly characterised by severe liver disease. Most patients present in their first months of life with liver failure, but others can present later with issues of compensated cirrhosis, renal tubulopathy or acute intermittent porphyria. If patients survive the acute phase with liver failure or if they present later with compensated cirrhosis, they often develop hepatocellular carcinoma early but also later in life. The course of the disease changed after the introduction of 2-(2 nitro-4-3 trifluoro-methylbenzoyl)-1, 3-cyclohexanedione (NTBC), which blocks the tyrosine degradation pathway at an earlier step. Therefore, the toxic products did not accumulate anymore and all clinical problems resolved. However, the risk (although clearly decreased) for developing liver cancer remained, especially if NTBC treatment is initiated late, a slow decrease of the tumor marker α-fetoprotein is seen or if the α-fetoprotein concentrations remain just above the normal range. A rise of α-fetoprotein in these HT1 patients is more or less pathognomonic for liver cancer. Although hepatoblastoma development occurs in HT1 patients, most HT1 patients develop hepatocellular carcinoma (HCC) or a mixed type of carcinoma consisting of HCC and hepatoblastoma. Due to the small risk of liver cancer development, screening for liver cancer (especially HCC) is still recommended in HT1 patients using regular measures of α-fetoprotein and imaging. Ultrasound is mostly the modality of choice for surveillance, because it is widely available, it does not use radiation and is noninvasive. When a suspicious lesion is present, the higher sensitivity of MRI could be used for characterization and staging of lesions. At this moment, no HCC development in pre-symptomatically treated patients is reported. These different situations could possibly indicate that NTBC can prevent the start of the development of HCC when initiated early, but can't stop the development of HCC if it is prescribed at a later stage, stressing the importance of early diagnosis.
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Affiliation(s)
- Willem G van Ginkel
- Beatrix Children's Hospital, Division of Metabolic Diseases, University of Groningen, University Medical Center of Groningen, HPC CA33, Antwoordnummer 333, 9700 VB, Groningen, The Netherlands
| | - Jan P Pennings
- Department of Radiology, University of Groningen, University Medical Center of Groningen, Groningen, The Netherlands
| | - Francjan J van Spronsen
- Beatrix Children's Hospital, Division of Metabolic Diseases, University of Groningen, University Medical Center of Groningen, HPC CA33, Antwoordnummer 333, 9700 VB, Groningen, The Netherlands.
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Breil T, Wenning D, Teufel U, Hoffmann GF, Ries M. An Assessment of Publication Status of Pediatric Liver Transplantation Studies. PLoS One 2016; 11:e0168251. [PMID: 27992485 PMCID: PMC5167264 DOI: 10.1371/journal.pone.0168251] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2016] [Accepted: 11/28/2016] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Pediatric liver transplantation is a highly specialized, challenging field. Selective reporting may introduce bias into evidence based clinical decision making, but the precise extent of unpublished data in pediatric liver transplantation is unknown today. We therefore assessed the public availability of completed clinical trials in pediatric liver transplantation. METHODS We determined the proportion of published and unpublished pre-registered, completed pediatric liver transplantation studies on ClinicalTrials.gov. The major trial and literature databases, i.e., clinicaltrials.gov, Pubmed, and Google Scholar were searched for publications. In addition, principal investigators or sponsors were contacted directly. STROBE criteria were applied for the descriptive analysis. RESULTS Out of N = 33 studies focusing on pediatric liver transplantation registered as completed until March 2014 on clinicaltrials.gov, N = 19 (58%) studies were published until February 2015, whereas N = 14 (42%) studies remained unpublished. The unpublished trials contain data from N = 2105 (35%) patients out of a total population of N = 6044 study participants. Median time-to-publication, i.e., the period from completion of the trial until public availability of the data was 23 IQR 10 to 28 months. Most pertinent key questions in pediatric liver transplantation, i.e., surgical procedures, immunosuppression, concomitant infections, and graft rejection were addressed in 48% of studies (N = 16/33), half of which were published. CONCLUSION Half of the clinical trials in pediatric liver transplantation focused on key questions such as surgical procedures, immunosuppression, concomitant infections, and graft rejection. There is still a considerable amount of unpublished studies results in pediatric liver transplantation. Time from study completion to publication was almost twice as long as the 12 months mandatory FDAAA-timeline with a trend towards acceleration over time. The data should serve as a baseline for future progress in the field. More stringent publication of completed trials and focused multicenter research should be encouraged.
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Affiliation(s)
- Thomas Breil
- Pediatric Gastroenterology and Hepatology, Center for Pediatric and Adolescent Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Daniel Wenning
- Pediatric Gastroenterology and Hepatology, Center for Pediatric and Adolescent Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Ulrike Teufel
- Pediatric Gastroenterology and Hepatology, Center for Pediatric and Adolescent Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Georg F. Hoffmann
- Pediatric Gastroenterology and Hepatology, Center for Pediatric and Adolescent Medicine, Heidelberg University Hospital, Heidelberg, Germany
- Pediatric Neurology and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus Ries
- Pediatric Neurology and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, Heidelberg University Hospital, Heidelberg, Germany
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Sakamoto R, Nakamura K, Kido J, Matsumoto S, Mitsubuchi H, Inomata Y, Endo F. Improvement in the prognosis and development of patients with methylmalonic acidemia after living donor liver transplant. Pediatr Transplant 2016; 20:1081-1086. [PMID: 27670840 DOI: 10.1111/petr.12804] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/15/2016] [Indexed: 01/13/2023]
Abstract
Liver transplant is a treatment option for patients with MMA-emia. While this therapy does not bring about a complete cure, it is expected to prolong survival and improve the QOL of patients. The aim of this study was to evaluate the significance of LDLT for patients with MMA-emia in Japan. Clinical information on 13 patients with MMA-emia who underwent LDLT was acquired using a self-developed questionnaire sent to the doctors who provided medical care to patients with MMA-emia after LDLT. Almost all of the patients continued on a protein-restricted diet, and the number of acidosis attacks had significantly decreased. Physical growth had recovered to within the normal range by 2.5 years after LDLT, especially in patients who underwent LDLT before the age of 1 year. The average propionyl carnitine (C3) level had significantly decreased after LDLT, and the DQs had not worsened. Liver transplant should be performed for MMA-emia in early life. This can be expected to maintain neurological development and improve the growth and QOL of patients. However, LDLT is not a curative treatment for MMA-emia. A protein-restricted diet should be continued, and renal function should be monitored closely, with consideration of a renal transplant.
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Affiliation(s)
| | | | - Jun Kido
- Pediatrics, Kumamoto University, Kumamoto, Japan
| | | | | | - Yukihiro Inomata
- Transplantation and Pediatric Surgery, Kumamoto University, Kumamoto, Japan
| | - Fumio Endo
- Pediatrics, Kumamoto University, Kumamoto, Japan
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Kubitz R, Dröge C, Kluge S, Stindt J, Stross C, Häussinger D, Flechtenmacher C, Wenning D, Teufel U, Schmitt CP, Engelmann G. High affinity anti-BSEP antibodies after liver transplantation for PFIC-2 - Successful treatment with immunoadsorption and B-cell depletion. Pediatr Transplant 2016; 20:987-993. [PMID: 27368585 DOI: 10.1111/petr.12751] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/06/2016] [Indexed: 01/22/2023]
Abstract
PFIC due to BSEP mutations (PFIC type 2) often necessitates OLT. It has recently been recognized that some PFIC-2 patients develop phenotypic disease recurrence post-OLT due to the appearance of anti-BSEP antibodies. Here, we describe a boy who became cholestatic four yr after OLT during modification of immunosuppression. Canalicular antibody deposits were detected in biopsies of the transplant and antibodies specifically reacting with BSEP were identified at high titers in his serum. These antibodies bound extracellular epitopes of BSEP and inhibited BS transport and were assumed to cause disease recurrence. Consequently, anti-BSEP antibody depletion was pursued by IA and B-cell depletion by anti-CD20 antibodies (rituximab) along with a switch of immunosuppression. This treatment resulted in prolonged relief of symptoms. Depletion of pathogenic anti-BSEP antibodies causing AIBD after OLT in PFIC-2 patients should be considered as a central therapeutic goal.
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Affiliation(s)
- Ralf Kubitz
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Carola Dröge
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Stefanie Kluge
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Jan Stindt
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Claudia Stross
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Dieter Häussinger
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | | | - Daniel Wenning
- Department of General Paediatrics, Centre for Paediatric and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
| | - Ulrike Teufel
- Department of General Paediatrics, Centre for Paediatric and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
| | - Claus Peter Schmitt
- Department of General Paediatrics, Centre for Paediatric and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
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Conjeevaram Selvakumar PK, Maksimak B, Hanouneh I, Youssef DH, Lopez R, Alkhouri N. Survival outcomes scores (SOFT, BAR, and Pedi-SOFT) are accurate in predicting post-liver transplant survival in adolescents. Pediatr Transplant 2016; 20:807-12. [PMID: 27478012 DOI: 10.1111/petr.12770] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/27/2016] [Indexed: 12/16/2022]
Abstract
SOFT and BAR scores utilize recipient, donor, and graft factors to predict the 3-month survival after LT in adults (≥18 years). Recently, Pedi-SOFT score was developed to predict 3-month survival after LT in young children (≤12 years). These scoring systems have not been studied in adolescent patients (13-17 years). We evaluated the accuracy of these scoring systems in predicting the 3-month post-LT survival in adolescents through a retrospective analysis of data from UNOS of patients aged 13-17 years who received LT between 03/01/2002 and 12/31/2012. Recipients of combined organ transplants, donation after cardiac death, or living donor graft were excluded. A total of 711 adolescent LT recipients were included with a mean age of 15.2±1.4 years. A total of 100 patients died post-LT including 33 within 3 months. SOFT, BAR, and Pedi-SOFT scores were all found to be good predictors of 3-month post-transplant survival outcome with areas under the ROC curve of 0.81, 0.80, and 0.81, respectively. All three scores provided good accuracy for predicting 3-month survival post-LT in adolescents and may help clinical decision making to optimize survival rate and organ utilization.
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Affiliation(s)
| | - Brian Maksimak
- Department of Pediatric Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Ibrahim Hanouneh
- Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Dalia H Youssef
- Department of Pediatric Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Rocio Lopez
- Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Naim Alkhouri
- Department of Pediatric Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA.,Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
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Wagenaar AE, Tashiro J, Sola JE, Ekwenna O, Tekin A, Perez EA. Pediatric liver transplantation: predictors of survival and resource utilization. Pediatr Surg Int 2016; 32:439-49. [PMID: 27001031 DOI: 10.1007/s00383-016-3881-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/01/2016] [Indexed: 02/06/2023]
Abstract
PURPOSE We sought to identify factors associated with increased resource utilization and in-hospital mortality for pediatric liver transplantation (LT). METHODS Kids' Inpatient Database (1997-2009) was used to identify cases of LT in patients <20 years old. RESULTS Overall, 2905 cases were identified, with an in-hospital survival of 91 %. LT was performed most frequently in < 5 year olds (61 %), females (51 %), and Caucasians (56 %). LT was performed at urban teaching hospitals (97 %) and facilities with children's units (51 %). Indications included pathologic conditions of the biliary tract (44 %) and inborn errors of metabolism (34 %), though unspecified end stage liver disease was the most common (75 %). Logistic regression found higher mortality in children undergoing LT for malignant conditions (odds ratio: 4.8) and acute hepatic failure (OR 3.4). Cases complicated by renal failure (OR 7.7) and complications of LT (OR 2.7) had higher mortality rates. Resource utilization increased for children with renal failure and those with hemorrhage as a complication of LT, p < 0.05. CONCLUSION Hospital survival is predicted by indication and complications associated with LT. Resource utilization increased with renal failure and complications related to LT. Admission length was sensitive to payer status, hospital characteristics, and UNOS region, whereas total costs were unaffected by payer status or hospital type.
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Affiliation(s)
- Amy E Wagenaar
- Division of Pediatric Surgery, DeWitt-Daughtry Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, 1120 NW 14th Street, Suite 450, Miami, FL, 33136, USA
| | - Jun Tashiro
- Division of Pediatric Surgery, DeWitt-Daughtry Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, 1120 NW 14th Street, Suite 450, Miami, FL, 33136, USA
| | - Juan E Sola
- Division of Pediatric Surgery, DeWitt-Daughtry Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, 1120 NW 14th Street, Suite 450, Miami, FL, 33136, USA
| | - Obi Ekwenna
- Miami Transplant Institute, Jackson Memorial Hospital, Miami, FL, USA
| | - Akin Tekin
- Miami Transplant Institute, Jackson Memorial Hospital, Miami, FL, USA
| | - Eduardo A Perez
- Division of Pediatric Surgery, DeWitt-Daughtry Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, 1120 NW 14th Street, Suite 450, Miami, FL, 33136, USA.
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