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Kwon YK, Valentino PL, Healey PJ, Dick AAS, Hsu EK, Perkins JD, Sturdevant ML. Optimizing pediatric liver transplantation: Evaluating the impact of donor age and graft type on patient survival outcome. Pediatr Transplant 2024; 28:e14771. [PMID: 38702924 DOI: 10.1111/petr.14771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 03/05/2024] [Accepted: 04/15/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND We examined the combined effects of donor age and graft type on pediatric liver transplantation outcomes with an aim to offer insights into the strategic utilization of these donor and graft options. METHODS A retrospective analysis was conducted using a national database on 0-2-year-old (N = 2714) and 3-17-year-old (N = 2263) pediatric recipients. These recipients were categorized based on donor age (≥40 vs <40 years) and graft type. Survival outcomes were analyzed using the Kaplan-Meier and Cox proportional hazards models, followed by an intention-to-treat (ITT) analysis to examine overall patient survival. RESULTS Living and younger donors generally resulted in better outcomes compared to deceased and older donors, respectively. This difference was more significant among younger recipients (0-2 years compared to 3-17 years). Despite this finding, ITT survival analysis showed that donor age and graft type did not impact survival with the exception of 0-2-year-old recipients who had an improved survival with a younger living donor graft. CONCLUSIONS Timely transplantation has the largest impact on survival in pediatric recipients. Improving waitlist mortality requires uniform surgical expertise at many transplant centers to provide technical variant graft (TVG) options and shed the conservative mindset of seeking only the "best" graft for pediatric recipients.
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Affiliation(s)
- Yong K Kwon
- Division of Transplantation, Department of Surgery, University of Washington, Seattle, Washington, USA
- Division of Transplantation, Seattle Children's Hospital, Seattle, Washington, USA
- Department of Surgery, Clinical and Bio-Analytics Transplant Laboratory, University of Washington, Seattle, Washington, USA
| | - Pamela L Valentino
- Division of Gastroenterology and Hepatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington, USA
| | - Patrick J Healey
- Division of Transplantation, Department of Surgery, University of Washington, Seattle, Washington, USA
- Division of Transplantation, Seattle Children's Hospital, Seattle, Washington, USA
- Department of Surgery, Clinical and Bio-Analytics Transplant Laboratory, University of Washington, Seattle, Washington, USA
| | - Andre A S Dick
- Division of Transplantation, Department of Surgery, University of Washington, Seattle, Washington, USA
- Division of Transplantation, Seattle Children's Hospital, Seattle, Washington, USA
- Department of Surgery, Clinical and Bio-Analytics Transplant Laboratory, University of Washington, Seattle, Washington, USA
| | - Evelyn K Hsu
- Division of Gastroenterology and Hepatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington, USA
| | - James D Perkins
- Department of Surgery, Clinical and Bio-Analytics Transplant Laboratory, University of Washington, Seattle, Washington, USA
| | - Mark L Sturdevant
- Division of Transplantation, Department of Surgery, University of Washington, Seattle, Washington, USA
- Department of Surgery, Clinical and Bio-Analytics Transplant Laboratory, University of Washington, Seattle, Washington, USA
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2
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Pandurangi S, Mourya R, Nalluri S, Fei L, Dong S, Harpavat S, Guthery SL, Molleston JP, Rosenthal P, Sokol RJ, Wang KS, Ng V, Alonso EM, Hsu EK, Karpen SJ, Loomes KM, Magee JC, Shneider BL, Horslen SP, Teckman JH, Bezerra JA. Diagnostic accuracy of serum matrix metalloproteinase-7 as a biomarker of biliary atresia in a large North American cohort. Hepatology 2024:01515467-990000000-00787. [PMID: 38446707 DOI: 10.1097/hep.0000000000000827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 12/20/2023] [Indexed: 03/08/2024]
Abstract
BACKGROUND AND AIMS High levels of serum matrix metalloproteinase-7 (MMP-7) have been linked to biliary atresia (BA), with wide variation in concentration cutoffs. We investigated the accuracy of serum MMP-7 as a diagnostic biomarker in a large North American cohort. APPROACH AND RESULTS MMP-7 was measured in serum samples of 399 infants with cholestasis in the Prospective Database of Infants with Cholestasis study of the Childhood Liver Disease Research Network, 201 infants with BA and 198 with non-BA cholestasis (age median: 64 and 59 days, p = 0.94). MMP-7 was assayed on antibody-bead fluorescence (single-plex) and time resolved fluorescence energy transfer assays. The discriminative performance of MMP-7 was compared with other clinical markers. On the single-plex assay, MMP-7 generated an AUROC of 0.90 (CI: 0.87-0.94). At cutoff 52.8 ng/mL, it produced sensitivity = 94.03%, specificity = 77.78%, positive predictive value = 64.46%, and negative predictive value = 96.82% for BA. AUROC for gamma-glutamyl transferase = 0.81 (CI: 0.77-0.86), stool color = 0.68 (CI: 0.63-0.73), and pathology = 0.84 (CI: 0.76-0.91). Logistic regression models of MMP-7 with other clinical variables individually or combined showed an increase for MMP-7+gamma-glutamyl transferase AUROC to 0.91 (CI: 0.88-0.95). Serum concentrations produced by time resolved fluorescence energy transfer differed from single-plex, with an optimal cutoff of 18.2 ng/mL. Results were consistent within each assay technology and generated similar AUROCs. CONCLUSIONS Serum MMP-7 has high discriminative properties to differentiate BA from other forms of neonatal cholestasis. MMP-7 cutoff values vary according to assay technology. Using MMP-7 in the evaluation of infants with cholestasis may simplify diagnostic algorithms and shorten the time to hepatoportoenterostomy.
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Affiliation(s)
- Sindhu Pandurangi
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Medical Center of Dallas, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Reena Mourya
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Medical Center of Dallas, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Shreya Nalluri
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Lin Fei
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Shun Dong
- University of Kansas School of Business, Lawrence, Kansas, USA
| | - Sanjiv Harpavat
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Texas Children's Hospital, Houston, Texas, USA
| | - Stephen L Guthery
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Utah and Intermountain Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Jean P Molleston
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Philip Rosenthal
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of California, San Francisco, California, USA
| | - Ronald J Sokol
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Kasper S Wang
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Vicky Ng
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Estella M Alonso
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Evelyn K Hsu
- Division of Pediatric Gastroenterology and Hepatology, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, Washington, USA
| | - Saul J Karpen
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Kathleen M Loomes
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - John C Magee
- Division of Transplant Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Simon P Horslen
- Division of Pediatric Gastroenterology, UPMC Children's Hospital, Pittsburgh, Pennsylvania, USA
| | - Jeffrey H Teckman
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Pediatrics, Cardinal Glennon Children's Hospital, Saint Louis, Missouri, USA
| | - Jorge A Bezerra
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Medical Center of Dallas, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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3
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McAteer J, Kalluri DD, Abedon RR, Qin CX, Auerbach SR, Charnaya O, Danziger-Isakov LA, Ebel NH, Feldman AG, Hsu EK, Mohammad S, Perito ER, Thomas AM, Chiang TPY, Garonzik-Wang JM, Segev DL, Werbel WA, Mogul DB. Omicron Infections in Vaccinated Pediatric Solid Organ Transplant Recipients. J Pediatric Infect Dis Soc 2024; 13:152-154. [PMID: 38035755 PMCID: PMC10896257 DOI: 10.1093/jpids/piad108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Indexed: 12/02/2023]
Abstract
SARS-CoV-2 infection during the Omicron period was frequent amongst a cohort of vaccinated pediatric solid organ transplant recipients (pSOTRs) despite robust anti-receptor-binding domain (anti-RBD) antibody response, suggesting poor neutralizing capacity against Omicron subvariants. Breakthrough infections among pSOTRs were overall limited in severity.
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Affiliation(s)
- John McAteer
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins Children’s Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Division of Nephrology, Department of Pediatrics, Johns Hopkins Children’s Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Divya D Kalluri
- Department of Surgery, The Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rivka R Abedon
- Department of Surgery, The Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Caroline X Qin
- Division of Nephrology, Department of Pediatrics, Johns Hopkins Children’s Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Surgery, The Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Scott R Auerbach
- Division of Cardiology, Department of Pediatrics, Children’s Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Olga Charnaya
- Division of Nephrology, Department of Pediatrics, Johns Hopkins Children’s Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lara A Danziger-Isakov
- Division of Infectious Diseases, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Noelle H Ebel
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Lucile Packard Children’s Hospital Stanford, Stanford University School of Medicine, Palo Alto, California, USA
| | - Amy G Feldman
- Section of Gastroenterology, Hepatology and Nutrition, Digestive Health Institute, Children’s Hospital Colorado, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Evelyn K Hsu
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, Washington, USA
| | - Saeed Mohammad
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Vanderbilt University Medical Center, Vanderbilt University, Nashville, Tennessee, USA
| | - Emily R Perito
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of California San Francisco Benioff Children’s Hospital, University of California San Francisco, San Francisco, California, USA
| | - Ashley M Thomas
- Section of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Johns Hopkins Children’s Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Teresa P Y Chiang
- Department of Surgery, The Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Dorry L Segev
- Division of Transplant Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Milwaukee, Wisconsin, USA
| | - William A Werbel
- Department of Surgery, The Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Douglas B Mogul
- Section of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Johns Hopkins Children’s Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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4
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Shifman HP, Huang CY, Beck AF, Bucuvalas J, Perito ER, Hsu EK, Ebel NH, Lai JC, Wadhwani SI. Association of state Medicaid expansion policies with pediatric liver transplant outcomes. Am J Transplant 2024; 24:239-249. [PMID: 37776976 PMCID: PMC10843745 DOI: 10.1016/j.ajt.2023.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 08/22/2023] [Accepted: 09/14/2023] [Indexed: 10/02/2023]
Abstract
Children from minoritized/socioeconomically deprived backgrounds suffer disproportionately high rates of uninsurance and graft failure/death after liver transplant. Medicaid expansion was developed to expand access to public insurance. Our objective was to characterize the impact of Medicaid expansion policies on long-term graft/patient survival after pediatric liver transplantation. All pediatric patients (<19 years) who received a liver transplant between January 1, 2005, and December 31, 2020 in the US were identified in the Scientific Registry of Transplant Recipients (N = 8489). Medicaid expansion was modeled as a time-varying exposure based on transplant and expansion dates. We used Cox proportional hazards models to evaluate the impact of Medicaid expansion on a composite outcome of graft failure/death over 10 years. As a sensitivity analysis, we conducted an intention-to-treat analysis from time of waitlisting to death (N = 1 1901). In multivariable analysis, Medicaid expansion was associated with a 30% decreased hazard of graft failure/death (hazard ratio, 0.70; 95% confidence interval, 0.62, 0.79; P < .001) after adjusting for Black race, public insurance, neighborhood deprivation, and living in a primary care shortage area. In intention-to-treat analyses, Medicaid expansion was associated with a 72% decreased hazard of patient death (hazard ratio, 0.28; 95% confidence interval, 0.23-0.35; P < .001). Policies that enable broader health insurance access may help improve outcomes and reduce disparities for children undergoing liver transplantation.
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Affiliation(s)
- Holly Payton Shifman
- Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA
| | - Chiung-Yu Huang
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Andrew F Beck
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio, USA
| | - John Bucuvalas
- Division of Pediatric Hepatology, Department of Pediatrics Icahn School of Medicine at Mount Sinai, New York, New York, USA; Division of Pediatric Hepatology, Department of Pediatrics, Kravis Children's Hospital, New York, New York, USA
| | - Emily R Perito
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
| | - Evelyn K Hsu
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Noelle H Ebel
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Stanford University School of Medicine, Lucile Packard Children's Hospital, Stanford, California, USA
| | - Jennifer C Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Sharad I Wadhwani
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA.
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5
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McAteer J, Kalluri DD, Abedon RR, Qin CX, Auerbach SR, Charnaya O, Danziger-Isakov LA, Ebel NH, Feldman AG, Hsu EK, Mohammad S, Perito ER, Thomas AM, Chiang TPY, Garonzik-Wang JM, Segev DL, Werbel WA, Mogul DB. Anti-spike antibody durability after SARS-CoV-2 vaccination in adolescent solid organ transplant recipients. Pediatr Transplant 2024; 28:e14671. [PMID: 38317335 PMCID: PMC11056938 DOI: 10.1111/petr.14671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/09/2023] [Accepted: 11/17/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND Adolescent solid organ transplant recipients (aSOTRs) who received three doses of the COVID-19 mRNA vaccine experience high seroconversion rates and antibody persistence for up to 3 months. Long-term antibody durability beyond this timeframe following three doses of the SARS-CoV-2 mRNA vaccine remains unknown. We describe antibody responses 6 months following the third vaccine dose (D3) of the BNT162b2 mRNA vaccination among aSOTRs. METHODS Participants in a multi-center, observational cohort who received the third dose of the vaccine were analyzed for antibodies to the SARS-CoV-2 spike protein receptor-binding domain (Roche Elecsys anti-SARS-CoV-2-S positive: ≥0.8, maximum: >2500 U/mL). Samples were collected at 1-, 3-, and 6-months post-D3. Participants were surveyed at each timepoint and at 12-months post-D3. RESULTS All 34 participants had positive anti-RBD antibody titers 6 months post-D3. Variations in titers occurred between 3 and 6 months post-D3, with 8/28 (29%) having decreased antibody levels at 6 months compared to 3 months and 2/28 (7%) reporting increased titers at 6 months. The remaining 18/28 (64%) had unchanged antibody titers compared to 3-month post-D3 levels. A total of 4/34 (12%) reported breakthrough infection within 6 months and 3/32 (9%) reported infection after 6-12 months following the third dose of the SARS-CoV-2 mRNA vaccine. CONCLUSIONS The results suggest that antibody durability persists up to 6 months following three doses of the SARS-CoV-2 mRNA in aSOTRs. Demography and transplant characteristics did not differ for those who experienced antibody weaning. Breakthrough infections did occur, reflecting immune-evasive nature of novel variants such as Omicron.
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Affiliation(s)
- John McAteer
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins Children’s Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Division of Nephrology, Department of Pediatrics, Johns Hopkins Children’s Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Divya D. Kalluri
- Department of Surgery, The Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rivka R. Abedon
- Department of Surgery, The Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Caroline X. Qin
- Department of Surgery, The Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Scott R. Auerbach
- Division of Cardiology, Department of Pediatrics, Children’s Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Olga Charnaya
- Division of Nephrology, Department of Pediatrics, Johns Hopkins Children’s Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lara A. Danziger-Isakov
- Division of Infectious Diseases, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Noelle H. Ebel
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Lucile Packard Children’s Hospital Stanford, Stanford University School of Medicine, Palo Alto, California, USA
| | - Amy G. Feldman
- Section of Gastroenterology, Hepatology and Nutrition, Digestive Health Institute, Children’s Hospital Colorado, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Evelyn K. Hsu
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, Washington, USA
| | - Saeed Mohammad
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Vanderbilt University Medical Center, Vanderbilt University, Nashville, Tennessee, USA
| | - Emily R. Perito
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of California San Francisco Benioff Children’s Hospital, University of California San Francisco, San Francisco, California, USA
| | - Ashley M. Thomas
- Section of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Johns Hopkins Children’s Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Teresa P. Y. Chiang
- Department of Surgery, NYU Grossman School of Medicine, New York City, New York, USA
| | - Jacqueline M. Garonzik-Wang
- Division of Transplant Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Milwaukee, Wisconsin, USA
| | - Dorry L. Segev
- Department of Surgery, NYU Grossman School of Medicine, New York City, New York, USA
| | - William A. Werbel
- Department of Surgery, The Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Douglas B. Mogul
- Section of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Johns Hopkins Children’s Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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6
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Wadhwani SI, Kumar WM, Hsu EK. Towards equity in paediatric liver transplantation: improving access and long-term outcomes. Lancet Gastroenterol Hepatol 2023; 8:600-602. [PMID: 37301205 DOI: 10.1016/s2468-1253(23)00099-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 03/29/2023] [Indexed: 06/12/2023]
Affiliation(s)
- Sharad I Wadhwani
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA 94143, USA.
| | - Wasan M Kumar
- Stanford University School of Medicine, Stanford University, Palo Alto, CA, USA
| | - Evelyn K Hsu
- University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA, USA
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7
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Feldman AG, Adams M, Griesemer AD, Horslen S, Kelly B, Mavis AM, Mazariegos GV, Ng VL, Perito ER, Rodriguez-Davalos MI, Squires JE, Tiao G, Yanni GS, Hsu EK. Advancing the Field of Pediatric Liver Transplantation: Urgent Action Items Identified During the 2022 Society of Pediatric Liver Transplantation Meeting. Transplantation 2023; 107:1223-1225. [PMID: 37220339 DOI: 10.1097/tp.0000000000004584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Affiliation(s)
- Amy G Feldman
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, The University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO
| | - Megan Adams
- Department of Surgery, Colorado Center for Transplantation Care, Research and Education, The University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO
| | | | - Simon Horslen
- Division of Gastroenterology, Hepatology and Nutrition, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | | | - Alisha M Mavis
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Duke University, Durham, NC
| | - George V Mazariegos
- Department of Surgery, Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Vicky L Ng
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Emily R Perito
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA
| | - Manuel I Rodriguez-Davalos
- Transplant and Hepatobiliary Surgery, Primary Children's Hospital- Intermountain Healthcare; University of Utah, Salt Lake City, Utah
| | - James E Squires
- Division of Gastroenterology, Hepatology and Nutrition, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Greg Tiao
- Department of Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - George S Yanni
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital of Los Angeles, The Keck USC School of Medicine, Los Angeles, CA
| | - Evelyn K Hsu
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition University of Washington School of Medicine, Seattle Children's Hospital, Seattle, WA
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Berkman ER, Hsu EK, Clark JD, Lewis-Newby M, Dick AAS, Diekema DS, Wightman AG. An Ethical Analysis of Obesity as a Contraindication to Pediatric Liver Transplant Candidacy. Am J Transplant 2023:S1600-6135(23)00360-X. [PMID: 36997027 DOI: 10.1016/j.ajt.2023.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 02/22/2023] [Accepted: 03/21/2023] [Indexed: 03/31/2023]
Abstract
Childhood obesity is becoming more prevalent in the United States (U.S.) and worldwide, including among children in need of liver transplant. Unlike with heart and kidney failure, end stage liver disease (ESLD) is unique in that no widely available medical technology can re-create the life-sustaining function a failing liver. Therefore, delaying life-saving liver transplant for weight loss, for example, is much harder, if not impossible for many pediatric patients, especially those with acute liver failure. For adults in the U.S., guidelines consider obesity a contraindication to liver transplant. While formal guidelines are lacking in children, many pediatric transplant centers also consider obesity a contraindication to pediatric liver transplant. Variations in practice among pediatric institutions may result in biased and ad hoc decisions that worsen health care inequities. In this paper we define and report the prevalence of childhood obesity among children with ESLD, 2) review existing guidelines for liver transplant in adults with obesity, 3) examine pediatric liver transplant outcomes and 4) discuss the ethical considerations of utilizing obesity as a contraindication to pediatric liver transplant informed by the principles of utility, justice and respect for persons.
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Affiliation(s)
- Emily R Berkman
- Division of Pediatric Critical Care Medicine, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA; Division of Bioethics and Palliative Care Medicine, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA; Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington, USA.
| | - Evelyn K Hsu
- Division of Pediatric Gastroenterology and Hepatology, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Jonna D Clark
- Division of Pediatric Critical Care Medicine, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA; Division of Bioethics and Palliative Care Medicine, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA; Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Mithya Lewis-Newby
- Division of Bioethics and Palliative Care Medicine, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA; Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington, USA; Division of Cardiac Critical Care, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - André A S Dick
- Division of Transplantation, Section of Pediatric Transplantation, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Douglas S Diekema
- Division of Bioethics and Palliative Care Medicine, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA; Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington, USA; Division of Pediatric Emergency Medicine, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Aaron G Wightman
- Division of Bioethics and Palliative Care Medicine, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA; Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington, USA; Division of Pediatric Nephrology, University of Washington School of Medicine, Seattle Children's Hospital Seattle, Washington, USA
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9
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Hernández Benabe S, Batsis I, Dipchand AI, Marks SD, McCulloch MI, Hsu EK. Allocation to pediatric recipients around the world: An IPTA global survey of current pediatric solid organ transplantation deceased donation allocation practices. Pediatr Transplant 2023; 27 Suppl 1:e14317. [PMID: 36468320 DOI: 10.1111/petr.14317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 04/25/2022] [Accepted: 04/29/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND There has not been a comprehensive global survey of pediatric-deceased donor allocation practices across all organs since the advent of deceased donor transplantation at the end of the 20th century. As an international community that is responsible for transplanting children, we set out to survey the existing landscape of allocation. We aimed to summarize current practices and provide a snapshot overview of deceased donor allocation practices to children across the world. METHODS The International Registry in Organ Donation and Transplantation (IRODAT, www.irodat.org) was utilized to generate a list of all countries in the world, divided by continent, that performed transplantation. We reviewed the published literature, published allocation policy, individual website references and associated links to publicly available listed allocation policies. Following this, we utilized tools of communication, relationships, and international fellowship to confirm deceased donation pediatric centers and survey pediatric allocation practices for liver, kidney, heart, and lung across the world. We summarize pediatric allocation practices by organ when available using source documents, and personal communication when no source documents were available. RESULTS The majority of countries had either formal or informal policies directed toward minimizing organ distribution disparity among pediatric patients. CONCLUSION Children have long-term life to gain from organ donation yet continue to die while awaiting transplantation. We summarize global strategies that have been employed to provide meaningful and sustained benefit to children on the waitlist.
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Affiliation(s)
| | | | | | - Stephen D Marks
- NIHR Great Ormond Street Hospital Biomedical Research Centre, University College London Great Ormond Street Institute of Child Health, London, UK
| | | | - Evelyn K Hsu
- University of Washington School of Medicine, Seattle, Washington, USA
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10
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Brewer ED, Hsu EK. Multiple organ transplant allocation and unintended impacts on children on the kidney waitlist: Pathway to a mutually beneficial way forward. Pediatr Transplant 2022; 26:e14395. [PMID: 36134702 DOI: 10.1111/petr.14395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 08/10/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Eileen D Brewer
- Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas, USA
| | - Evelyn K Hsu
- Department of Pediatrics, University of Washington School of Medicine/Seattle Children's Hospital, Seattle, Washington, USA
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11
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Qin CX, Auerbach SR, Charnaya O, Danziger-Isakov LA, Ebel NH, Feldman AG, Hsu EK, McAteer J, Mohammad S, Perito ER, Thomas AM, Chiang TP, Garonzik-Wang JM, Segev DL, Mogul DB. Antibody response to three SARS-CoV-2 mRNA vaccines in adolescent solid organ transplant recipients. Am J Transplant 2022; 22:2481-2483. [PMID: 35510786 PMCID: PMC9348453 DOI: 10.1111/ajt.17085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 04/08/2022] [Accepted: 05/02/2022] [Indexed: 01/25/2023]
Affiliation(s)
- Caroline X. Qin
- Division of Gastroenterology, Hepatology, and Nutrition Department of Pediatrics Johns Hopkins Children’s Center Johns Hopkins University School of Medicine Baltimore, Maryland USA
- Department of Surgery The Johns Hopkins Hospital Johns Hopkins University School of Medicine Baltimore, Maryland USA
| | - Scott R. Auerbach
- Division of Cardiology Department of Pediatrics Children’s Hospital Colorado University of Colorado School of Medicine Aurora, Colorado USA
| | - Olga Charnaya
- Division of Nephrology Department of Pediatrics Johns Hopkins Children’s Center Johns Hopkins University School of Medicine Baltimore, Maryland USA
| | - Lara A. Danziger-Isakov
- Division of Infectious Diseases Department of Pediatrics Cincinnati Children’s Hospital Medical Center University of Cincinnati College of Medicine Cincinnati, Ohio USA
| | - Noelle H. Ebel
- Division of Gastroenterology, Hepatology and Nutrition Department of Pediatrics Lucile Packard Children’s Hospital Stanford Stanford University School of Medicine Palo Alto, California USA
| | - Amy G. Feldman
- Section of Gastroenterology, Hepatology and Nutrition Digestive Health Institute Children’s Hospital Colorado University of Colorado School of Medicine Aurora, Colorado USA
| | - Evelyn K. Hsu
- Division of Gastroenterology, Hepatology and Nutrition Department of Pediatrics Seattle Children’s Hospital University of Washington School of Medicine Seattle, Washington USA
| | - John McAteer
- Division of Nephrology Department of Pediatrics Johns Hopkins Children’s Center Johns Hopkins University School of Medicine Baltimore, Maryland USA
- Division of Infectious Diseases Department of Pediatrics Johns Hopkins Children’s Center Johns Hopkins University School of Medicine Baltimore, Maryland USA
| | - Saeed Mohammad
- Division of Gastroenterology, Hepatology and Nutrition Department of Pediatrics Ann & Robert H. Lurie Children’s Hospital of Chicago Northwestern University Feinberg School of Medicine Chicago, Illinois USA
| | - Emily R. Perito
- Division of Gastroenterology, Hepatology and Nutrition Department of Pediatrics University of California San Francisco Benioff Children’s Hospital University of California San Francisco School of Medicine San Francisco, California USA
| | - Ashley M. Thomas
- Division of Gastroenterology, Hepatology, and Nutrition Department of Pediatrics Johns Hopkins Children’s Center Johns Hopkins University School of Medicine Baltimore, Maryland USA
| | - Teresa P.Y. Chiang
- Department of Surgery The Johns Hopkins Hospital Johns Hopkins University School of Medicine Baltimore, Maryland USA
| | - Jacqueline M. Garonzik-Wang
- Department of Surgery University of Wisconsin Health University Hospital University of Wisconsin School of Medicine and Public Health Madison, Wisconsin USA
| | - Dorry L. Segev
- Department of Surgery The Johns Hopkins Hospital Johns Hopkins University School of Medicine Baltimore, Maryland USA
- Department of Surgery New York University Langone Health New York University Grossman School of Medicine New York, New York USA
| | - Douglas B. Mogul
- Division of Gastroenterology, Hepatology, and Nutrition Department of Pediatrics Johns Hopkins Children’s Center Johns Hopkins University School of Medicine Baltimore, Maryland USA
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12
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Ebel NH, Dike PN, Hsu EK. Addressing Racism in Pediatric Liver Transplantation: A Moral Imperative. J Pediatr 2022; 246:8-10. [PMID: 35504347 DOI: 10.1016/j.jpeds.2022.04.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 04/20/2022] [Accepted: 04/27/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Noelle H Ebel
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Stanford University School of Medicine, Lucile Packard Children's Hospital, Stanford, California.
| | - Peace N Dike
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Evelyn K Hsu
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington
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13
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Qin CX, Auerbach SR, Charnaya O, Danziger-Isakov LA, Ebel NH, Feldman AG, Hsu EK, McAteer J, Mohammad S, Perito ER, Thomas AM, Chiang TP, Garonzik-Wang JM, Segev DL, Mogul DB. Antibody response to 2-dose SARS-CoV-2 mRNA vaccination in pediatric solid organ transplant recipients. Am J Transplant 2022; 22:669-672. [PMID: 34517430 PMCID: PMC8653193 DOI: 10.1111/ajt.16841] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 09/02/2021] [Accepted: 09/09/2021] [Indexed: 01/25/2023]
Affiliation(s)
- Caroline X. Qin
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Johns Hopkins Children’s Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA,Department of Surgery, The Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA,Correspondence Caroline X. Qin, Epidemiology Research Group in Organ Transplantation, Baltimore, MD, USA.
| | - Scott R. Auerbach
- Division of Cardiology, Department of Pediatrics, Children’s Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Olga Charnaya
- Division of Nephrology, Department of Pediatrics, Johns Hopkins Children’s Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lara A. Danziger-Isakov
- Division of Infectious Diseases, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Noelle H. Ebel
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Lucile Packard Children’s Hospital Stanford, Stanford University School of Medicine, Palo Alto, California, USA
| | - Amy G. Feldman
- Section of Gastroenterology, Hepatology and Nutrition, Digestive Health Institute, Children’s Hospital Colorado, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Evelyn K. Hsu
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, Washington, USA
| | - John McAteer
- Division of Nephrology, Department of Pediatrics, Johns Hopkins Children’s Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA,Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins Children’s Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Saeed Mohammad
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Emily R. Perito
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of California San Francisco Benioff Children’s Hospital, University of California San Francisco, San Francisco, California, USA
| | - Ashley M. Thomas
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Johns Hopkins Children’s Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Teresa P.Y. Chiang
- Department of Surgery, The Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jacqueline M. Garonzik-Wang
- Department of Surgery, The Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Dorry L. Segev
- Department of Surgery, The Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Douglas B. Mogul
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Johns Hopkins Children’s Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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14
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Monroe EJ, Blondet N, Chick JFB, Hsu EK. Portal Bypass Complicated by Hepatopulmonary Syndrome. JPGN Rep 2022; 3:e155. [PMID: 37168748 PMCID: PMC10158389 DOI: 10.1097/pg9.0000000000000155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 11/03/2021] [Indexed: 05/13/2023]
Affiliation(s)
- Eric J. Monroe
- From the Department of Radiology, Division of Interventional Radiology, American Family Children’s Hospital & University of Wisconsin, Madison, WI
| | - Niviann Blondet
- Division of Gastroenterology and Hepatology, Seattle Children’s Hospital & University of Washington, Seattle, WA
| | | | - Evelyn K. Hsu
- Division of Gastroenterology and Hepatology, Seattle Children’s Hospital & University of Washington, Seattle, WA
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15
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Feldman AG, Squires JE, Hsu EK, Lobritto S, Mohammad S. The current state of pediatric transplant hepatology fellowships: A survey of recent graduates. Pediatr Transplant 2021; 25:e14065. [PMID: 34120405 PMCID: PMC10155256 DOI: 10.1111/petr.14065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/03/2021] [Accepted: 05/17/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND The number of programs offering a PTH fellowship has grown rapidly over the last 10 years. This study aimed to describe the clinical, didactic, procedural, and research experiences of recent PTH fellowship graduates. In addition, we sought to understand graduates' post-fellowship professional responsibilities and their perception about the utility of the PTH fellowship. METHODS An anonymous survey was distributed from February to October 2020 through REDCap to all recent graduates (2015-2019) of an ACGME-approved PTH fellowship program. The survey consisted of 49 questions focused on the PTH fellowship experience. Results were summarized using descriptive statistics. RESULTS Thirty-eight of 43 graduates (88%) responded to the survey representing 12 PTH fellowship programs. The didactic experience varied; 97% received pathology lectures, 81% radiology lectures, 54% organ allocation lectures, 54% procedural lectures, 57% immunology lectures, and 43% live donation lectures. During the PTH fellowship, the majority of fellows performed >10 liver biopsies (82%) and >5 variceal bandings (58%); however, 63%, 32%, 8%, and 8% never performed paracentesis, variceal sclerotherapy, variceal banding, and liver biopsies, respectively. The majority of fellows (95%) completed a research project during PTH fellowship. Currently, 84% of graduates are employed at a transplant academic institution. All graduates recommended the fellowship. CONCLUSIONS There is variability in the didactic, clinical, and procedural training among PTH fellowship programs. Although uniformly viewed as a beneficial fellowship year, there is an opportunity to collaborate to create a more standardized training experience.
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Affiliation(s)
- Amy G Feldman
- Section of Gastroenterology, Hepatology and Nutrition, The Digestive Health Institute, Children's Hospital Colorado, University of Colorado Denver School of Medicine, Aurora, CO, USA
| | - James E Squires
- Division of Gastroenterology, Hepatology and Nutrition, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Evelyn K Hsu
- Division of Gastroenterology, Hepatology and Nutrition, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
| | - Steven Lobritto
- Center for Liver Disease and Transplantation, NY Presbyterian-Morgan Stanley Children's Hospital, New York, NY, USA
| | - Saeed Mohammad
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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16
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Wood NL, Mogul DB, Perito ER, VanDerwerken D, Mazariegos GV, Hsu EK, Segev DL, Gentry SE. Liver simulated allocation model does not effectively predict organ offer decisions for pediatric liver transplant candidates. Am J Transplant 2021; 21:3157-3162. [PMID: 33891805 DOI: 10.1111/ajt.16621] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 04/12/2021] [Accepted: 04/13/2021] [Indexed: 01/25/2023]
Abstract
The SRTR maintains the liver-simulated allocation model (LSAM), a tool for estimating the impact of changes to liver allocation policy. Integral to LSAM is a model that predicts the decision to accept or decline a liver for transplant. LSAM implicitly assumes these decisions are made identically for adult and pediatric liver transplant (LT) candidates, which has not been previously validated. We applied LSAM's decision-making models to SRTR offer data from 2013 to 2016 to determine its efficacy for adult (≥18) and pediatric (<18) LT candidates, and pediatric subpopulations-teenagers (≥12 to <18), children (≥2 to <12), and infants (<2)-using the area under the receiver operating characteristic (ROC) curve (AUC). For nonstatus 1A candidates, all pediatric subgroups had higher rates of offer acceptance than adults. For non-1A candidates, LSAM's model performed substantially worse for pediatric candidates than adults (AUC 0.815 vs. 0.922); model performance decreased with age (AUC 0.898, 0.806, 0.783 for teenagers, children, and infants, respectively). For status 1A candidates, LSAM also performed worse for pediatric than adult candidates (AUC 0.711 vs. 0.779), especially for infants (AUC 0.618). To ensure pediatric candidates are not unpredictably or negatively impacted by allocation policy changes, we must explicitly account for pediatric-specific decision making in LSAM.
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Affiliation(s)
- Nicholas L Wood
- Department of Mathematics, United States Naval Academy, Annapolis, Maryland, USA
| | - Douglas B Mogul
- Department of Pediatrics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Emily R Perito
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Douglas VanDerwerken
- Department of Mathematics, United States Naval Academy, Annapolis, Maryland, USA
| | - George V Mazariegos
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Evelyn K Hsu
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA.,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
| | - Sommer E Gentry
- Department of Mathematics, United States Naval Academy, Annapolis, Maryland, USA
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17
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Perito ER, Squires JE, Bray D, Bucuvalas J, Krise-Confair C, Eisenberg E, Gonzalez-Peralta RP, Gupta N, Hsu EK, Kosmach-Park B, Lobritto S, Logan B, Mohammad S, Ng VL, Pillari T, Rasmussen S, Shemesh E, Soltys K, Szolna J, Superina R, Tunno J, Mazariegos GV. A Learning Health System for Pediatric Liver Transplant: The Starzl Network for Excellence in Pediatric Transplantation. J Pediatr Gastroenterol Nutr 2021; 72:417-424. [PMID: 33560758 DOI: 10.1097/mpg.0000000000002974] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE Learning health systems (LHS) integrate research, improvement, management, and patient care, such that every child receives "the right care at the right time...every time," that is, evidence-based, personalized medicine. Here, we report our efforts to establish a sustainable, productive, multicenter LHS focused on pediatric liver transplantation. METHODS The Starzl Network for Excellence in Pediatric Transplantation (SNEPT) is the first multicenter effort by pediatric liver transplant families and providers to develop shared priorities and a shared agenda for innovation in clinical care. This report outlines SNEPT's structure, accomplishments, and challenges as an LHS. RESULTS We prioritized 4 initial projects: immunosuppression, perioperative anticoagulation, quality of life, and transition of care. We shared center protocols/management to identify areas of practice variability between centers. We prioritized actionable items that address barriers to providing "the right care at the right time" to every pediatric liver transplant recipient: facilitating transparency of practice variation and the connection of practices to patient outcomes, harnessing existing datasets to reduce the burden of tracking outcomes, incorporating patient-reported outcomes into outcome metrics, and accelerating the implementation of knowledge into clinical practice. This has allowed us to strengthen collaborative relationships, design quality improvement projects, and collect pilot data for each of our priority projects. CONCLUSIONS The field of pediatric liver transplantation can be advanced through application of LHS principles. Going forward, SNEPT will continue to unite patient advocacy, big data, technology, and transplant thought leaders to deliver the best care, while developing new, scalable solutions to pediatric transplantation's most challenging problems.
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Affiliation(s)
- Emily R Perito
- University of California San Francisco, Benioff Children's Hospital, San Francisco, CA
| | - James E Squires
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - David Bray
- Patient and Family Voice. Starzl Network for Excellence in Pediatric Transplantation
| | - John Bucuvalas
- Recanati Miller Transplant Institute, Icahn School of Medicine at Mount Sinai, Mount Sinai Kravis Children's Hospital, New York, NY
| | - Cassandra Krise-Confair
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Elizabeth Eisenberg
- Patient and Family Voice. Starzl Network for Excellence in Pediatric Transplantation
| | | | - Nitika Gupta
- Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA
| | - Evelyn K Hsu
- University of Washington School of Medicine, Department of Pediatrics, Division of Gastroenterology and Hepatology, Seattle Children's Hospital, Seattle, WA
| | - Beverly Kosmach-Park
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Steven Lobritto
- Columbia University Medical Center, Children's Hospital of New York, New York, NY
| | - Beth Logan
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Saeed Mohammad
- Northwestern University Feinberg School of Medicine, Lurie Children's Hospital, Chicago, IL
| | - Vicky L Ng
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Eyal Shemesh
- Recanati Miller Transplant Institute, Icahn School of Medicine at Mount Sinai, Mount Sinai Kravis Children's Hospital, New York, NY
| | - Kyle Soltys
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Jonathan Szolna
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Riccardo Superina
- Northwestern University Feinberg School of Medicine, Lurie Children's Hospital, Chicago, IL
| | - John Tunno
- Patient and Family Voice. Starzl Network for Excellence in Pediatric Transplantation
| | - George V Mazariegos
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
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Gorbounova I, Hsu EK. When, Where and How: Lack of Management Consensus for Liver Transplantation in Children With Congenital Extrahepatic Portosystemic Shunts. Liver Transpl 2021; 27:163-164. [PMID: 37160005 DOI: 10.1002/lt.25907] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 09/23/2020] [Indexed: 01/13/2023]
Affiliation(s)
- Irina Gorbounova
- Department of Pediatrics, Division of Gastroenterology and Hepatology, University of Washington School of Medicine, Seattle, WA
| | - Evelyn K Hsu
- Department of Pediatrics, Division of Gastroenterology and Hepatology, University of Washington School of Medicine, Seattle, WA
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19
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Slowik V, Hildreth A, Pacheco MC, Finn LS, King J, Shivaram G, Files M, Hsu EK, Horslen S. Hepatopulmonary Syndrome in an Adolescent With Insidious Hypoxia and Small Intrahepatic Portal Venous Shunts: Posttransplant Benefit From Sildenafil. Pediatr Dev Pathol 2020; 23:467-471. [PMID: 32813578 DOI: 10.1177/1093526620945951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We report a patient without known preexisting liver disease who presented with hepatopulmonary syndrome (HPS) due to aberrant intrahepatic portal venous development leading to portosystemic shunting. Liver transplantation resulted in resolution of portal hypertension and HPS and sildenafil was safely tolerated in the treatment of persistent fatigue and hypoxemia. Twelve months later, patient has normal allograft function and has returned to normal activity.
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Affiliation(s)
- Voytek Slowik
- Division of Gastroenterology Hepatology and Nutrition, Children's Mercy Kansas City, Kansas City, Missouri
| | - Amber Hildreth
- Division of Gastroenterology Hepatology and Nutrition, Presbyterian/St. Luke's Transplant Center, Rocky Mountain Hospital for Children, Denver, Colorado
| | - M Cristina Pacheco
- Department of Laboratories, Seattle Children's Hospital, Seattle, Washington
| | - Laura S Finn
- Department of Laboratories, Seattle Children's Hospital, Seattle, Washington
| | - Jeremy King
- Department of Pediatrics, Kapi'olani Medical Center for Women and Children, Honolulu, Hawaii
| | - Giridhar Shivaram
- Department of Radiology, Seattle Children's Hospital, Seattle, Washington
| | - Matthew Files
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, Washington
| | - Evelyn K Hsu
- Division of Gastroenterology Hepatology and Nutrition, Seattle Children's Hospital, Seattle, Washington
| | - Simon Horslen
- Division of Gastroenterology Hepatology and Nutrition, Seattle Children's Hospital, Seattle, Washington
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20
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Ebel NH, Hsu EK, Dick AAS, Shaffer ML, Carlin K, Horslen SP. Decreased Incidence of Hepatic Artery Thrombosis in Pediatric Liver Transplantation Using Technical Variant Grafts: Report of the Society of Pediatric Liver Transplantation Experience. J Pediatr 2020; 226:195-201.e1. [PMID: 32585237 PMCID: PMC9380891 DOI: 10.1016/j.jpeds.2020.06.053] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 05/26/2020] [Accepted: 06/17/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To evaluate risk factors for hepatic artery thrombosis (HAT) and examine the long-term outcomes of graft and patient survival after HAT in pediatric recipients of liver transplantation. STUDY DESIGN Using multicenter data from the Society of Pediatric Liver Transplantation, Kaplan-Meier and Cox regression analyses were performed on first-time pediatric (aged <18 years) liver transplant recipients (n = 3801) in the US and Canada between 1995 and 2016. RESULTS Of children undergoing their first liver transplantation, 7.4% developed HAT within the first 90 days of transplantation and, of those who were retransplanted, 20.7% developed recurrent HAT. Prolonged warm ischemia times increased the odds of developing HAT (OR, 1.11; P = .02). Adolescents aged 11-17 years (OR, 0.53; P = .03) and recipients with split, reduced, or living donor grafts had decreased odds of HAT (OR, 0.59; P < .001 compared with whole grafts). Fifty percent of children who developed HAT developed graft failure within the first 90 days of transplantation (adjusted hazard ratio, 11.87; 95% CI, 9.02-15.62) and had a significantly higher post-transplant mortality within the first 90 days after transplantation (adjusted hazard ratio, 6.18; 95% CI, 4.01-9.53). CONCLUSIONS These data from an international registry demonstrate poorer long-term graft and patient survival in pediatric recipients whose post-transplant course is complicated by HAT. Notably, recipients of technical variant grafts had lower odds of HAT compared with whole liver grafts.
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Affiliation(s)
- Noelle H. Ebel
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Evelyn K. Hsu
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington,Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, Washington
| | - André A. S. Dick
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington
| | | | - Kristen Carlin
- Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, Washington
| | - Simon P. Horslen
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington,Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, Washington
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21
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Little CJ, Dick AAS, Perkins JD, Hsu EK, Reyes JD. Livers From Pediatric Donation After Circulatory Death Donors Represent a Viable and Underutilized Source of Allograft. Liver Transpl 2020; 26:1138-1153. [PMID: 32403205 DOI: 10.1002/lt.25795] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 04/16/2020] [Accepted: 05/04/2020] [Indexed: 01/13/2023]
Abstract
Despite increased numbers of donation after circulatory death (DCD) donors, pediatric DCD livers are underused. To investigate possible reasons for this discrepancy, we conducted a retrospective cohort study using 2 data sets from the Organ Procurement and Transplantation Network for all deceased liver donors and for all recipients of DCD liver transplants from March 8, 1993, to June 30, 2018. Pediatric (0-12 years) and adolescent (13-17 years) DCD donors were compared with those aged 18-40 years. We found that pediatric DCD allografts are recovered at a significantly lower rate than from 18-to-40-year-old donors (27.3% versus 56.3%; P < 0.001). However, once recovered, these organs are transplanted at a similar rate to those from the 18-to-40-year-old donor cohort (74.7% versus 74.2%). Significantly more pediatric DCD livers (odds ratio [OR], 3.75; confidence interval [CI], 3.14-4.47) were not recovered compared with adult organs, which were most commonly not recovered due to organ quality (10.2% versus 7.1%; P < 0.001). The 10-year relative risks (RRs) for graft failure and patient death were similar between pediatric and adult DCD donors, with adolescent DCD livers demonstrating improved outcomes. DCD livers transplanted into pediatric donors were protective against graft failure (RR, 0.46; 95% confidence interval [CI], 0.21-0.99) and patient death (RR, 0.16; 95% CI, 0.04-0.69). In conclusion, despite lower rates of recovery, pediatric DCD livers represent a viable organ source for certain adults and children.
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Affiliation(s)
| | - Andre A S Dick
- Division of Transplantation, University of Washington Medical Center, Seattle, WA.,Seattle Children's Hospital, Section of Pediatric Transplantation, Seattle, WA
| | - James D Perkins
- Division of Transplantation, University of Washington Medical Center, Seattle, WA
| | - Evelyn K Hsu
- Division of Gastroenterology, Department of Pediatrics, University of Washington Medical Center, Seattle, WA
| | - Jorge D Reyes
- Division of Transplantation, University of Washington Medical Center, Seattle, WA.,Seattle Children's Hospital, Section of Pediatric Transplantation, Seattle, WA
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22
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Rosenthal P, Narkewicz MR, Yao BB, Jolley CD, Lobritto SJ, Wen J, Molleston JP, Hsu EK, Jonas MM, Zha J, Liu L, Leung DH. Ombitasvir, Paritaprevir, Ritonavir, and Dasabuvir Mini-Tabs Plus Ribavirin for Children Aged 3-11 Years with Hepatitis C Genotype 1a. Adv Ther 2020; 37:3299-3310. [PMID: 32451952 PMCID: PMC7467405 DOI: 10.1007/s12325-020-01389-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Indexed: 12/21/2022]
Abstract
Introduction To assess the safety, efficacy, and pharmacokinetics of mini-tablet formulations of ombitasvir (OBV), paritaprevir (PTV), ritonavir, and dasabuvir (DSV) with or without ribavirin for 12 weeks in children infected with chronic hepatitis C virus (HCV) genotype (GT) 1. Methods This is an ongoing, open-label, Phase 2/3 study in children 3–11 years old infected with HCV GT1 who were HCV treatment-naïve and non-cirrhotic. Pediatric mini-tablet formulations of OBV, PTV, ritonavir, and DSV plus ribavirin oral solution were administered for 12 weeks based on body weight. Endpoints included SVR12, adverse events (AEs), and pharmacokinetic parameters. Results Overall, 26 children received OBV, PTV, ritonavir, and DSV plus ribavirin; 14 were 3–8 years old and 12 were 9–11 years old; 35% were male; and all had chronic HCV GT1a infection. The SVR12 rate was 96% (25/26; 95% CI 81.1–99.3), with 1 child failing to achieve SVR12 due to non-adherence and treatment discontinuation. Treatment-emergent AEs of Grade ≥ 3 occurred in 3 children; 2 events in 1 child were considered serious; and none were considered treatment-related. No AEs led to discontinuation of study treatment. The most common AEs were headache (27%), fatigue (23%), pyrexia (19%), and vomiting (19%). Pharmacokinetic results showed mini-tablet formulations of OBV, PTV, DSV, and ritonavir drug exposures were comparable to the adult formulation. Conclusion The mini-tablet combination of OBV, PTV, ritonavir, and DSV plus ribavirin to treat HCV GT1a infection for 12 weeks was highly effective and suitable in children 3–11 years of age. Trial Registration ClinicalTrials.gov identifier, NCT02486406. Electronic supplementary material The online version of this article (10.1007/s12325-020-01389-9) contains supplementary material, which is available to authorized users.
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23
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Murray KF, Gold BD, Shamir R, Agostoni C, Pierre-Alvarez R, Kolacek S, Hsu EK, Chen J. Coronavirus Disease 2019 and the Pediatric Gastroenterologist. J Pediatr Gastroenterol Nutr 2020; 70:720-726. [PMID: 32443019 PMCID: PMC7273939 DOI: 10.1097/mpg.0000000000002730] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 03/30/2020] [Indexed: 12/22/2022]
Affiliation(s)
- Karen F. Murray
- Pediatrics Institute, Cleveland Clinic Children's Hospital, and Cleveland Clinic Children's Hospital for Rehabilitation, Cleveland Clinic, Cleveland, OH
| | - Benjamin D. Gold
- Gi Care for Kids, LLC; Children's Center for Digestive Healthcare, LLC, Atlanta, GA
| | - Raanan Shamir
- Institute for Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center, Lea and Arieh Pickel Chair for Pediatric Research, Sackler Faculty of Medicine, Tel Aviv University, Petach Tikva, Israel
| | - Carlo Agostoni
- Pediatric Intermediate Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy, and Department of Clinical Sciences and Community Health, University of Milan, 20126 Milan, Italy
| | | | - Sanja Kolacek
- Department of Pediatrics, Children's Hospital Zagreb, University of Zagreb Medical School, Zagreb, Klaićeva, Croatia
| | - Evelyn K. Hsu
- Division of Gastroenterology and Hepatology, Liver Transplant Program, Seattle Children's Hospital, Seattle, WA
| | - Jie Chen
- Division of Gastroenterology, Department of Pediatrics, Children's Hospital Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
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24
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Reyes JD, Dick AA, Hendele JB, Perkins JD, Hsu EK. Adults transplanted as children as retransplant candidates: Analysis of outcomes support optimism in a population mislabeled as high risk. Clin Transplant 2020; 34:e13880. [PMID: 32282089 DOI: 10.1111/ctr.13880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/02/2020] [Accepted: 04/05/2020] [Indexed: 11/29/2022]
Abstract
Adult liver transplant programs have heretofore been hesitant to perform liver retransplantation in adult patients who underwent primary liver transplantation as a child (P_A). Areas of concern include: (a) potential disruption in care when transferring from a pediatric to an adult transplant center; (b) generally inferior outcomes of retransplantation; (c) reputation of young adults for non-adherence to post-transplant regimen; and (d) potential higher work effort for equivalent outcomes. To examine these concerns, we reviewed data on all US liver adult retransplants from 10/01/1987 to 9/30/2017. We propensity matched the P_A patients to patients who received both primary and retransplantation as adults (A_A), with ≥550 days between transplants. A mixed Cox proportional hazards model with program size and time period of transplantation as random variables revealed that retransplantation of P_A patients produced no significantly different graft survival or patient survival rates than retransplantation of the matched A_A patients. Therefore, inferior rates of liver retransplantation in these patients and concerns about continuity of care in changing transplant programs are not as believed in the wider liver transplant community. In conclusion, liver transplant centers should be optimistic about retransplanting adults who received their primary transplants as children.
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Affiliation(s)
- Jorge D Reyes
- Division of Transplantation, Department of Surgery, University of Washington, Seattle, Washington.,Section of Pediatric Transplantation, Seattle Children's Hospital, Seattle, Washington
| | - Andre A Dick
- Division of Transplantation, Department of Surgery, University of Washington, Seattle, Washington.,Section of Pediatric Transplantation, Seattle Children's Hospital, Seattle, Washington
| | - James B Hendele
- Division of Transplantation, Department of Surgery, University of Washington, Seattle, Washington
| | - James D Perkins
- Division of Transplantation, Department of Surgery, University of Washington, Seattle, Washington
| | - Evelyn K Hsu
- Section of Pediatric Transplantation, Seattle Children's Hospital, Seattle, Washington.,Division of Gastroenterology and Hepatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
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25
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Ge J, Perito ER, Bucuvalas J, Gilroy R, Hsu EK, Roberts JP, Lai JC. Split liver transplantation is utilized infrequently and concentrated at few transplant centers in the United States. Am J Transplant 2020; 20:1116-1124. [PMID: 31705730 PMCID: PMC7103556 DOI: 10.1111/ajt.15696] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 09/19/2019] [Accepted: 11/01/2019] [Indexed: 01/25/2023]
Abstract
Split liver transplantation (SLT) is 1 strategy for maximizing the number of deceased donor liver transplants. Recent reports suggest that utilization of SLT in the United States remains low. We examined deceased donor offers that were ultimately split between 2010 and 2014. SLTs were categorized as "primary" and "secondary" transplants. We analyzed allocation patterns and used logistic regression to evaluate factors associated with secondary split discard. Four hundred eighteen livers were split: 54% from adult, 46% from pediatric donors. Of the 227 adult donor livers split, 61% met United Network for Organ Sharing "optimal" split criteria. A total of 770 recipients (418 primary and 352 secondary) were transplanted, indicating 16% discard. Ninety-two percent of the 418 primary recipients were children, and 47% were accepted on the first offer. Eighty-seven percent of the 352 secondary recipients were adults, and 7% were accepted on the first offer. Of the 352 pairs, 99% were transplanted in the same region, 36% at the same center. In logistic regression, shorter donor height was associated with secondary discard (odds ratio 0.97 per cm, 95% CI 0.94-1.00, P = .02). SLT volume by center was not predictive of secondary discard. Current policy proposals that incentivize SLT in the United States could increase the number of transplants to children and adults.
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Affiliation(s)
- Jin Ge
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California – San Francisco, San Francisco, CA
| | - Emily R. Perito
- Division of Gastroenterology and Hepatology, Department of Pediatrics, University of California – San Francisco, San Francisco, CA
| | - John Bucuvalas
- Mount Sinai Kravis Children’s Hospital and Recanati/Miller Transplant Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Richard Gilroy
- Liver Transplant Program, Intermountain Medical Center, Murray, UT
| | - Evelyn K. Hsu
- Division of Gastroenterology and Hepatology, Seattle Children’s Hospital, Seattle, WA
| | - John P. Roberts
- Division of Transplant Surgery, Department of Surgery, University of California – San Francisco, San Francisco, CA
| | - Jennifer C. Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California – San Francisco, San Francisco, CA
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26
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Indur Wadhwani S, Hsu EK, Shaffer ML, Anand R, Lee Ng V, Bucuvalas JC. Predicting ideal outcome after pediatric liver transplantation: An exploratory study using machine learning analyses to leverage Studies of Pediatric Liver Transplantation Data. Pediatr Transplant 2019; 23:e13554. [PMID: 31328849 PMCID: PMC7980252 DOI: 10.1111/petr.13554] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 05/21/2019] [Accepted: 06/27/2019] [Indexed: 12/15/2022]
Abstract
Machine learning analyses allow for the consideration of numerous variables in order to accommodate complex relationships that would not otherwise be apparent in traditional statistical methods to better classify patient risk. The SPLIT registry data were analyzed to determine whether baseline demographic factors and clinical/biochemical factors in the first-year post-transplant could predict ideal outcome at 3 years (IO-3) after LT. Participants who received their first, isolated LT between 2002 and 2006 and had follow-up data 3 years post-LT were included. IO-3 was defined as alive at 3 years, normal ALT (<50) or GGT (<50), normal GFR, no non-liver transplants, no cytopenias, and no PTLD. Heat map analysis and RFA were used to characterize the impact of baseline and 1-year factors on IO-3. 887/1482 SPLIT participants met inclusion criteria; 334 had IO-3. Demographic, biochemical, and clinical variables did not elucidate a visual signal on heat map analysis. RFA identified non-white race (vs white race), increased length of operation, vascular and biliary complications within 30 days, and duct-to-duct biliary anastomosis to be negatively associated with IO-3. UNOS regions 2 and 5 were also identified as important factors. RFA had an accuracy rate of 0.71 (95% CI: 0.68-0.74), PPV = 0.83, and NPV = 0.70. RFA identified participant variables that predicted IO-3. These findings may allow for better risk stratification and personalization of care following pediatric liver transplantation.
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Affiliation(s)
| | - Evelyn K. Hsu
- University of Washington School of Medicine, Seattle Children’s Hospital, Seattle, WA
| | | | | | - Vicky Lee Ng
- Hospital for Sick Children, Transplant and Regenerative Medicine Center, University of Toronto, Toronto, Canada
| | - John C. Bucuvalas
- Icahn School of Medicine at Mount Sinai, Kravis Children’s Hospital New York, NY
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27
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Slowik V, Monroe EJ, Friedman SD, Hsu EK, Horslen S. Pressure gradients, laboratory changes, and outcomes with transjugular intrahepatic portosystemic shunts in pediatric portal hypertension. Pediatr Transplant 2019; 23:e13387. [PMID: 30932316 DOI: 10.1111/petr.13387] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 01/22/2019] [Accepted: 01/24/2019] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Indications for TIPS are well described in adults and involve complications of PHTN. Complications from PHTN are associated with PSG of > 12 mm Hg in adults. It is unclear if these parameters apply to children with PHTN. OBJECTIVE To assess whether adult criteria for TIPS placement can be utilized in children, describe laboratory changes over time, and report outcomes. METHODS We performed a retrospective review of 34 pediatric patients who underwent TIPS, examining indications, radiology, PSG reductions, laboratory changes, and outcomes. RESULTS Most patients had PHTN due to parenchymal liver disease including congenital hepatic fibrosis (n = 5), biliary atresia (n = 5), cystic fibrosis-related liver disease (n = 3) and cavernous transformation of the portal vein (n = 6). Indications for TIPS included variceal bleeding, recurrent ascites, and maintenance of portal vein flow following thrombolysis. Variceal bleeding was observed in six children with PSG < 12 mm Hg. Minor complications occurred in eight subjects. Continued bleeding occurred in one patient. Six patients were successfully bridged to transplantation, and three patients died secondary to end-stage disease. Standard laboratory tests stabilized after TIPS placement and hematocrit increased. CONCLUSION TIPS placement in pediatric patients was performed for complications of PHTN. Unlike adult series, a substantial proportion of our cases treated extrahepatic PHTN from cavernous transformation of the portal vein. Children presented with sequelae of PHTN with PSG below 12 mm Hg, below the adult standard. We found TIPS in pediatrics to be safe and effective with laboratory stabilization and improvement in hematocrit.
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Affiliation(s)
- Voytek Slowik
- Division of Gastroenterology and Hepatology, Department of Pediatrics, University of Washington School of Medicine/Seattle Children's Hospital, Seattle, Washington
| | - Eric J Monroe
- Department of Radiology, Seattle Children's Hospital, Seattle, Washington
| | - Seth D Friedman
- Department of Radiology, Seattle Children's Hospital, Seattle, Washington
| | - Evelyn K Hsu
- Division of Gastroenterology and Hepatology, Department of Pediatrics, University of Washington School of Medicine/Seattle Children's Hospital, Seattle, Washington
| | - Simon Horslen
- Division of Gastroenterology and Hepatology, Department of Pediatrics, University of Washington School of Medicine/Seattle Children's Hospital, Seattle, Washington
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28
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Ge J, Hsu EK, Bucuvalas J, Lai JC. Deceased Pediatric Donor Livers: How Current Policy Drives Allocation and Transplantation. Hepatology 2019; 69:1231-1241. [PMID: 30281806 PMCID: PMC6881175 DOI: 10.1002/hep.30295] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Accepted: 09/16/2018] [Indexed: 01/10/2023]
Abstract
Each year, approximately 60 children, representing 12% of waitlist candidates, die awaiting liver transplantation. The current allocation algorithm for pediatric donor livers prioritizes local/regional adults over national children. We attempted to better understand the impact of the present algorithm on pediatric candidates. We analyzed pediatric donor liver offers from 2010 to 2014. Donors and recipients were classified based on age. We mapped allocation and acceptance patterns and used subgroup analyses to explore the significance of donor service areas (DSAs) with low pediatric transplant volumes. We used Cox proportional hazard regressions to evaluate posttransplantation outcomes: 3,318 pediatric donor livers were transplanted into 3,482 recipients, and 45% (1,569) were adults. Of the 1,569 adults, 25% (390) received a pediatric organ that was never offered to children; 52% (204) of these 390 pediatric organs originated in the 37 DSAs, with ≤25 pediatric liver transplantations; 278 children died or were delisted due to illness during the same time, with higher mortality rates in the 37 DSAs (10% versus 6%, P < 0.01). Compared to adults, pediatric recipients aged <12 years had lower risks of posttransplant mortality (hazard ratio, 0.62; 95% confidence interval, 0.46-0.81; P < 0.01). Conclusions: We found that 45% of pediatric donor livers were transplanted into adults: 390 adults were transplanted with pediatric organs never offered to children, while 278 children died or were delisted due to illness, which was more apparent in DSAs with low pediatric transplant volumes; we advocate for a change to allocation policies to allow pediatric organs to be offered to national children with status 1B or Model for End-Stage Liver Disease/Pediatric End-Stage Liver Disease >15 before being offered to local/regional + circle non-status 1A adults.
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Affiliation(s)
- Jin Ge
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California–San Francisco, San Francisco, CA
| | - Evelyn K. Hsu
- Division of Gastroenterology and Hepatology, Seattle Children’s Hospital, Seattle, WA
| | - John Bucuvalas
- Department of Pediatrics and Recanati-Miller Transplant Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jennifer C. Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California–San Francisco, San Francisco, CA
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29
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Monroe EJ, Jeyakumar A, Ingraham CR, Shivaram G, Koo KSH, Hsu EK, Dick AAS. Doppler ultrasound predictors of transplant hepatic venous outflow obstruction in pediatric patients. Pediatr Transplant 2018; 22:e13310. [PMID: 30338622 DOI: 10.1111/petr.13310] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 08/25/2018] [Accepted: 09/03/2018] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To investigate Doppler US and catheter venogram correlates to improve detection of transplant HVOO and avoid unnecessary invasive imaging procedures. MATERIALS AND METHODS A retrospective review was performed in all pediatric OLT patients undergoing catheter venography of the hepatic veins between 2007 and 2017 at a single large tertiary pediatric liver transplant institution. RESULTS Forty-four transplant hepatic venograms in 32 OLT patients were included (mean 1.38, range 1-4 venograms per patient). All venograms were preceded by an independent Doppler US examination. Twenty-one (47.7%) venograms were performed for the investigation of suspected HVOO based on Doppler US alone, 19 (43.2%) were performed for TJLB without suspected HVOO, 4 (9.1%) were performed for both. Sixteen (36.3%) instances of >50% anastomotic stenosis were identified. Mean peak anastomotic velocities were 208 cm/s and 116 cm/s in the presence and absence of a >50% venographic stenosis, respectively (P < 0.004). In all cases where there was a monophasic waveform seen on Doppler US, there was a > 50% stenosis seen on hepatic vein venogram. In all cases where a triphasic waveform was seen on Doppler US, there was no stenosis seen on hepatic vein venogram. CONCLUSION While a Doppler US velocity threshold providing both high sensitivity and specificity has yet to be identified, increasing peak anastomotic velocity and decreasing intrahepatic venous velocity correlate strongly with venographic outflow stenosis. The presence of a triphasic intrahepatic waveform provides good NPV.
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Affiliation(s)
- Eric J Monroe
- Interventional Radiology, Seattle Children's Hospital and University of Washington, Seattle, Washington
| | - Arthie Jeyakumar
- Interventional Radiology, Seattle Children's Hospital and University of Washington, Seattle, Washington
| | - Christopher R Ingraham
- Interventional Radiology, Seattle Children's Hospital and University of Washington, Seattle, Washington
| | - Giri Shivaram
- Interventional Radiology, Seattle Children's Hospital and University of Washington, Seattle, Washington
| | - Kevin S H Koo
- Interventional Radiology, Seattle Children's Hospital and University of Washington, Seattle, Washington
| | - Evelyn K Hsu
- Gastroenterology and Hepatology, Seattle Children's Hospital and University of Washington, Seattle, Washington
| | - Andre A S Dick
- Pediatric Transplantation, Seattle Children's Hospital and University of Washington, Seattle, Washington
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30
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Hsu EK, Horslen SP, Reyes JD. Pediatric End-stage Liver Disease Scores as a Method of Assessing Mortality Risk or Prioritization to Transplantability: Let Us Save the Children. JAMA Pediatr 2018; 172:1015-1017. [PMID: 30242376 DOI: 10.1001/jamapediatrics.2018.2889] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Evelyn K Hsu
- Division of Pediatric Gastroenterology and Hepatology, Department of Pediatrics, University of Washington School of Medicine, Seattle
| | - Simon P Horslen
- Division of Pediatric Gastroenterology and Hepatology, Department of Pediatrics, University of Washington School of Medicine, Seattle
| | - Jorge D Reyes
- Division of Transplant Surgery, Department of Surgery, University of Washington School of Medicine, Seattle
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Leung DH, Wirth S, Yao BB, Viani RM, Gonzalez‐Peralta RP, Jonas MM, Lobritto SJ, Narkewicz MR, Sokal E, Fortuny C, Hsu EK, Del Valle‐Segarra A, Zha J, Larsen L, Liu L, Shuster DL, Cohen DE, Rosenthal P. Ombitasvir/Paritaprevir/Ritonavir With or Without Dasabuvir and With or Without Ribavirin for Adolescents With HCV Genotype 1 or 4. Hepatol Commun 2018; 2:1311-1319. [PMID: 30411078 PMCID: PMC6211326 DOI: 10.1002/hep4.1250] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 07/31/2018] [Indexed: 12/12/2022] Open
Abstract
In adults, treatment of hepatitis C virus (HCV) infection with ombitasvir (OBV)/paritaprevir (PTV)/ritonavir (r) with or without dasabuvir (DSV) and ±ribavirin (RBV) results in high rates of sustained virologic response (SVR). However, these regimens have not been investigated in adolescents. This ongoing, open-label, phase 2/3 study evaluated the pharmacokinetics, safety, and efficacy of OBV/PTV/r+DSV±RBV treatment for 12 weeks in adolescents infected with HCV genotype (GT) 1 without cirrhosis (part 1) and the safety and efficacy of OBV/PTV/r±DSV±RBV treatment for 12 or 24 weeks in adolescents infected with GT1 or GT4 without cirrhosis or with compensated cirrhosis (parts 1 and 2). Patients were 12-17 years of age and treatment naive or interferon experienced. Treatment regimens were based on HCV GT and cirrhosis status. Endpoints were SVR at posttreatment week 12 (SVR12), adverse events (AEs), and pharmacokinetic parameters. Thirty-eight adolescents were enrolled, 66% were female patients, and 76% were White; 42%, 40%, and 18% of patients had HCV GT1a, GT1b, and GT4 infections, respectively. Median age was 15 years (range, 12-17 years), and 1 patient had cirrhosis. The SVR12 rate was 100% (38/38; 95% confidence interval [CI], 90.8%-100%). No treatment-emergent grade 3 or 4 laboratory abnormalities were reported. No serious AEs occurred on treatment, and no AEs led to study drug discontinuation. The most common AEs were headache (21%), fatigue (18%), nasopharyngitis (13%), pruritus (13%), and upper respiratory tract infection (11%). Intensive pharmacokinetic results showed OBV, PTV, DSV, and ritonavir drug exposures were comparable to those seen in adults. Conclusion: Treatment with OBV/PTV/r±DSV±RBV was well tolerated and highly efficacious in adolescents with HCV GT1 or GT4 infection.
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Affiliation(s)
- Daniel H. Leung
- Division of Gastroenterology, Hepatology, and Nutrition, Texas Children’s Hospital and Department of PediatricsBaylor College of MedicineHoustonTX
| | - Stefan Wirth
- HELIOS Medical Center Wuppertal, Department of PediatricsWitten/Herdecke UniversityWuppertalGermany
| | | | - Rolando M. Viani
- AbbVie IncNorth ChicagoIL
- Present address:
University of California San DiegoSchool of MedicineSan DiegoCA
| | - Regino P. Gonzalez‐Peralta
- Department of PediatricsUniversity of Florida College of Medicine and Shands Children’s HospitalGainesvilleFL
- Present address:
Division of GastroenterologyHepatology and Liver TransplantationFlorida Hospital for ChildrenOrlandoFL
| | - Maureen M. Jonas
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children’s Hospital and Department of PediatricsHarvard Medical SchoolBostonMA
| | - Steven J. Lobritto
- New York‐Presbyterian Morgan Stanley Children’s HospitalDepartment of PediatricsColumbia University Medical CenterNew YorkNY
| | - Michael R. Narkewicz
- Digestive Health InstituteChildren’s Hospital Colorado and Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of PediatricsUniversity of Colorado School of MedicineAuroraCO
| | - Etienne Sokal
- Cliniques Universitaires Saint‐Luc, Université Catholique de LouvainBrusselsBelgium
| | - Clàudia Fortuny
- Servei de PediatriaHospital Sant Joan de Déu y Universitat de BarcelonaBarcelonaSpain
| | - Evelyn K. Hsu
- Seattle Children’s Hospital and Department of PediatricsUniversity of Washington School of MedicineSeattleWA
| | | | | | | | - Li Liu
- AbbVie IncNorth ChicagoIL
| | - Diana L. Shuster
- AbbVie IncNorth ChicagoIL
- Present address:
PRA Health SciencesRaleighNC
| | | | - Philip Rosenthal
- Department of PediatricsUniversity of California San FranciscoSan FranciscoCA
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32
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Woerner A, Shivaram G, Koo KSH, Hsu EK, Dick AAS, Monroe EJ. Clinical and Imaging Predictors of Surgical Splenorenal Shunt Dysfunction in Pediatric Patients. J Pediatr Gastroenterol Nutr 2018; 66:e139-e145. [PMID: 29470285 DOI: 10.1097/mpg.0000000000001931] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
PURPOSE Few established criteria exist to prompt angiographic evaluation and intervention for surgically created splenorenal shunts (SRS). Clinical and Doppler ultrasound (DUS) imaging predictors of shunt dysfunction were evaluated in this retrospective study. MATERIALS AND METHODS Consecutive patients undergoing SRS angiography over a 10-year period were retrospectively identified. Preangiography platelet count and DUS measurements of spleen diameter, maximum splenic vein velocity, and maximum shunt velocity were assessed and compared to findings at subsequent catheter angiography. RESULTS Twenty-six SRS angiograms were performed in 16 patients. Two of the 26 procedures were excluded from analysis due to insufficient baseline preangiography clinical and DUS data. In the remaining 24 cases, significant stenosis/occlusion was confirmed at angiography in 20, whereas wide patency was seen in 4. For the 20 cases of angiographically confirmed significant stenosis/occlusion, when compared to baseline post-SRS creation to immediate preangiography evaluation there was a greater decrease in platelet count (-51.8% vs -19.4%), a greater increase in spleen diameter (+13.4% vs +3.7%), a greater increase in maximum shunt velocity (+74.7% vs +59.7%), and a greater decrease in splenic vein velocity (-25.0% vs -18.5%). CONCLUSION Clinical evidence of splenic sequestration and DUS finding of increased maximum shunt velocity correlate with angiographic findings of SRS dysfunction and could be used to help predict the need for shunt intervention.
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Affiliation(s)
| | | | | | | | - Andre A S Dick
- Department of Pediatric Transplantation, Seattle Children's Hospital and University of Washington, Seattle, WA
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Lurz E, Quammie C, Englesbe M, Alonso EM, Lin HC, Hsu EK, Furuya KN, Gupta NA, Venkat VL, Daniel JF, Leonis MA, Miloh T, Telega GW, Yap J, Menendez J, Book LS, Himes RW, Sundaram SS, Parekh R, Sonnenday C, Bucuvalas J, Ng VL, Kamath BM. Frailty in Children with Liver Disease: A Prospective Multicenter Study. J Pediatr 2018; 194:109-115.e4. [PMID: 29478492 DOI: 10.1016/j.jpeds.2017.10.066] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 10/02/2017] [Accepted: 10/26/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To assess frailty, a measure of physiologic declines in multiple organ systems, in children with chronic liver disease using a novel pediatric frailty tool. STUDY DESIGN We performed a prospective cross-sectional multicenter study at 17 liver transplantation (LT) centers. 71 children (5-17 years of age), 36 with compensated chronic liver disease (CCLD) and 35 with end-stage liver disease (ESLD) and listed for LT, were assessed for frailty using validated pediatric tools to assess the 5 classic Fried Frailty Criteria-slowness, weakness, exhaustion, diminished physical activity, and shrinkage. Test scores were translated to age- and sex-dependent z scores, generating a maximum frailty score of 10. RESULTS The median frailty score of the cohort was 4 (IQR 3, 5). Subjects with ESLD had significantly higher frailty scores (median 5; IQR 4, 7) than subjects with CCLD (median 3; IQR 2, 4); (P < .0001). Area under the curve receiver operating characteristic for frailty scores to discriminate between ESLD and CCLD was 0.83 (95% CI 0.73, 0.93). Forty-six percent of children with ESLD were frail and there was no correlation between pediatric frailty scores and physician's global assessments (r = -0.24, 95% CI -0.53, 0.10). CONCLUSIONS A novel frailty tool assessed additional dimensions of health, not captured by standard laboratory measures and identified the sickest individuals among a cohort of children with chronic liver disease. This tool may have applicability to other children with chronic disease.
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Affiliation(s)
- Eberhard Lurz
- Division of Gastroenterology, Hepatology and Nutrition, Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatric, University of Toronto, Toronto, Ontario, Canada
| | - Claudia Quammie
- Division of Gastroenterology, Hepatology and Nutrition, Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatric, University of Toronto, Toronto, Ontario, Canada
| | - Michael Englesbe
- Department of Transplantation Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Estella M Alonso
- Division of Gastroenterology, Hepatology and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Henry C Lin
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Evelyn K Hsu
- Division of Gastroenterology, Hepatology and Nutrition, University of Washington-Seattle Children's Hospital, Seattle, WA, USA
| | - Katryn N Furuya
- Division of Gastroenterology, Hepatology and Nutrition, Alfred I. duPont Hospital for Children, Wilmington, NC, USA; Division of Gastroenterology, Hepatology and Nutrition, Mayo clinic, Rochester, MN, USA
| | - Nitika A Gupta
- Division of Gastroenterology, Hepatology and Nutrition, Children's Healthcare of Atlanta Emory University School of Medicine, Atlanta, GA, USA
| | - Veena L Venkat
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - James F Daniel
- Division of Pediatric Gastroenterology, Children's Mercy Hospital, Kansas City, MO, USA
| | - Mike A Leonis
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Tamir Miloh
- Division of Gastroenterology, Hepatology and Nutrition, Phoenix Children's Hospital, Phoenix, AZ, USA; Division of Gastroenterology, Hepatology and Nutrition, Texas Children's Hospital, Houston, TX, USA
| | - Grzegorz W Telega
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Jason Yap
- Division of Gastroenterology, Hepatology and Nutrition, Stollery Children's Hospital/Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Jerome Menendez
- Division of Pediatric Gastroenterology, Levine Children's Hospital Carolinas Health Care Center, Charlotte, NC, USA
| | - Linda S Book
- Division of Pediatric Gastroenterology, Primary Children's Hospital, Salt Lake, UT, USA
| | - Ryan W Himes
- Division of Gastroenterology, Hepatology and Nutrition, Texas Children's Hospital, Houston, TX, USA
| | - Shikha S Sundaram
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital Colorado, Aurora, CO, USA
| | - Rulan Parekh
- Division of Gastroenterology, Hepatology and Nutrition, Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatric, University of Toronto, Toronto, Ontario, Canada
| | - Chris Sonnenday
- Department of Transplantation Surgery, University of Michigan, Ann Arbor, MI, USA
| | - John Bucuvalas
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Vicky L Ng
- Division of Gastroenterology, Hepatology and Nutrition, Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatric, University of Toronto, Toronto, Ontario, Canada
| | - Binita M Kamath
- Division of Gastroenterology, Hepatology and Nutrition, Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatric, University of Toronto, Toronto, Ontario, Canada.
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Weaver JJ, Dobrow EM, Hsu EK, Monroe EJ. Single-access liver floss technique with antegrade hepatic vein access and recanalization in Budd-Chiari syndrome. Diagn Interv Radiol 2018; 24:38-41. [PMID: 29187341 PMCID: PMC5765927 DOI: 10.5152/dir.2017.17327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 08/29/2017] [Accepted: 10/10/2017] [Indexed: 03/14/2024]
Abstract
A 14-year-old boy presented with several months of increasing abdominal girth and fatigue. Imaging confirmed massive ascites and hepatic congestion secondary to central hepatic venous obstruction. Several large intrahepatic collateral veins were seen draining via caudate and emissary veins. After an unsuccessful attempt at retrograde recanalization utilizing intravascular ultrasound, the right hepatic vein was recanalized in an antegrade fashion by way of a prominent caudate collateral vein, and subsequently stented. We herein discuss the established treatment options for Budd-Chiari syndrome and describe our experience employing a single-access liver floss technique.
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Affiliation(s)
- John J. Weaver
- From the Departments of Radiology (J.J.W., E.J.M ) and Gastroenterology and Hepatology (E.K.H.), Seattle Children’s Hospital, Seattle, WA, USA; Department of Radiology (J.J.W., E.M.D., E.J.M.), University of Washington, Seattle, WA, USA
| | - Ethan M. Dobrow
- From the Departments of Radiology (J.J.W., E.J.M ) and Gastroenterology and Hepatology (E.K.H.), Seattle Children’s Hospital, Seattle, WA, USA; Department of Radiology (J.J.W., E.M.D., E.J.M.), University of Washington, Seattle, WA, USA
| | - Evelyn K. Hsu
- From the Departments of Radiology (J.J.W., E.J.M ) and Gastroenterology and Hepatology (E.K.H.), Seattle Children’s Hospital, Seattle, WA, USA; Department of Radiology (J.J.W., E.M.D., E.J.M.), University of Washington, Seattle, WA, USA
| | - Eric J. Monroe
- From the Departments of Radiology (J.J.W., E.J.M ) and Gastroenterology and Hepatology (E.K.H.), Seattle Children’s Hospital, Seattle, WA, USA; Department of Radiology (J.J.W., E.M.D., E.J.M.), University of Washington, Seattle, WA, USA
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Hsu EK, Shaffer ML, Gao L, Sonnenday C, Volk ML, Bucuvalas J, Lai JC. Analysis of Liver Offers to Pediatric Candidates on the Transplant Wait List. Gastroenterology 2017; 153:988-995. [PMID: 28711630 PMCID: PMC6288076 DOI: 10.1053/j.gastro.2017.06.053] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 06/13/2017] [Accepted: 06/26/2017] [Indexed: 12/02/2022]
Abstract
BACKGROUND & AIMS Approximately 10% of children on the liver transplant wait-list in the United States die every year. We examined deceased donor liver offer acceptance patterns and their contribution to pediatric wait-list mortality. METHODS We performed a retrospective cohort study of children on the US liver transplant wait-list from 2007 through 2014 using national transplant registry databases. We determined the frequency, patterns of acceptance, and donor and recipient characteristics associated with deceased donor liver organ offers for children who died or were delisted compared with those who underwent transplantation. Children who died or were delisted were classified by the number of donor liver offers (0 vs 1 or more), limiting analyses to offers of livers that were ultimately transplanted into pediatric recipients. The primary outcome was death or delisting on the wait-list. RESULTS Among 3852 pediatric liver transplant candidates, children who died or were delisted received a median 1 pediatric liver offer (inter-quartile range, 0-2) and waited a median 33 days before removal from the wait-list. Of 11,328 donor livers offered to children, 2533 (12%) were transplanted into children; 1179 of these (47%) were immediately accepted and 1354 (53%) were initially refused and eventually accepted for another child. Of 27,831 adults, 1667 (6.0%; median, 55 years) received livers from donors younger than 18 years (median, 15 years), most (97%) allocated locally or regionally. Of children who died or were delisted, 173 (55%) received an offer of 1 or more liver that was subsequently transplanted into another pediatric recipient, and 143 (45%) died or were delisted with no offers. CONCLUSIONS Among pediatric liver transplant candidates in the US, children who died or were delisted received a median 1 pediatric liver offer and waited a median of 33 days. Of livers transplanted into children, 47% were immediately accepted and 53% were initially refused and eventually accepted for another child. Of children who died or were delisted, 55% received an offer of 1 or more liver that was subsequently transplanted into another pediatric recipient, and 45% died or were delisted with no offers. Pediatric prioritization in the allocation and development of improved risk stratification systems is required to reduce wait-list mortality among children.
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Affiliation(s)
- Evelyn K. Hsu
- University of Washington School of Medicine, Seattle, Washington
| | - Michele L. Shaffer
- University of Washington School of Medicine, Seattle, Washington;,Seattle Children’s Core for Biomedical Statistics, Seattle, Washington
| | - Lucy Gao
- Department of Biostatistics, University of Washington, Seattle, Washington
| | | | | | - John Bucuvalas
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Jennifer C. Lai
- Division of Gastroenterology and Hepatology, University of California San Francisco, San Francisco, California
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Hsu EK, Mazariegos GV. Global lessons in graft type and pediatric liver allocation: A path toward improving outcomes and eliminating wait-list mortality. Liver Transpl 2017; 23:86-95. [PMID: 27706890 PMCID: PMC6767049 DOI: 10.1002/lt.24646] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 09/24/2016] [Indexed: 12/11/2022]
Abstract
Current literature and policy in pediatric liver allocation and organ procurement are reviewed here in narrative fashion, highlighting historical context, ethical framework, technical/procurement considerations, and support for a logical way forward to an equitable pediatric liver allocation system that will improve pediatric wait-list and posttransplant outcomes without adversely affecting adults. Where available, varying examples of successful international pediatric liver allocation and split-liver policy will be compared to current US policy to highlight potential strategies that can be considered globally. Liver Transplantation 23:86-95 2017 AASLD.
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Affiliation(s)
- Evelyn K. Hsu
- University of Washington School of Medicine, Seattle Children's HospitalSeattleWA
| | - George V. Mazariegos
- Pediatric Transplant Surgery, Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of UPMCPittsburghPA
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Hsu EK, Bucuvalas J. The Trouble With Exceptional Exceptions. Am J Transplant 2016; 16:3073-3074. [PMID: 27305346 DOI: 10.1111/ajt.13920] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Revised: 06/06/2016] [Accepted: 06/08/2016] [Indexed: 01/25/2023]
Affiliation(s)
- E K Hsu
- Department of Pediatrics and Department of Transplantation, Seattle Children's Hospital, Seattle, WA
| | - J Bucuvalas
- Pediatric Liver Care Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
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Choy CS, Chen H, Yau CS, Hsu EK, Chik NY, Wong AT. Prevalence of infections among residents of Residential Care Homes for the Elderly in Hong Kong. Hong Kong Med J 2016; 22:347-55. [PMID: 27380752 DOI: 10.12809/hkmj164865] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION A point prevalence study was conducted to study the epidemiology of common infections among residents in Residential Care Homes for the Elderly in Hong Kong and their associated factors. METHODS Residential Care Homes for the Elderly in Hong Kong were selected by stratified single-stage cluster random sampling. All residents aged 65 years or above from the recruited homes were surveyed. Infections were identified using standardised definitions. Demographic and health information-including medical history, immunisation record, antibiotic use, and activities of daily living (as measured by Barthel Index)-was collected by a survey team to determine any associated factors. RESULTS Data were collected from 3857 residents in 46 Residential Care Homes for the Elderly from February to May 2014. A total of 105 residents had at least one type of infection based on the survey definition. The overall prevalence of all infections was 2.7% (95% confidence interval, 2.2%-3.4%). The three most common infections were of the respiratory tract (1.3%; 95% confidence interval, 0.9%-1.9%), skin and soft tissue (0.7%; 95% confidence interval, 0.5%-1.0%), and urinary tract (0.5%; 95% confidence interval, 0.3%-0.9%). Total dependence in activities of daily living, as indicated by low Barthel Index score of 0 to 20 (odds ratio=3.0; 95% confidence interval, 1.4-6.2), and presence of a wound or stoma (odds ratio=2.7; 95% confidence interval, 1.4-4.9) were significantly associated with presence of infection. CONCLUSIONS This survey provides information about infections among residents in Residential Care Homes for the Elderly in the territory. Local data enable us to understand the burden of infections and formulate targeted measures for prevention.
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Affiliation(s)
- C Sm Choy
- Accident and Emergency Department, Queen Elizabeth Hospital, Jordan, Hong Kong
| | - H Chen
- Infection Control Branch, Centre for Health Protection, Hong Kong
| | - C Sw Yau
- Surveillance and Epidemiology Branch, Centre for Health Protection, Hong Kong
| | - E K Hsu
- Infection Control Branch, Centre for Health Protection, Hong Kong
| | - N Y Chik
- Infection Control Branch, Centre for Health Protection, Hong Kong
| | - A Ty Wong
- Infection Control Branch, Centre for Health Protection, Hong Kong
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Abstract
Ascites is the pathologic accumulation of fluid within the peritoneal cavity. There are many causes of fetal, neonatal and pediatric ascites; however, chronic liver disease and subsequent cirrhosis remain the most common. The medical and surgical management of ascites in children is dependent on targeting the underlying etiology. Broad categories of management strategies include: sodium restriction, diuresis, paracentesis, intravenous albumin, prevention and treatment of infection, surgical and endovascular shunts and liver transplantation. This review updates and expands the discussion of the unique considerations regarding the management of cirrhotic and non-cirrhotic ascites in the pediatric patient.
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Affiliation(s)
- Erin R Lane
- a 1 Pediatric Gastroenterology, University of Washington School of Medicine, 4800 Sand Point Way, NE, PO Box 5371/OB.9.640, Seattle, WA 98105, USA
| | - Evelyn K Hsu
- b 2 Division of Gastroenterology and Hepatology Seattle Children's and the University of Washington, PO Box 5371/OB.9.640, Seattle, WA 98155, USA
| | - Karen F Murray
- b 2 Division of Gastroenterology and Hepatology Seattle Children's and the University of Washington, PO Box 5371/OB.9.640, Seattle, WA 98155, USA
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Hsu EK, Shaffer M, Bradford M, Mayer-Hamblett N, Horslen S. Heterogeneity and disparities in the use of exception scores in pediatric liver allocation. Am J Transplant 2015; 15:436-44. [PMID: 25612496 DOI: 10.1111/ajt.13089] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Revised: 08/20/2014] [Accepted: 09/07/2014] [Indexed: 01/25/2023]
Abstract
Physicians apply for Model for End-Stage Liver Disease/Pediatric End-Stage Liver Disease exception points on a case-by-case basis to improve an individual patient's chances of receiving a liver transplant. This retrospective cohort study describes trends in the use of exceptions among the pediatric liver waitlist population with chronic liver disease. The cohort (n = 3728) included all children with a diagnosis of chronic liver disease listed in the United Network for Organ Sharing transplant database for first isolated liver transplant between February 27, 2002 and March 31, 2013. Exception score requests were common (34%); 90% of requests were approved. The rate of exception score requests in 2013 was five times that of 2002 (incident rate ratios [IRR] 5.25, 95% confidence interval [CI] 3.19-8.63, p < 0.01). Patients of non-White race had exception score request rates 13% lower than patients of White race (IRR 0.87, 95% CI 0.77-0.98, p = 0.02). Older patients had lower rates of exception score requests than younger patients (p = 0.03). Request rates varied by region. Time spent at an active exception status nearly tripled the hazard rate for transplantation (hazard ratio = 2.90, 95% CI 2.62-3.21, p < 0.01). There is disparity in use of exceptions by race that is not explained by clinical disease severity, diagnosis, geography or other demographic factors.
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Affiliation(s)
- E K Hsu
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington; Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington
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Hsu EK, Chugh P, Kronman MP, Markowitz JE, Piccoli DA, Mamula P. Incidence of perforation in pediatric GI endoscopy and colonoscopy: an 11-year experience. Gastrointest Endosc 2013; 77:960-6. [PMID: 23433599 DOI: 10.1016/j.gie.2012.12.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Accepted: 12/26/2012] [Indexed: 12/13/2022]
Affiliation(s)
- Evelyn K Hsu
- Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington 98115, USA
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