Liver transplantation in children weighing less than 10 kg: Chilean experience

BACKGROUND

Orthotopic liver transplantation is the treatment of choice for most terminal liver diseases in children. In small children (≤ 10 kg), this procedure is challenging and has special considerations. The aim of this study is to describe the experience of a Chilean liver transplantation program in this subgroup of patients.

METHODS

The liver transplant database of Hospital Luis Calvo Mackenna and Clinica Las Condes was reviewed. All children less than 10 kg undergoing liver transplantation between January 1994 and July 2011 were included. Patient and graft outcomes and main complications were analyzed.

RESULTS

We have performed 230 pediatric liver transplantations, 49 of them in 41 patients weighing less than 10 kg. The first indication for transplantation was biliary atresia in 25 patients (61%). A living related donor was used in 23 cases (51%). Actuarial survival was 75.7% at 1 year and 67.1% at 5 years. The main cause of death was infection, and the leading cause of graft loss was vascular complication.

DISCUSSION

Our transplant program includes 2 centers that perform more than 90% of pediatric liver transplantations in Chile, including public health pediatric patients from all around the country. Patients weighing less than 10 kg represent the most challenging group in pediatric liver transplantation due to higher rates of vascular and biliary complications and postoperative infections.

Chilean experience in liver transplantation for acute liver failure in children

BACKGROUND

Acute liver failure (ALF) in children is a life-threatening condition, associated with high mortality, and in almost one third of the cases, with no other therapeutic option than orthotopic liver transplant (OLT). The aim of this study was to present our experience with OLT for ALF in pediatric patients in Chile. Patients fulfilling the criteria for ALF who were transplanted in our centers were prospectively included in an excel Microsoft database. We analyzed demographics, etiology, surgical techniques, complications, and long-term results.

PATIENTS AND METHODS

Between 1994 and 2009, we transplanted 52 pediatric patients with ALF. The most frequent known etiology was acute hepatitis A in 9 cases (18%), but in 26 cases (50%) it was impossible to determine the etiology. Thirty- one patients were males (63%). The overall mean age was 7.5 years and the mean weight, 28.1 kg. Thirty-five (67%) received a cadaveric graft. Among them in 18 cases (34%) the liver had to be reduced but 17 (33%) received whole livers. There were 17 (33%) recipients of living-related livers. Twenty-two patients needed reoperation, including 13 due to surgical complications (59%) and 9 (41%) as planned interventions. Ten patients were retransplanted.

RESULTS

Actuarial survival of patients at 1 year was 80% and at 5 and 10 years, 72%. Graft survival at 1 year was 79%, at 5 years 69%, and at 10 years 50%.

CONCLUSION

We have reported a series of pediatric liver transplant patients due to ALF whose results were comparable to other reported series. Living donor transplantation for ALF should be considered and offers a low morbidity rate without mortality.

Family interactions of liver transplanted children: are they normal?

Several psychosocial and behavioral problems have been reported in liver transplanted children. Most publications have focused on them, without considering their family environment. The aim of this study was to evaluate the interaction between liver transplanted children and their families, compared with a healthy control group. We selected liver transplanted children, between 8 and 12 years of age, with at least 6 months follow-up posttransplantation and in good clinical condition. Family structure also included 1 to 3 other children. Evaluable patients must have been living with their parents throughout the whole posttransplantation period. They were compared with a similar group of children without any chronic disease. A written informed consent was signed by both parents. All families were evaluated using a standard test consisting of different situations. The information was evaluated by 3 independent experts. Factors evaluated were limits (rules and limits of behavior), alliance-opposition (interaction between members to act), and hierarchy. Scoring was given to all observed acts. Statistical analysis was performed using chi-square tests with P < .05 considered significant. No statistical differences were found between groups in limits, alliance, and hierarchy. Our results showed that there were no differences in family structure and behavior between families of liver-transplanted and healthy children belonging to a similar socioeconomic level.

Pediatric Liver Retransplantation: Indications and Outcome

INTRODUCTION

Liver transplantation is the only treatment for end-stage liver disease. Not all patients have a favorable outcome. Graft failure secondary to primary nonfunction, vascular complications, or chronic rejection among other problems may lead to retransplantation. Retransplantation represents 8% to 29% of liver transplantations in the pediatric population. The aim of this study was to present our experience with retransplanted children by analyzing the indications and the results.

METHODS

All patients were prospectively included in our database, including 125 children. We included the indications for retransplantation, complications, and mortality. Kaplan-Meier curves were used for survival analysis.

RESULTS

Since 1994, 125 patients were transplanted and 25 were retransplanted (20%), including 5 who received a third graft. Primary nonfunction represented 30% of the indications for retransplantation and hepatic artery thrombosis, 20%. Six of 25 patients who received a first retransplantation and 2 of 5 who received a second retransplantation died. The most frequent cause of death was multiorgans failure. The survivals at 1 and 5 years were 82% and 76% for children receiving a first retransplantation, and 60% at 1 and 5 years for those who received a second retransplantation.

CONCLUSIONS

Organ failure after liver transplantation was a common event in pediatric transplantation. Survival was similar between patients transplanted once and those who received one retransplantation. Survival decreased among patients who received a third graft but was maintained at 60%, which is better than most published results for first retransplanted patients. Retransplantation is a valid option with good results for selected pediatric cases.

Living Related Liver Transplantation. Why This Option Has Been Discarded in a Pediatric Liver Transplant Program in Chile

Living related living transplantation (LRLT) has opened new possibilities for planning transplantation in better conditions for children with emergency situations and chronic liver diseases. Since we began the LRLT program in 1999, we have performed 57 pediatric liver transplants, 17 (29.8%) using living related donors (LRD). The aim of this study was to analyze the reasons why LRD were discarded as a therapeutic option. All pediatric patients were prospectively included in our Microsoft Excel database that was reviewed for obtaining information about causes why the LRLT could not be done. LRLT was proposed in 28 cases and performed in 17 (60.7%). The reasons for LRD rejection were: parent's fear of surgical complications in four cases; drug abuse in two; a mother without family support; medical reasons in two; and only one, due to anatomical reasons and in one case, cadaveric graft transplantation was performed while completing the father's evaluation. From these eleven cases, the indications for liver transplant were acute liver failure (ALF) in seven, biliary atresia in three, and Alagille syndrome in one. Nine were transplanted with cadaveric organs, but two patients with ALF died awaiting a liver. Efforts should be made to clarify the advantages and the disadvantages of LRD in each case, allowing parents to make a free, well-informed decision.

Pediatric Liver Transplantation: Ten Years of Experience in a Multicentric Program in Chile

Liver transplantation is the only treatment for patients with terminal acute and chronic diseases. Liver transplantation was started in Chile in 1985; our pediatric program began in 1993. The aim of this paper work was to present our experience from 1993 through 2004. One hundred and thirty two orthotopic liver transplants (OLT) were performed in children of mean age 5 years and median age 4 years (8 months to 15 years). The most frequent indications were biliary atresia, (43.1%) and acute liver failure (ALF; 20.4%), whose frequent cause was unknown but viral hepatitis A was the second one. A complete liver was transplanted in 59 patients, reduced in 39, split in one, and as an auxiliary liver in another one. Living related liver transplantation was performed in 32 cases (24.2%), of which thirty included segments II and III, and two, a right liver. A terminal arterial anastomosis was performed in 102 (77.2%) recipients and a graft interposition in 32 patients (24.2%). In 16 cases, biliary reconstruction was performed through an enterobiliary anastomosis. Immunosuppression included cyclosporine (Neoral), steroids, and azathioprine with conversion to tacrolimus (Prograf) as indicated. Rejection episodes, which were always biopsy-proven, were treated either with methylprednisolone or with antibodies. Biliary complications were the most frequent (21.4%) and the second cause was vascular complications (13%). Sixty-six patients suffered an acute rejection episode. Actuarial graft survival was 81.3% at 1 year and 72% at 5 years, while actuarial graft survival for ALF was 75.9% at 1 year and 67.8% at 5 years. Our results are comparable to those reported by most international groups.

ABO-incompatible liver transplantation: a new therapeutic option for patients with acute liver failure in Chile

Different ways have been suggested to expand donor numbers for liver transplantation. Transplantation using ABO-incompatible hepatic grafts has recently been a controversial issue due to the high risk of hyperacute rejection mediated by preformed anti-ABO antibodies. We report three patients with acute liver failure who were transplanted with ABO-incompatible livers: A to O in two patients and A to B in one case. We used pre- and posttransplant total plasma exchange, splenectomy, and triple immunosuppression. All three patients are alive; one graft was lost, probably secondary to thrombotic microangiopathy with low isohemagglutinin titers of 1:8. One patient developed acute cellular rejection that was reversed with a bolus of methylprednisolone. No antibody-mediated rejection occurred. Financial and infectious considerations have to be considered. In our series, the final liver transplantation cost was higher than average for acute liver failure. Plasmapheresis has the highest cost of all the additional procedures. ABO-incompatible liver transplantation, because of the splenectomy it requires, has been associated with more infections due to encapsulated organisms. However, with splenectomy in our three patients, none had infections due to these bacteria. In our country, we do not consider ABO-incompatible liver transplantation as a first-line option, except for highly selected patients.

Trends in mechanical ventilation and immediate extubation after liver transplantation in a single center in Chile

INTRODUCTION

Some groups have reported early extubation post-liver transplantation in patients with previously defined criteria, in an attempt to shorten the ICU stay and decrease costs. We review our experience with trends in mechanical ventilation and resource utilization.

METHODS

We retrospectively reviewed the length of mechanical ventilation, ICU stay, hospital stay, transfusions, and costs of liver transplants performed since the program's inception in 1993 and 2002 including 82 OLT in 71 patients. We also report our experience with immediate postoperative extubation, which we have done from October to December of 2002. We compare different periods: the early days (1993 to 1997), namely, fewer than 10 OLT per year, with the subsequent years assessed individually.

RESULTS

There has been a progressive decrease over time in the length of mechanical ventilation, ICU stay, hospital stay, and costs. Since the program's inception actuarial adult patient 1- and 5-year survival rates were 88.7% and 78%, respectively. The 1-year survival rate increased to 97% during the period of 2000 to 2002 (n = 30). From October to the present, we extubated four of seven adult patients who met criteria with none of them requiring reintubation.

CONCLUSIONS

We demonstrate improved results, decreased length of mechanical ventilation, ICU, and hospital stay, and costs. The immediate postoperative extubation may be feasible for patients who meet previously defined criteria.

Epidemiology and results of liver transplantation for acute liver failure in Chile

Acute liver failure (ALF) is a severe, life-threatening condition associated with a high mortality rate. The objective of this study is to present the experience of a Chilean liver transplant program with orthotopic liver transplantation (OLT) for ALF. All patients with the diagnosis of ALF evaluated in our program between January 1995 and May 2003 were included in the analyses of etiology and outcomes. Candidates for OLT activated on a national waiting list were transplanted with cadaveric or living-related donor (LRD) organs. Twenty-seven patients age 1 to 19 years (median, 7.4 years) were transplanted at a median weight of 30.7 kg including 17 cadaveric and 10 with LRD livers. Most frequent etiologies were hepatitis A in 10 cases (37%) and unknown in 12 (48.1%). One donor experienced superficial phlebitis. Four patients were retransplanted (14.8%). Twenty patients are alive with 1- and 5-year survival rates of 74.1% At a median follow up of 34 months (range = 2 to 120). Seven patients died due to sepsis, multiorganic failure, graft primary nonfunction, intracranial hemorrhage, and intraoperative cardiac arrest. This experience revealed results comparable to international reports, allowing survival of patients destined to die.

[Hematological serological valves, and organ weight in adult Sprague-Dawley rats]

Sprague-Dawley rats are frequently used in experiments and their normal hematological, serologic and anatomical parameters are not easily available. The aim of this study was to measure these parameters in adult Sprague-Dawley rats. Twenty-four rats (12 males) whose weight ranged between 200 and 300 g, raised at the Instituto de Salud Pública in controlled environmental conditions and fed with pellets were studied. After a 24 h fast, animals were anesthetized with Droperidol and Ketamine, and after obtaining a cardiac blood sample, sacrificed by exsanguination. Most organs were withdrawn and weighed. Mean values for blood glucose, calcium, amylase, total proteins, cholesterol, AST, ALT, bilirubin, alkaline phosphatases, electrolytes and complete blood count were determined. Heart, lung, pancreas, kidney and testicle mean weight was also calculated. Male and female rats had significant differences in packed red cell volume, white blood cell count and hemoglobin.

Intraoperative autologous transfusion in emergency surgery for spine trauma

Although numerous studies have reported the use of intraoperative blood salvage in elective spine, cardiac, and vascular surgery, very few have assessed its efficiency during emergency surgery after spine trauma. We therefore retrospectively analyzed 238 cases of patients with spine trauma who had emergency surgery. Three variables were significantly associated with the risk of perioperative blood transfusion: thoracolumbar spine injury, a preoperative hematocrit < 35%, and an Injury Severity Score > 20. Among the 118 patients who received blood transfusions, 53 benefitted from intraoperative blood salvage using the Cell-Saver apparatus (Cell-Saver group) and 65 did not (control group). The Cell-Saver enabled a 47% reduction in homologous blood requirements (743 +/- 1191 mL vs. 1403 +/- 1453 mL, p < 0.008) and a 45% reduction in the number of patients who received homologous blood (45% vs. 82%, p < 0.001). Between these two groups, no significant differences were observed in the evolution of hematocrit, platelet count, and hemostasis values, but a slight increase in postoperative blood loss was noted in the Cell-Saver group (465 +/- 383 mL vs. 301 +/- 292 mL, p < 0.01). In conclusion, the efficiency of intraoperative blood salvage in emergency surgery for spine trauma is high and similar to that previously reported in elective spine surgery. The cost-effectiveness of this technique may be improved by appropriate selection of the patient.