Quality of life after orthotopic liver transplantation in children. An overview of physical, psychological and social outcome

Liver transplantation in an African setting

Liver disease in children in the developing world is a frequent occurrence, which is generally inadequately managed because of lack of resources. However, increasingly, there has been a demand for liver transplantation, where primary medical or surgical therapies have failed. The expertise and infrastructure required for a successful outcome are no different from those in more developed countries; if anything, the challenges are greater. Lack of deceased donors because of cultural and religious factors has driven the use of living donors. Short-term survival has generally been good, but long-term outcomes have rarely been reported. In this article, we review the experience of 2 centers at opposite ends of the continent and share our experience of slightly different settings and show that success can be achieved even in resource-reduced environments.

Psychosocial implications during adolescence for infant heart transplant recipients

BACKGROUND & OBJECTIVES

As more heart transplant recipients survive into late adolescence, research addressing long-term psychosocial and neurodevelopmental outcomes is imperative. The limited literature available suggests risk for psychosocial difficulties and lower cognitive, academic, and neuropsychological functioning. This paper reviews topic-related literature and provides preliminary data examining psychosocial and neuropsychological functioning of adolescents who received their heart transplant during infancy.

METHOD

This paper offers a literature review AND presents preliminary data from studies conducted through Loma Linda University Children's Hospital (LLUCH). Study one examined psychosocial functioning and quality of life of adolescent infant heart transplant recipients. In study two, cognitive, academic, and neuropsychological data were analyzed.

RESULTS

Study 1: Overall psychosocial functioning fell in the Average range, however, a significant percentage of participants presented with difficulties on one or more of the psychosocial domains. Quality of life was also within normal limits, though concerns with general health and bodily discomfort were noted. Study 2: Cognitive functioning was assessed to be Below Average, with 43-62% of the participants demonstrating significant impairments. Neuropsychological functioning yielded significant weakness on language functioning, and mild weakness on visual-motor integration and executive functioning.

CONCLUSION

While the majority of the participants demonstrate psychosocial resiliency, a subgroup present with difficulties suggesting the need for intervention. Cognitive/neuropsychological functioning suggests poorer functioning with patterns similar to other high-risk pediatric populations. These results are preliminary and further research on long-term psychosocial and neuropsychological development of pediatric heart transplant recipients is needed to better understand and ameliorate developmental trajectories.

Aspectos psicossociais associados a diferentes fases do transplante hepático pediátrico

Este estudo buscou investigar os aspectos psicossociais associados a diferentes fases do processo de transplante hepático pediátrico. Participaram do estudo seis mães de crianças com idades entre 4 e 8 anos e que haviam realizado transplante hepático há menos de seis anos. As mães responderam a uma entrevista que investigava sentimentos e vivências da família, nas diferentes fases da doença. Análise de conteúdo qualitativa mostrou intenso sofrimento emocional da criança e da família durante todo o processo. O período de espera e a cirurgia foram vivenciados como os mais estressantes, em virtude do medo intenso da morte. Os resultados apontam para importância do acompanhamento psicológico precoce e sistemático às crianças e às famílias, em todas as fases do processo.

Measuring quality of life in children and young people after transplantation: methodological considerations

The measurement of QoL has become an important area for research in paediatric transplantation over the past 15 yr. While much of this work remains descriptive and exploratory, advances in treatment and the trend towards outcomes being patient centred and not just survival based suggest the measurement of QoL will be of far more importance and relevance in the future. In this discussion article, we will outline some of the issues that need to be considered when embarking on a QoL study. The aim of our account is not to be prescriptive, rather to present researchers and clinicians with questions and possible solutions to help increase the scientific robustness of future studies. We have included summary tables of instruments that are currently available as a resource for those wanting to evaluate QoL in paediatric transplantation.

Approach to optimizing growth, rehabilitation, and neurodevelopmental outcomes in children after solid-organ transplantation

One of the most critical differences between the posttransplant care of children and adults is the requirement in children to maintain a state of health that supports normal physical and psychological growth and development. Most children with organ failure have some degree of growth failure and developmental delay, which is not quickly reversed after successful transplantation. The challenge for clinicians caring for these children is to use strategies that minimize these deficits before transplantation and provide maximal opportunity for recovery of normal developmental processes during posttransplant rehabilitation. The effect of chronic organ failure, frequently complicated by malnutrition, on growth potential and cognitive development is poorly understood. This review presents a summary of what is known regarding risk factors for suboptimal growth and development following solid-organ transplant and describe possible strategies to improve these outcomes.

Liver transplantation in children: part 2--long-term issues

This two-part review provides a comprehensive summary of clinical and research literature on paediatric liver transplantation. Part 2 focuses on the long-term physical consequences and psychological impact of transplantation and critically examines neurobehavioural, sexual development, psychosocial function and overall impact on children's quality of life. This review highlights the implications for clinical practice in specialist and local services and suggests areas where research is required to improve the lives of children after liver transplantation.

Short- and long-term results of liver transplantation in infants aged less than 6 months

BACKGROUND

Despite major surgical and medical advances, it is still a challenge to perform transplantation in small infants. This study, focusing on short- and long-term outcomes, summarizes our 10-year experience with liver transplantation (LTx) in infants aged less than 6 months.

PATIENTS AND METHODS

We analyzed 43 patients aged 6 months or less (range: 12-184 days, median: 136 days) whose median weight at the time of LTx was 5.8 kg (range: 2.8-8.0 kg). The reasons for LTx were biliary atresia (n=27; 62.8%), neonatal hepatitis (n=6; 14%), neonatal cholestasis (n=4; 9.3%), and miscellaneous (n=6; 14%). The patients were followed up for a median time of 3 years and evaluated with respect to graft function, physical, and neurodevelopmental outcome.

RESULTS

The patient survival was 90.7% after 1 year and 87.2% after 2 years. The graft survival was 86% after 1 year and 82.1% after 2 years. Twelve patients (27.9%) experienced 15 surgical complications requiring intervention, two of whom demonstrated vascular thrombosis (4.7%). Acute early rejection occurred in 15 patients (34.9%), and chronic rejection occurred in 3 patients (7%); 83.3% of the patients had normal liver function test results at the time of evaluation. Complications such as posttransplant lymphoproliferative disease (4.7%) and persistent arterial hypertension (4.7%) were rarely seen. The physical and neurodevelopmental outcomes were good.

CONCLUSIONS

LTx in infants aged less than 6 months provides excellent short- and long-term results. Low weight or young age of infants awaiting LTx should not be exclusion criteria for LTx.

Psychosocial adaptation after solid organ transplantation in children

The possibility of extending life with advanced medical procedures such as organ transplantation in childhood has made it possible to focus on patients' well-being in a wider perspective. They still experience a high prevalence of medical and physical disabilities, which definitively have an impact on a child's psychosocial adjustment after transplantation. Many disabilities originate before transplantation, and much effort should be taken to diminish possible complications and ameliorate growth and neurodevelopment, which have an impact for later adjustment regardless of a successful transplantation. Well-being and QOL are not necessarily always correlated to the degree of physical disability. Different social, financial, and demographic factors also have an impact, as do children's and families' ability to cope with a chronic disorder. Nonadherence and noncompliance are a great problem, particularly in adolescents. They are the result and a possible cause of inferior psychosocial adjustment. Continuous multidisciplinary support, follow-up, and education are needed to cope with this problem. Validated and reliable health status measures in pediatric transplant recipients are scarce in the literature, and few assessments can be completed by the children themselves. A continuing effort must be made to improve psychosocial adjustment and QOL after transplantation to achieve the ultimate goal in medicine: the overall well-being of our patients.

Functional outcomes of pediatric liver transplantation

The functional status and health-related quality of life (HRQOL) of children who survive liver transplantation (LT) have not been well documented. The purpose of this study was to determine the functional status and HRQOL in this population using a validated measure for children, the Child Health Questionnaire-Parent Form 50 (CHQ-PF50).

METHODS

The CHQ-PF50 instrument was completed by the parents of 55 children who agreed to participate in a mailing survey. Subscale scores for the sample were compared with those of a published normal population (n = 391).

RESULTS

Study sample characteristics were: 87% Caucasian, 54.5% female, mean age at survey was 9.6 years (range, 5-17 years). Responding caregivers were 95% biologic parents and 93% female. Compared with the normal population, LT recipients had lower subscale scores for general health perceptions (P < 0.0005), emotional impact on parents (<0.0005) and disruption of family activities (0.0005). The mean physical summary score of the LT recipients was lower than that of the normal population 48.1 +/- 12.1 (P = 0.005), but the mean psychosocial summary score was similar 48.8 +/- 11.9 (P = 0.156). Within the LT population, the original diagnosis (biliary atresia vs. other), type of LT (living donor vs. cadaveric), age at LT, z score for height, and hospital days did not significantly influence any of the subscale scores.

CONCLUSIONS

Children who have survived LT have functional outcomes in the physical domain that are lower than those of normal children. Self-esteem and mental health in this group appeared normal. The parents in this sample experienced more emotional stress and disruption of family activities than did parents in a normal population.

Health-related quality of life in pediatric liver transplant recipients: A single-center study

The goals of the present study were (1) to measure health-related quality of life (HRQOL) in pediatric liver transplantation (LT), (2) to identify demographic and clinical factors that correlate with HRQOL, and (3) to compare two instruments that have been used to measure HRQOL in children and adolescents. We conducted a single-center cross-sectional study of 77 pediatric LT recipients ages 5 to 18 years, all of whom had had LT at least 6 months previously. We used the Child Health Questionnaire Parent Form 50 (CHQPF50) and the PedsQL4.0 to determine measured dimensions of physical and psychosocial health from the parents' perspective. Individual scale scores range from 0 to 100, with higher scores reflecting better health. Data on demographics, clinical status at transplantation, posttransplantation clinical course, and graft function were collected to identify predictors of posttransplantation HRQOL. Fifty-three percent of the liver transplant recipients had biliary atresia, 78% were white, and 61% were female. The mean age at LT was 3.8 +/- 3.6 years, and the range of time since LT was 1 to 15 years. HRQOL in pediatric liver transplant recipients was lower than that reported for healthy children but similar to that for children with other chronic illness. Age at transplantation, the time elapsed since transplantation, hospitalizations within the previous year, maternal education, and race were significant predictors of physical health. Age at transplantation and maternal education predicted psychosocial function. HRQOL was decreased in a population of pediatric liver transplant recipients compared with the general population and similar to that for children with chronic illness. Prospective longitudinal studies will permit us to define predictors of HRQOL at different periods of time after transplantation. The information gained from this study will help us to better define expectations and the clinical course after liver transplantation to patients and their families.

Psychological impact of liver transplantation on children's inner worlds

We carried out an in-depth evaluation of psychosocial status in a sample of 18 children (mean age 6.8 yr, range 4.4-10.8 yr) who had suffered from severe liver disease and undergone orthotopic liver transplantation (OLT). Mean age at OLT was 3.4 yr. The assessment was psychoanalytically oriented and included individual sessions and testing procedures for children--the Children Apperception Test (CAT), the Weschsler Intelligence Scale for Children (WISC-R), the Weschsler Preschool and Primary Scale of Intelligence (WIPPSI), and the Human Figure Test--and a semi-structured interview with a separate questionnaire for parents. Patients were compared with an age- and gender-matched control group. The main findings in patients compared with controls were: IQ 91.6 (range 70-117) vs. 118 (range 94-135) (p<0.0001); immaturity of ego and drives (72.2% vs. 27.7%; p=0.018), fear of death (61.1% vs. 11.1%; p=0.04), anxiety of loss (50%, vs. 27.7%; p=NS), and depressive feelings (61.1% vs. 22.2%; p=0.04); a mild defect of body image (44.4% vs. 33.3%; p=NS) associated with recurrent representations of motionless (72.2% vs. 38.8%; p=NS) and inexpressive (88.8% vs. 16.6%; p<0.0001) human figures. Fantasies about OLT as a 'magic rebirth' or a 'body transformation' were detected in few patients (30%). Although a recurrent set of feelings, conflicts, and fantasies about OLT were expressed by children, individual specific psychological responses to this experience were often detected. In spite of the fact that approximately 50% of the parents mentioned emotional or behavioral disturbances of their child, only three parents were seriously concerned about this problem. The theme of transplantation was most often absent from communication between the child and their parents. Our results suggest that psychic 'working through' of the chronic liver disease and OLT experience is difficult for children. Further studies are necessary to verify whether changes of parental attitude to OLT as a 'family secret' may facilitate integration of the OLT experience in the child's personality development.

[Liver transplantation in infants and children. Evaluation of the first 40 cases (March 1991-March 1997)]

BACKGROUND

Liver transplantation (LT) is the treatment of end-stage liver disease in children. We report our experience with LT using grafts from living related (LRD) and cadaver donors (CD).

POPULATION

From March 1991 to March 1997, 40 children and infants received a total of 42 liver grafts. A reduced-size liver was used in 28 cases. We studied pre-transplantation status, survival rate, and medical and surgical complications in these patients.

RESULTS

The survival rate in our series was respectively 85 and 80% at 1 and 7 years after LT. Low weight infants required a prolonged ventilatory assistance. Five of the six deaths noticed during the first three months after LT occurred in children weighing less than 12 kg. One year after LT, no significant difference in the incidence of rejection was found, neither between low-weight children and the others, nor between patients transplanted from CD or LRD. Biliary tract stricture was the major surgical complication.

CONCLUSION

This series consisted of a majority of low-weight children. The survival rate in the patients weighting less than 12 kg is lower than in the others. This may be explained by the nutritional status of these patients and early postsurgical complications. The use of grafts from living donors offers more flexibility since the operation is performed electively, but it did not seem to modify the incidence of acute rejections and surgical complications.

Herz- bzw. Lebertransplantation bei Jugendlichen. Ergebnisse einer Expertenbefragung

Zusammenfassung: Es werden Ergebnisse einer Expertenbefragung mit Ärzten und Psychologen aus dem Transplantationsbereich dargestellt. Fragestellung: Welche Beratungskonzepte haben die Experten? Wie wird die postoperative Lebensqualität und die psychosoziale Entwicklung jugendlicher Transplantierter dargestellt? Methodik: Es wurden Interviews mit vier Ärzten und zwei Psychologen, die im Bereich Herz- bzw. Lebertransplantationen tätig sind, durchgeführt. Die Auswertung erfolgte entsprechend der Qualitativen Inhaltsanalyse nach Mayring . Ergebnisse: Die Beratung der Patienten vor der Transplantation wird als sehr schwierig beschrieben, da nicht abzuschätzen ist, inwieweit die Jugendlichen die Implikationen des Eingriffs antizipieren können. Obwohl die Lebensqualität sich in medizinischer Hinsicht verbessert, kann die psychosoziale Entwicklung beeinträchtigt sein. Der Beziehung zwischen Arzt und Patient kommt im Transplantationsbereich eine besondere Bedeutung zu. Diskussion: Bei den Experten besteht ein großer Bedarf an psychologischer Forschung. Im Bereich der Lebensqualitätsforschung wird der Einsatz qualitativer Verfahren gefordert. Gleichzeitig machen die Ergebnisse deutlich, wie wichtig die Entwicklung psychologischer Betreuungskonzepte für transplantierte Jugendliche ist.

Psychological support of children undergoing liver transplantation and their parents: a single-centre experience

Children undergoing liver transplantation, and their parents, are regularly provided with psychological support by a team of social workers and psychologists in the Children's Hospital of the Medical School Hannover, Germany. We would like to highlight the structure of this psychosocial care and its development since the first liver transplantation in 1978. As most of the stress related to the procedures of transplantation is inevitable, emotional support provided by such a team approach is essential.

Analysis of growth in children after orthotopic liver transplantation

Growth after pediatric liver transplantation is an important factor in determining the quality of life. We collected data on height, skeletal age, and liver function of 45 consecutive pediatric transplant recipients and assessed the influence of primary diagnosis, liver function, and immunosuppressive regimen on their growth. Height and skeletal age were plotted as median standard deviation scores versus years post-transplantation. Growth, in terms of both height and skeletal age, were continuous without catch-up growth. Primary diagnosis was found to have no influence on height and poor liver function had a negative effect on both height and skeletal growth. A higher alternate day prednisolone maintenance dose also had negative effect on skeletal growth. Thus, it can be concluded that a pretransplant lack of growth will not be restored and is an indication for early transplantation in end-stage liver disease, especially in younger children.

Successful medical treatment of severely decompensated Wilson disease

Delayed response to medical treatment sometimes leads to unnecessary liver transplantation in patients with severely decompensated Wilson disease. We report the course of five patients (mean age 13.4 years, range 11 to 15 years) with severely decompensated Wilson disease who were successfully treated medically. Prothrombin time improved after a minimum of 1 month and returned to normal within 3 months to 1 year or more.

Growth and height in children after liver transplantation

To assess the linear growth after liver transplantation, height curves were constructed for 45 children who underwent liver transplantation at the Children's Hospital "La Paz", Madrid, and were followed for more than 2 years. The prednisolone dose was progressively tapered and switched to alternate-day administration at 12 months. Growth was severely impaired during daily steroid therapy but the mean growth rate normalized in the second year and a significant improvement was observed in successive years. Observations over a long period revealed fluctuating growth rates under stable or decreasing doses of prednisolone on alternate-day administration. Beyond the first year, some annual periods of abnormal growth rate occurred in 57% of the children. Marginally better posttransplantation growth was observed in children transplanted for intrahepatic cholestatic diseases. The prednisolone dose did not correlate with growth rate. In the long term, short stature was highly prevalent due to an accumulation of factors: previous disease, daily prednisolone period, inconstant growth rate under alternate-day steroid therapy, and pubertal delay.