Liver disease in the adolescent

Liver Transplantation Profile Among Teenagers in the United States

PURPOSE

Indications for liver transplantation (LT) vary across age groups. We identified predictors of outcomes for teenage LT waitlisted candidates and recipients in the United States from 2008 to 2022.

METHODS

The Scientific Registry of Transplant Recipients 2008-2022 provided data (clinical, sociodemographic, indications for LT, outcomes) for all teenagers (13-19 years) waitlisted for LT in the United States. Sociodemographic and clinical characteristics, including primary listing diagnoses, were evaluated and compared by age group (13-16 vs. 17-19 years) among waitlisted teenage candidates.

RESULTS

There were 2,813 teenage LT candidates listed between 2008 and 2022. The most common LT indication was acute liver disease (23.5%), followed by biliary atresia or hypoplasia (11.9%), autoimmune hepatitis (11.1%), and primary sclerosing cholangitis (9.7%). In contrast, chronic viral hepatitis, metabolic dysfunction-associated steatotic liver disease, and alcohol-related liver disease (the most common indications in adults) did not exceed 1% each; 2.8% had hepatocellular carcinoma. Excluding the two most recent years, 67.2% of candidates received a transplant; mean time to transplant was 217.0 days (standard deviation 371.6). Independent predictors of receiving a transplant were a more recent calendar year, younger age, higher model for end-stage liver disease score, and an acute liver disease diagnosis (all p < .05). Among the LT group, 3-year survival was 90%, with an improving survival trend. Higher post-transplant mortality was associated with earlier years of transplantation, older age, having Medicaid, being retransplanted, and having hepatocellular carcinoma (adjusted hazard ratios >1, all p < .05).

DISCUSSION

Indications for LT among US teenagers are different from adults or younger children. There is a trend toward improved post-transplant outcomes.

Free-breathing radial magnetic resonance elastography of the liver in children at 3 T: a pilot study

BACKGROUND

Magnetic resonance (MR) elastography of the liver measures hepatic stiffness, which correlates with the histopathological staging of liver fibrosis. Conventional Cartesian gradient-echo (GRE) MR elastography requires breath-holding, which is challenging for children. Non-Cartesian radial free-breathing MR elastography is a potential solution to this problem.

OBJECTIVE

To investigate radial free-breathing MR elastography for measuring hepatic stiffness in children.

MATERIALS AND METHODS

In this prospective pilot study, 14 healthy children and 9 children with liver disease were scanned at 3 T using 2-D Cartesian GRE breath-hold MR elastography (22 s/slice) and 2-D radial GRE free-breathing MR elastography (163 s/slice). Each sequence was acquired twice. Agreement in the stiffness measurements was evaluated using Lin's concordance correlation coefficient (CCC) and within-subject mean difference. The repeatability was assessed using the within-subject coefficient of variation and intraclass correlation coefficient (ICC).

RESULTS

Fourteen healthy children and seven children with liver disease completed the study. Median (±interquartile range) normalized measurable liver areas were 62.6% (±26.4%) and 44.1% (±39.6%) for scan 1, and 60.3% (±21.8%) and 43.9% (±44.2%) for scan 2, for Cartesian and radial techniques, respectively. Hepatic stiffness from the Cartesian and radial techniques had close agreement with CCC of 0.89 and 0.94, and mean difference of 0.03 kPa and -0.01 kPa, for scans 1 and 2. Cartesian and radial techniques achieved similar repeatability with within-subject coefficient of variation=1.9% and 3.4%, and ICC=0.93 and 0.92, respectively.

CONCLUSION

In this pilot study, radial free-breathing MR elastography was repeatable and in agreement with Cartesian breath-hold MR elastography in children.

Effect of different driver power amplitudes on liver stiffness measurement in pediatric liver MR elastography

PURPOSE

To assess how different driver power amplitudes affect the measurement of liver stiffness in pediatric liver magnetic resonance elastography (MRE).

METHODS

From January 2018 to May 2018, pediatric patients (≤ 18 years) who underwent liver MRE with 20% and 56% driver power amplitudes were included in this retrospective study. Region-of-interests (ROIs) were drawn on four stiffness maps to include the largest area of the liver parenchyma. Intraclass correlation coefficients (ICCs) were used to assess agreements for the area, mean, maximum, minimum and standard deviation of liver stiffness between the driver power amplitudes.

RESULTS

128 MRE stiffness maps from 16 patients (M:F = 10:6, median 12.5 years old) were included. On MRE, median ROI areas of liver were 83.1 cm2 (range, 46.9-144.1 cm2) and 63.0 cm2 (range, 5.4-123.4 cm2) for the driver power amplitudes of 20% and 56%, respectively. Median liver stiffness values were 2.3 kPa (range, 1.7-8.0 kPa) and 2.8 kPa (range, 1.7-8.5 kPa). Maximum and minimum liver stiffness values were 5.3 kPa and 1.0 kPa for 20% and 7.8 kPa and 1.1 kPa for 56%. Standard deviation was 0.6 kPa for 20% and 1.0 kPa for 56%. ICC values between the two power amplitudes were 0.33-0.51 for the ROI area and the maximum, minimum and standard deviation values of liver stiffness. The ICC value for liver stiffness was 0.857 (95% confidence interval, 0.760-0.915).

CONCLUSION

Liver stiffness with two driver power amplitudes on MRE showed good reliability in pediatric patients. Driver power amplitudes need to be optimized according to the pediatric liver size.

The erroneous perception of a clinical sign: Cholestasis preceding sepsis mimicking hepatitis in an adolescent patient

Jaundice should be considered as a first clinical sign preceding severe invasive bacterial infection or sepsis in patients of all ages including childhood and adolescence. Early laboratory investigations and MR imaging studies for osteomyelitis or myositis are paramount to avoid progression to life-threatening sepsis and significant morbidity and mortality.

MR elastography: high rate of technical success in pediatric and young adult patients

BACKGROUND

Magnetic resonance (MR) elastography allows the noninvasive assessment of liver stiffness, which is a surrogate for fibrosis.

OBJECTIVE

The purpose of this study was to describe our experience using liver MR elastography in a large pediatric population with attention to the frequency and causes of exam failure.

MATERIALS AND METHODS

Imaging records were searched for patients ≤18 years of age who underwent 2-D gradient recalled echo (GRE) MR elastography of the liver between September 2011 and August 2015 on one of two 1.5-T MRI platforms. Imaging reports and clinical records were reviewed for failed MR elastography acquisitions, factor(s) resulting in failure and whether a subsequent successful examination had been performed.

RESULTS

Four hundred sixty-eight MR elastography examinations were performed in 372 patients between 1.5 months and 18 years of age during the study period. Ninety-six percent (450/468) of the examinations were successful. There was no significant difference in mean age (12.6±3.6 vs. 11.2±4.1 years, P=0.12) or body mass index (BMI) (28.2±12.4 vs. 29.5±10 kg/m², P=0.6) between patients with and without successful examinations. MR elastography failures were due to poor paddle positioning resulting in inadequate generation of hepatic shear waves (n=5), iron overload (n=4), patient inability to tolerate MRI (n=3), patient breathing/motion (n=3), artifact from implanted hardware (n=1) and technical malfunction (n=2). Seven of nine (78%) repeat examinations were successful (78%).

CONCLUSION

Hepatic 2-D GRE MR elastography at 1.5 T is technically robust in children. Exam failure is infrequent and largely reflects patient specific factors, some of which can be mitigated with careful technique.