Chilean experience in liver transplantation for acute liver failure in children

Fulminant acute hepatitis in pediatrics in Latin America and the Caribbean

SUMMARY OBJECTIVE: The objective of this review was to investigate the epidemiology of Fulminant Acute Hepatitis in Latin America and the Caribbean and identify possible measures aimed at a better understanding and improvement of patient support. METHODS: We used 3 different researchers to investigate the topic of Fulminant Acute Hepatitis in pediatrics in papers published by Latin American and Caribbean authors in the PubMed and SciELO databases from 2000 to 2016. RESULTS: We found 2,879 articles in the databases searched. After selecting and excluding articles according to the study protocol, 68 remaining studies were obtained for analysis. A total of 1,265 cases of acute fulminant hepatitis were detected, with a predominance of females (42.9%), followed by males (39.4%), with no description of sex in 17.7% of the cases. The main cause was viral hepatitis, representing 45.1% of the cases. The hepatitis A virus was responsible for 34.7% of the total cases and 76.9% of the infectious causes. Of the total number of patients, 26.9% were described as idiopathic, and 11.5% had no cause. CONCLUSION: The preventable causes of Fulminant Acute Hepatitis include hepatitis viruses - primarily the hepatitis A virus - and poisoning. Active vaccination, basic sanitation, and public awareness can reduce the number of patients and, consequently, the costs of liver transplantation due to these causes.

Early critical care course in children after liver transplant

Objective. To review the critical care course of children receiving orthotopic liver transplantation (OLT). Methods. A retrospective chart review of patients admitted to the pediatric critical care following OLT performed in our center between 1988 and 2011. Results. A total of 149 transplants in 145 patients with a median age of 2.7 (IQR 0.9–7) years were analyzed. Mortality in the first 28 days was 8%. The median length of stay (LOS) was 7 (4.0–12.0) days. The median length of mechanical ventilation (MV) was 3 (1.0–6.2) days. Open abdomen, age, and oxygenation index on the 2nd day predicted LOS. Open abdomen, age, amount of blood transfused during surgery, and PRISM III predicted length of MV. 28% of patients had infection and 24% developed acute rejection. In recent group (2000–2011) OLT was performed in younger patients; the risk of infection and acute rejection was reduced and patients required longer LOS and MV compared with old group (1988–1999). Conclusion. The postoperative course of children after OLT is associated with multiple complications. In recent years OLT was performed in younger children; living donors were more common; the rate of postoperative infection and suspected rejection was reduced significantly; however patients required longer MV and LOS in the PCCU.

Decline in HAV-associated fulminant hepatic failure and liver transplant in children in Argentina after the introduction of a universal hepatitis A vaccination program

INTRODUCTION

Hepatitis A virus (HAV) infection is a vaccine-preventable disease. The most severe complication in children is fulminant hepatic failure (FHF), estimated to occur in 0.4% of cases; patients with FHF often require a liver transplant (LT). Following another outbreak of HAV infection in Argentina during 2003-2004, a one-dose HAV universal immunization (UI) program was started in 2005, resulting in a reduction in the incidence of HAV infection. We have investigated the impact of HAV UI on the trends in the occurrence of FHF and LT in children.

METHODS

All pediatric cases of FHF admitted to four pediatric centers in Buenos Aires during March 1993-July 2005 were retrospectively reviewed, and data of cases during August 2005-December 2008 were collected. Information about demography, HAV infections and vaccination status, diagnostic data for FHF using the Pediatric Acute Liver Failure criteria, clinical laboratory results, encephalopathy, the severity of liver disease using the Pediatric End Stage Liver Disease score, assessment of patients on the LT waiting list using King's College Criteria for LT, treatment given for FHF (pre- and post-transplant), and clinical outcome were collected using a case report form. The frequency and outcomes of HAV-associated FHF and LT cases before and after UI were analyzed.

RESULTS

During the pre-immunization period, March 1993-July 2005, 54.6% (N = 165) of FHF cases were caused by HAV; HAV-associated FHF cases peaked during 2003-2004. During the post-immunization period, August 2005-December 2008, only 27.7% (N = 18) of FHF cases were caused by HAV infection; only one of these patients had received the HAV vaccine (one dose only). The number of HAV-associated FHF cases decreased from 2005, and no cases were reported from November 2006-December 2008. Multivariate analyses showed that the association of FHF with HAV infection rather than other etiologies decreased with increasing age (P = 0.03), UI against HAV (P = 0.002), and anti-actin antibodies (P = 0.002), and increased with increasing weight (P = 0.0004).

CONCLUSIONS

The number of children with HAV-associated FHF in Argentina has strongly decreased since the initiation of the UI program. Further monitoring is required to confirm the long-term health and economic benefits of UI against HAV infection.