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Hou Y, Wang X, Yang H, Zhong S. Survival and Complication of Liver Transplantation in Infants: A Systematic Review and Meta-Analysis. Front Pediatr 2021; 9:628771. [PMID: 33996682 PMCID: PMC8116516 DOI: 10.3389/fped.2021.628771] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 03/17/2021] [Indexed: 01/16/2023] Open
Abstract
Background: Modern surgical techniques and scientific advancements have made liver transplant (LT) in infants feasible. However, there are only a small number of studies examining the short- as well as long-term outcomes of LT in this vulnerable subset of children. Methods: Comprehensive searches were done systematically through the PubMed, Scopus, and Google scholar databases. Studies that were retrospective record based or adopted a cohort approach and reported either patient survival rates or graft survival rates or complications of LT in infants were included in the meta-analysis. Statistical analysis was done using STATA version 13.0. Results: A total of 22 studies were included in the meta-analysis. The overall pooled patient survival rate at 1 year, >1-5 years, and >5 years post-transplantation was 85% (95% CI: 78--92%), 71% (95% CI: 59-83%), and 80% (95% CI: 69-91%), respectively. The overall pooled graft survival rate at 1 year, >1-5 years, and >5 years post-transplantation was 72% (95% CI: 68-76%), 62% (95% CI: 46-78%), and 71% (95% CI: 56-86%), respectively. The overall pooled rate for vascular complications, need for re-transplantation, biliary complications, and infection/sepsis was 12% (95% CI: 10-15%), 16% (95% CI: 12-20%), 15% (95% CI: 9-21%), and 50% (95% CI: 38-61%), respectively. Conclusion: The current meta-analysis showed modest patient and graft survival rates for infant liver transplantation. However, the complication rates related to infection/sepsis were high. More comprehensive evidence is required from studies with larger sample sizes and a longer duration of follow-up.
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Affiliation(s)
- Yifu Hou
- Department of Organ Transplantation, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China.,Chinese Academy of Sciences Sichuan Translational Medicine Research Hospital, Chengdu, China
| | - Xiaoxiao Wang
- Department of Organ Transplantation, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China.,Chinese Academy of Sciences Sichuan Translational Medicine Research Hospital, Chengdu, China
| | - Hongji Yang
- Department of Organ Transplantation, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China.,Chinese Academy of Sciences Sichuan Translational Medicine Research Hospital, Chengdu, China
| | - Shan Zhong
- Department of Organ Transplantation, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China.,Chinese Academy of Sciences Sichuan Translational Medicine Research Hospital, Chengdu, China
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2
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One Thousand Pediatric Liver Transplants During Thirty Years: Lessons Learned. J Am Coll Surg 2018; 226:355-366. [DOI: 10.1016/j.jamcollsurg.2017.12.042] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 12/21/2017] [Indexed: 12/30/2022]
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Sundaram SS, Mack CL, Feldman AG, Sokol RJ. Biliary atresia: Indications and timing of liver transplantation and optimization of pretransplant care. Liver Transpl 2017; 23:96-109. [PMID: 27650268 PMCID: PMC5177506 DOI: 10.1002/lt.24640] [Citation(s) in RCA: 138] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Accepted: 09/10/2016] [Indexed: 12/12/2022]
Abstract
Biliary atresia (BA) is a progressive, fibro-obliterative disorder of the intrahepatic and extrahepatic bile ducts in infancy. The majority of affected children will eventually develop end-stage liver disease and require liver transplantation (LT). Indications for LT in BA include failed Kasai portoenterostomy, significant and recalcitrant malnutrition, recurrent cholangitis, and the progressive manifestations of portal hypertension. Extrahepatic complications of this disease, such as hepatopulmonary syndrome and portopulmonary hypertension, are also indications for LT. Optimal pretransplant management of these potentially life-threatening complications and maximizing nutrition and growth require the expertise of a multidisciplinary team with experience caring for BA. The timing of transplant for BA requires careful consideration of the potential risk of transplant versus the survival benefit at any given stage of disease. Children with BA often experience long wait times for transplant unless exception points are granted to reflect severity of disease. Family preparedness for this arduous process is therefore critical. Liver Transplantation 23:96-109 2017 AASLD.
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Affiliation(s)
- Shikha S. Sundaram
- Digestive Health Institute and Pediatric Liver Center, Children’s Hospital Colorado, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Cara L. Mack
- Digestive Health Institute and Pediatric Liver Center, Children’s Hospital Colorado, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Amy G. Feldman
- Digestive Health Institute and Pediatric Liver Center, Children’s Hospital Colorado, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Ronald J. Sokol
- Digestive Health Institute and Pediatric Liver Center, Children’s Hospital Colorado, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
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Sanna C, Stéphenne X, Revencu N, Smets F, Sassolas A, Di Filippo M, Descamps OS, Sokal EM. Homozygous familial hypercholesterolemia in childhood: Genotype-phenotype description, established therapies and perspectives. Atherosclerosis 2016; 247:97-104. [PMID: 26894473 DOI: 10.1016/j.atherosclerosis.2016.02.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Revised: 01/31/2016] [Accepted: 02/03/2016] [Indexed: 12/22/2022]
Abstract
Familial hypercholesterolemia (FH) is a co-dominantly inherited disorder of plasma lipoprotein metabolism. The prevalence of heterozygous FH (HeFH) is between 1/500 and 1/200 whereas that of homozygous form (HoFH) is about 1/1,000,000. Diagnosis is based on cutaneous xanthomas and untreated levels of LDL-cholesterol over 500 mg/dl before 10 years of age. Life expectancy, without treatment, does not exceed 20 years of age. The aim of this study is to characterise in details a cohort of 8 HoFH paediatric patients in order to illustrate all the current therapeutic options and to add some clinical and genetic information about this rare disease. We collected demographic, clinical, biological, imaging and genotype details. Furthermore, clinical and biochemical response to different treatment methods was retrospectively evaluated. All patients had genetically proven HoFH. All patients were subject to a lipid-lowering diet and medical treatment (except one), three patients underwent a liver transplant and one an hepatocytes infusion. Medical treatment was well tolerated with a median reduction of 44% and 47% in LDL-Cholesterol and Total Cholesterol respectively. The hepatocytes transplant produced a further, though slight, decrease in cholesterol levels as opposed to medical therapy alone. Transplanted patients normalized their cholesterol levels. Since the very high cardiovascular risk, HoFH requires immediate diagnosis, treatment and monitoring. Nowadays, the use of statins remains the cornerstone of medical therapy and liver transplantation is the possibly curative therapy. Besides, high hopes are pinned in new drugs (antibody targeting PCSK9, Mipomersen and Lomitapide) and stem cells.
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Affiliation(s)
- Claudia Sanna
- Université catholique de Louvain, Cliniques Universitaires Saint Luc, Service de Gastroentérologie et Hépatologie Pédiatrique, Bruxelles, Belgium
| | - Xavier Stéphenne
- Université catholique de Louvain, Cliniques Universitaires Saint Luc, Service de Gastroentérologie et Hépatologie Pédiatrique, Bruxelles, Belgium
| | - Nicole Revencu
- Université catholique de Louvain, Cliniques Universitaires Saint Luc, Centre de Génétique Humaine, Bruxelles, Belgium
| | - Françoise Smets
- Université catholique de Louvain, Cliniques Universitaires Saint Luc, Service de Gastroentérologie et Hépatologie Pédiatrique, Bruxelles, Belgium
| | - Agnes Sassolas
- UF Lipides-Dyslipidémies, Laboratoire de Biochimie, CBE, 59 boulevard Pinel, Bron Cedex, France; INSERM U1060, INSA de Lyon, INRA U1235, Univ Lyon-1, Université de Lyon, Villeurbanne, Oullins, France
| | - Mathilde Di Filippo
- UF Lipides-Dyslipidémies, Laboratoire de Biochimie, CBE, 59 boulevard Pinel, Bron Cedex, France; INSERM U1060, INSA de Lyon, INRA U1235, Univ Lyon-1, Université de Lyon, Villeurbanne, Oullins, France
| | | | - Etienne M Sokal
- Université catholique de Louvain, Cliniques Universitaires Saint Luc, Service de Gastroentérologie et Hépatologie Pédiatrique, Bruxelles, Belgium.
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Outcomes of Technical Variant Liver Transplantation versus Whole Liver Transplantation for Pediatric Patients: A Meta-Analysis. PLoS One 2015; 10:e0138202. [PMID: 26368552 PMCID: PMC4569420 DOI: 10.1371/journal.pone.0138202] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Accepted: 08/27/2015] [Indexed: 02/06/2023] Open
Abstract
Objective To overcome the shortage of appropriate-sized whole liver grafts for children, technical variant liver transplantation has been practiced for decades. We perform a meta-analysis to compare the survival rates and incidence of surgical complications between pediatric whole liver transplantation and technical variant liver transplantation. Methods To identify relevant studies up to January 2014, we searched PubMed/Medline, Embase, and Cochrane library databases. The primary outcomes measured were patient and graft survival rates, and the secondary outcomes were the incidence of surgical complications. The outcomes were pooled using a fixed-effects model or random-effects model. Results The one-year, three-year, five-year patient survival rates and one-year, three-year graft survival rates were significantly higher in whole liver transplantation than technical variant liver transplantation (OR = 1.62, 1.90, 1.65, 1.78, and 1.62, respectively, p<0.05). There was no significant difference in five-year graft survival rate between the two groups (OR = 1.47, p = 0.10). The incidence of portal vein thrombosis and biliary complications were significantly lower in the whole liver transplantation group (OR = 0.45 and 0.42, both p<0.05). The incidence of hepatic artery thrombosis was comparable between the two groups (OR = 1.21, p = 0.61). Conclusions Pediatric whole liver transplantation is associated with better outcomes than technical variant liver transplantation. Continuing efforts should be made to minimize surgical complications to improve the outcomes of technical variant liver transplantation.
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Dick AAS, Horslen S. Impact of donor weight in pediatric liver transplantation. Pediatr Transplant 2015; 19:343-4. [PMID: 25940372 DOI: 10.1111/petr.12485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- André A S Dick
- Division of Transplantation, Seattle Children's Hospital, Seattle, WA, USA.
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Chung PHY, Chan SC, Mok VWK, Tam PKH, Lo CM. Recipient body size does not matter in pediatric liver transplantation. J Pediatr Surg 2014; 49:1734-7. [PMID: 25487472 DOI: 10.1016/j.jpedsurg.2014.09.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Accepted: 09/05/2014] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND PURPOSE It is controversial whether small size recipient is associated with adverse outcome in liver transplantation. This study aims to evaluate the outcomes of pediatric liver transplantation according to body weight of recipients. METHODS Liver transplant recipients (age <18years, from 1993 to 2011) were studied retrospectively. They were categorized according to the body size at the time of transplantation (A: <6kg; B: between 6kg to 10kg; C: >10kg). RESULTS A total of 113 patients (83 LDLTs and 30 DDLTs) were studied. Thirteen (11.5%) belonged to group A, 56 (49.6%) belonged to group B, and 44 (38.9%) belonged to group C. The best graft and patient survivals were found in group A (Figs. 1 and 2), and none of the patients required re-laparotomy for general surgical complications, while 32 patients (32%) in groups B and C did. Regarding transplant-related complications, although group A patients had the highest incidence of biliary tract complications (38.5%, n=5), the incidence of vascular complications (hepatic artery: 7%, portal vein: 0%, hepatic vein: 0%) in this group was the lowest among the three groups. CONCLUSION Outcomes of small-sized recipients are not inferior. Less technical-related vascular complications, which may lead to early graft loss, were observed. This could be patient-related (less advanced cirrhosis) or surgeon-related (additional attention paid).
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Affiliation(s)
- Patrick Ho Yu Chung
- Division of Paediatric Surgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China.
| | - See Ching Chan
- Division of Liver Transplantation, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China.
| | - Vivian Way Kay Mok
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China.
| | - Paul Kwong Hang Tam
- Division of Paediatric Surgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China.
| | - Chung Mau Lo
- Division of Liver Transplantation, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China.
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Byun J, Yi NJ, Lee JM, Suh SW, Yoo T, Choi Y, Ko JS, Seo JK, Kim H, Lee HW, Kim HY, Lee KW, Jung SE, Lee SC, Park KW, Suh KS. Long term outcomes of pediatric liver transplantation according to age. J Korean Med Sci 2014; 29:320-7. [PMID: 24616578 PMCID: PMC3945124 DOI: 10.3346/jkms.2014.29.3.320] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Accepted: 12/16/2013] [Indexed: 01/27/2023] Open
Abstract
Liver transplantation (LT) has been the key therapy for end stage liver diseases. However, LT in infancy is still understudied. From 1992 to 2010, 152 children had undergone LT in Seoul National University Hospital. Operations were performed on 43 patients aged less than 12 months (Group A) and 109 patients aged over 12 months (Group B). The mean age of the recipients was 7 months in Group A and 74 months in Group B. The patients' survival rates and post-LT complications were analyzed. The mean Pediatric End-stage Liver Disease score was higher in Group A (21.8) than in Group B (13.4) (P = 0.049). Fulminant hepatitis was less common in Group A (4.8%) than in Group B (13.8%) (P = 0.021). The post-transplant lymphoproliferative disorder and portal vein complication were more common in Group A (14.0%, 18.6%) than in Group B (1.8%, 3.7%) (P = 0.005). However, the 1, 5, and 10 yr patient survival rates were 93%, 93%, and 93%, in Group A and 92%, 90%, and 88% in Group B (P = 0.212). The survival outcome of pediatric LT is excellent and similar regardless of age. LTs in infancy are not riskier than those of children.
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Affiliation(s)
- Jeik Byun
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Nam-Joon Yi
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jeong-Moo Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Suk-won Suh
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Tae Yoo
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - YoungRok Choi
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jae-Sung Ko
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Jeong-Kee Seo
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Hyeyoung Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hae Won Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun-Young Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kwang-Woong Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sung-Eun Jung
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Seong-Cheol Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kwi-Won Park
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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Arnon R, Annunziato R, Miloh T, Sogawa H, Nostrand KV, Florman S, Suchy F, Kerkar N. Liver transplantation in children weighing 5 kg or less: analysis of the UNOS database. Pediatr Transplant 2011; 15:650-8. [PMID: 21797956 DOI: 10.1111/j.1399-3046.2011.01549.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
UNLABELLED LT is a major medical and surgical challenge in very small patients. Aim of the study is to determine the outcomes after LT in infants ≤ 5 kg at transplant in a large cohort of patients. METHODS Infants ≤ 5 kg who had LT between 10/1987 and 5/2008 were identified from the UNOS database. Risk factors for death and graft loss were analyzed by multivariate logistic regression. RESULTS Of 11,467 children, 570 (5%) were ≤ 5 kg at LT. Mean age and weight at LT were 0.11 ± 0.48 yr, 4.32 ± 0.74 kg, respectively. One- and five-yr patient and graft survival were 77.7%, 72.2% and 66.1%, 57.6%, respectively. The primary cause of death was infection (25.9%). Recipient age was a predictor of graft loss. Patient and graft survival have improved over time. Life support at transplant was identified as a risk factor for both death and graft loss (p < 0.02, p < 0.01, respectively). CONCLUSION LT recipients ≤5 kg have high mortality and graft loss. Over time, graft survival has improved, although it is still inferior to the overall reported outcomes of pediatric LT. Being on life support at transplant is a significant risk factor for death and graft loss in very small recipients.
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Affiliation(s)
- Ronen Arnon
- Department of Pediatrics, Mount Sinai School of Medicine, Mount Sinai Medical Center, NY, USA.
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Predictors of survival following liver transplantation in infants: a single-center analysis of more than 200 cases. Transplantation 2010; 89:600-5. [PMID: 19997060 DOI: 10.1097/tp.0b013e3181c5cdc1] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Infants (<12 months) who require liver transplantation (LTx) represent a particularly challenging and understudied group of patients. METHODS This retrospective study aimed to describe a large single-center experience of infants who received isolated LTx, illustrate important differences in infants versus older children, and identify pretransplant factors which influence survival. More than 25 pre-LTx demographic, laboratory, and operative variables were analyzed using the Log-rank test and Cox proportional hazards model. RESULTS Between 1984 and 2006, 216 LTx were performed in 186 infants with a mean follow-up time of 62 months. Median age at LTx was 9 months, the majority had cholestatic liver disease, were hospitalized pre-LTx, and received whole grafts. Leading indications for re-LTx (n=30) included vascular complications (43%) and graft nonfunction (40%), whereas leading causes of death were sepsis and multiorgan failure. One-, 5-, and 10-year graft and patient survivals were 75%/72%/68% and 79%/77%/75%, respectively. Relative to older pediatric recipients, infants had worse overall patient survival (P=0.05). The following were significant univariate predictors of graft loss: age less than 6 months and reduced cadaveric grafts; and of patient loss: age less than 6 months, calculated CrCl less than 90, pre-LTx hospitalization, pre-LTx mechanical ventilation, repeat LTx, infants transplanted for reasons other than cholestatic liver disease, and patients transplanted between 1984 and 1994. CONCLUSIONS Long-term outcomes for infants undergoing LTx are excellent and have improved over time. As the largest, single-center analysis of LTx in infants, this study elucidates a unique set of predictors that can aid in medical decision making.
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Abstract
In previous decades, pediatric liver transplantation has become a state-of-the-art operation with excellent success and limited mortality. Graft and patient survival have continued to improve as a result of improvements in medical, surgical and anesthetic management, organ availability, immunosuppression, and identification and treatment of postoperative complications. The utilization of split-liver grafts and living-related donors has provided more organs for pediatric patients. Newer immunosuppression regimens, including induction therapy, have had a significant impact on graft and patient survival. Future developments of pediatric liver transplantation will deal with long-term follow-up, with prevention of immunosuppression-related complications and promotion of as normal growth as possible. This review describes the state-of-the-art in pediatric liver transplantation.
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Polak WG, Peeters PM, Miyamoto S, Sieders E, De Jong KP, Porte RJ, Bijleveld CM, Hendriks HG, TenVergert EM, Slooff MJ. The outcome of primary liver transplantation from deceased donors in children with body weight ≤10 kg. Clin Transplant 2007; 22:171-9. [DOI: 10.1111/j.1399-0012.2007.00762.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Abstract
Orthotopic liver transplantation remains a major medical and surgical challenge in small pediatric patients. From April 2003 to June 2006, 21 small babies (each of whom weighed less than 10 kg or was younger than 1 year of age) underwent orthotopic liver transplantation. Five were girls and 16 were boys with a mean age of 15.7 +/- 9.3 months (range, 2-24 months); their mean weight at the time of transplantation was 9.8 +/- 3.6 kg (range, 6-16 kg). All transplants were obtained from a living-related donor. Left lateral segment was used for all transplantations. The median graft-to-recipient weight ratio was 3.5% +/- 1.2% (range, 1.5%-6.1%). During the early postoperative period, hepatic arterial thrombosis was identified in 4 patients, and a biliary leak was detected in 2 patients. In 2 patients, portal vein stenosis was identified during the late postoperative period. At the time of this writing, the 17 alive patients (81%) exhibited good graft function at median follow-up of 14.8 +/- 10.9 months (range, 1-39 months). Four patients died during the follow-up. Histological examination revealed hepatocellular carcinoma in 2 patients, and Burkitt's lymphoma in 1 patient. In conclusion, our data confirmed that living-related donors, especially in this age group, provide a reliable source for the organ pool. Satisfactory results can be achieved despite the anatomic handicaps of this age group.
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Affiliation(s)
- H Karakayali
- Department of General Surgery, Başkent University Faculty of Medicine, Ankara, Turkey
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14
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15
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Abstract
BACKGROUND This study examines the results of liver transplantation (LT) in children 5 kg or less. Reports suggest an increased morbidity and mortality in children weighing 5 kg or less as compared to larger children. However, over half of all children needing LT are <1 year old. Improving outcomes in very small children is a major goal of liver transplantation. METHODS All children under 21 years of age transplanted from January 1990 to June 2005 were included in this study. One hundred sixty-eight primary liver transplants were done: 61 in children less than one year of age and 20 in infants weighing 5 kg or less at LT (2 to 5 kg). These 20 infants underwent 23 transplants. Whole organs were used in 39% of transplants, and reduced or split grafts were used in 61%. Arterial reconstruction using aortic conduits was done in 22%. Analysis included Fischer's exact or Chi square test for non-parametric analysis while patient survival was calculated using the Kaplan-Meier method test with differences in survival assessed using the log rank test. RESULTS Five-year survival for infants 5 kg or less was 74%, and graft survival was 60%, which was not different from patients transplanted that were >5 kg. There were three perioperative deaths, one from primary graft non-function, and two from portal vein thrombosis. There were no bile leaks or hepatic artery thromboses. Bacterial, fungal, and viral infections made up the vast majority of the postoperative complications (65%), with viral infections resulting in two graft losses requiring re-transplantation. Rejection occurred in 25% of patients, of which one required OKT3. Five of the 23 liver transplants in infants less than 5 kg were done prior to 1996, with a five-year graft survival of only 20%. Improvements in technique and postoperative care after 1996 led to improved graft and patient survival of 77% and 86% respectively. CONCLUSIONS Liver transplantation for infants weighing less than 5 kilograms can be technically challenging but can have equivalent graft and patient survival when compared to larger children requiring liver transplantation. Infants should not be denied liver transplantation based on weight alone.
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Affiliation(s)
- Kristin L Mekeel
- Division of Transplantation and Hepatobiliary Surgery, University of Florida, Gainesville, FL 32410, USA
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Haberal M, Karakayali H, Arslan G, Ozcay F, Boyvat F, Sevmis S, Demirhan B. Liver Transplantation in Children Weighing Less Than 10 Kilograms. Transplant Proc 2006; 38:3585-7. [PMID: 17175338 DOI: 10.1016/j.transproceed.2006.10.106] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2006] [Indexed: 10/23/2022]
Abstract
Orthotopic liver transplantation (OLT) remains a major medical and surgical challenge in small pediatric patients. From April 2003 through October 2005, 17 infants (each of whom weighed less than 10 kg) underwent the procedure. Four were girls and 13 were boys (mean age, 15.7 +/- 9.3 months [range, 2-36 months]; mean weight at the time of transplantation, 7.4 +/- 2.6 kg [range, 6-10 kg]). All transplants were obtained from living-related donors. Sixteen left lateral segments and 1 left lobe were transplanted. The median graft-to-recipient weight ratio was 3.5% +/- 1.2% (range, 1.5%-6.1%). During the early postoperative period, hepatic arterial thrombosis was identified in 2 infants, and a biliary leak in 1. Hepatic arterial thrombosis was treated by reanastomosis with polytetrafluoroethylene grafting in the first patient and by surgical embolectomy in the second. The biliary leak was treated with percutaneous drainage. In 1 infant, portal vein stenosis, which was identified during the late postoperative period, was treated by percutaneous balloon dilatation. At this time, 14 (82.3%) infants were alive, exhibiting good graft function at a median follow-up of 11 months (range, 2-36 months). Three infants died: 1 on postoperative day 47 from adult respiratory distress syndrome, 1 on postoperative day 12 from sepsis, and 1 on postoperative day 65 from sepsis associated with EBV infection. Episodes of acute rejection, which occurred in 5 patients, were treated with pulse steroid therapy. On follow-up, histologic examination revealed hepatocellular carcinoma in 2 infants and Burkitt's lymphoma in 1 infant. Our data confirm that extensive use of living-related donors in liver transplantation can result in an excellent outcome for small pediatric patients.
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Affiliation(s)
- M Haberal
- Department of General Surgery, Baskent University, Ankara, Turkey.
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Abstract
Liver transplantation has become the accepted standard of care in the treatment of a child with a failing liver. Advances in the management of critical care and immunosuppression along with the development of innovative operative procedures have improved outcome such that 5-year survival rates of 80% to 90% are expected following liver transplantation. Organ allocation schemes have evolved in an effort to better stratify recipient risk thereby more appropriately distributing deceased donor grafts. A persistent shortage of appropriate donors continues to contribute to patient mortality. The consequences of long-term immunosuppression have become increasingly apparent such that health care providers need to be aware of the side effects of chronic immunosuppression. New strategies need to be defined to minimize the need of continuous immunosuppression. The continued success of pediatric liver transplantation will require multi-disciplinary health care teams comprised of general pediatricians, pediatric hepatologists, transplant surgeons, and transplant coordinators who focus on the complex needs of the transplant recipient.
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Affiliation(s)
- Gregory M Tiao
- Department of Pediatric Surgery, Pediatric Liver Care Center, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio 45229, USA.
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18
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Affiliation(s)
- James Bennett
- The Liver Unit, Anaesthetic Birmingham Children's Hospital, Birmingham, England
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19
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Abstract
In the past two decades, pediatric liver transplantation has become the state-of-the-art operation with anticipated success and limited mortality. The future success of pediatric liver transplantation will require thoughtful solutions to the delicate balance of risk to donors and recipients, the complex needs of the acute postoperative patient, and the long-term challenges of chronic immunosuppression in these previously unsalvageable patients.
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Affiliation(s)
- Greg Tiao
- Department of Pediatric Surgery, Pediatric Liver Care Center, Cincinnati Children's Hospital Medical Center, University of Cincinnati, 3333 Burnet Avenue Cincinnati, OH 45229, USA
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20
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McCabe AJ, Orr JD, Sharif K, De Ville de Goyet J. Right-sided diaphragmatic hernia in infants after liver transplantation. J Pediatr Surg 2005; 40:1181-4. [PMID: 16034767 DOI: 10.1016/j.jpedsurg.2005.03.063] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Liver transplantation is just as successful in infants as in older children, but more challenging. This relates to the low weight of the recipients and to their rapidly deteriorating clinical condition (malnutrition and end-stage liver disease) ( J Pediatr 1990;117:205-210; BMJ 1993;307:825-828; Ann Surg 1996;223:658-664; Transplantation 1997;64:242-248; J Pediatr Surg 1998;33:20-23). In addition, higher rates of diaphragmatic complications have been shown to significantly correlate with a younger age ( Transplantation 2002;73:228-232; Transpl Int 1998;11:281-283; Pediatr Transplant 2000;4:39-44), but diaphragmatic hernia has never been reported as a complication of liver transplantation. In this report, 2 patients who developed diaphragmatic hernia after liver transplantation are presented. The possible role of several contributing factors resulting in diaphragmatic hernia is discussed. These factors include (1) diaphragm thinness related to low weight and malnutrition, (2) direct trauma at operation (dissection and diathermy), (3) increased abdominal pressure after transplantation caused by the use of a slightly oversized liver graft, and (4) the medial positioning of the partial liver graft in the abdomen.
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Affiliation(s)
- Amanda J McCabe
- Department of Paediatric Surgery, Royal Hospital for Sick Children, EH9 1LF Edinburgh, UK
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21
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Tiao GM, Alonso M, Bezerra J, Yazigi N, Heubi J, Balistreri W, Bucuvalas J, Ryckman F. Liver transplantation in children younger than 1 year--the Cincinnati experience. J Pediatr Surg 2005; 40:268-73. [PMID: 15868596 DOI: 10.1016/j.jpedsurg.2004.09.021] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND/PURPOSE The success of pediatric orthotopic liver transplantation (OLTxp) has improved greatly since its widespread application in the 1980s. No group has benefited more from this than infants younger than 1 year. The authors reviewed their experience in the management and outcome of children who underwent OLTxp when they were younger than 1 year. METHODS A retrospective review of the medical records of patients who at the time of OLTxp were younger than 1 year was performed. Patients were stratified according to the period when transplanted. RESULTS Eighty-one infants younger than 1 year underwent OLTxp. End-stage liver disease secondary to biliary atresia was the most common indication for transplantation. The overall survival was 77%. One-year patient and graft survival improved from 58% and 50% in the period 1986-1989, respectively, to 88% and 81% in the period 2000-2003, respectively. Technical complications such as hepatic artery thrombosis (n = 5) and portal vein thrombosis (n = 8) occurred, and although 4 patients required retransplantation, all but one survived. Complications associated with immunosuppression, sepsis/multisystem organ failure (MSOF) (n = 11), and posttransplant lymphoproliferative disease (PTLD) (n = 1) were the most common cause of poor outcome. CONCLUSIONS Successful OLTxp in infants is possible with improved posttransplant survival during the study period. Technical complications (hepatic artery thrombosis/portal vein thrombosis) may require retransplantation but were uncommon causes of patient loss. Multisystem organ failure was the most significant adverse complication. The consequences of immunosuppression (MSOF/PTLD) were the most common cause of patient loss. Further improvement in overall survival will require better immunosuppressive strategies.
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Affiliation(s)
- Gregory M Tiao
- Pediatric Liver Care Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229-3039, USA.
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22
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Iglesias J, López JA, Ortega J, Roqueta J, Asensio M, Margarit C. Liver transplantation in infants weighing under 7 kilograms: management and outcome of PICU. Pediatr Transplant 2004; 8:228-32. [PMID: 15176958 DOI: 10.1111/j.1399-3046.2004.00128.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Liver transplantation (LT) is an established treatment for children with acute and chronic liver failure. Some reports suggest that infants under the age of 1 yr and children weighing under 13 kg are high-risk groups associated with less satisfactory results. This report describes our experience during the pediatric intensive care unit stay of 16 infants weighing <7 kg who received LT. We reviewed the records of 16 infants with median age 7.4 months and median weight 5.8 kg, who received 18 liver allografts, nine whole and nine reduced. We also reviewed the use of adrenergic agonist agents, anti-infectious agents, antihypertensive agents, diuretics, immunosuppression protocol, sedation-analgesia agents, others agents (prostaglandin E(1), heparin and dipyridamole), diagnosis and management of rejection episodes, follow-up examination, nutrition and outcome. Mean peri-operative blood transfusions were 204 mL/kg, 188 mL/kg of plasma and 36 mL/kg of platelets; mean operative time was 5 h. Primary abdominal wound closure was possible in nine patients. Median initial intensive care unit stay was 18 days. Reasons for an initial stay of more than 18 days were retransplantation (1), gastrointestinal bleeding (2), paralytic ileus and atelectasis (2), septic shock (2), diaphragmatic paralysis, renal impairment and acute respiratory distress syndrome (2). Mean requirement for artificial ventilation was 168 h. Mean use of dobutamine, prostaglandin E(1) and dopamine was 3.3, 7.5 and 8.8 days, respectively. Parenteral nutrition was started at a mean of 48 h and oral food intake was started at a mean of 72 h. The most frequent complications were infection, atelectasis, gastrointestinal bleeding, acute renal failure and hepatic artery thrombosis. Four children required six re-explorations and two received retransplantation. Mean overall survival rate was 82% and graft survival was 72%. Weight alone (under 7 kg) should not be considered as a contraindication for LT. The survival rate of children post-LT is excellent regardless of graft type.
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Affiliation(s)
- Juan Iglesias
- Pediatric ICU Service, Hospital Vall d'Hebron, Passeig Vall d'Hebron, Barcelona, Spain.
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23
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Evrard V, Otte JB, Sokal E, Rochet JS, Haccourt F, Gennari F, Latinne D, Jamart J, Reding R. Impact of surgical and immunological parameters in pediatric liver transplantation: a multivariate analysis in 500 consecutive recipients of primary grafts. Ann Surg 2004; 239:272-80. [PMID: 14745337 PMCID: PMC1356222 DOI: 10.1097/01.sla.0000108681.24374.02] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To assess the respective impact of surgical and immunologic factors on patient/graft outcome and rejection after pediatric liver transplantation. SUMMARY BACKGROUND DATA Orthotopic liver transplantation (OLT) constitutes a validated therapeutic modality for acute liver failure and end-stage liver disease in children. Only a few large studies of factors influencing outcome of pediatric OLT are available in the literature. Studies considering the impact of rejection on graft outcome are scarce in adult OLT and are not even available for pediatric recipients. METHODS Five hundred consecutive pediatric recipients (<15 years) of a primary OLT performed between March 1984 and July 2000 were retrospectively reviewed. The main indication was biliary atresia (n = 328). A living related donor graft was used from July 1993 onwards in 82 children (16%). Survival was calculated and multivariate analysis was performed. RESULTS Actuarial survival rates at 1, 5, and 10 years were 85%, 81%, and 79% for patients, and 76%, 71%, and 70% for grafts, respectively. At the multivariate analysis, only 3 factors were found to be independently correlated with better patient survival: year of transplantation (P = 0.001), pretransplant diagnosis (P < 0.001, worst results for liver tumors), and ABO matching (P < 0.001, worst results for ABO incompatibility). Similarly, 3 factors were independently correlated with better rejection-free graft survival: tacrolimus as primary immunosuppressant (P < 0.001), a negative T-cell crossmatch (P = 0.016), and younger age of the donor (P < 0.001). CONCLUSIONS Pediatric OLT constitutes a complex undertaking with multifactorial impact on results: (1). a strong learning curve effect was shown to impact on overall results; (2). pediatric liver tumors still represent a challenging indication for OLT; (3). primary immunoprophylaxis with tacrolimus provided a lower rejection incidence; (4). the younger donor age effect deserves further immunologic investigations.
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Affiliation(s)
- Veerle Evrard
- Pediatric Liver Transplant Program, Saint-Luc University Clinics Université catholique de Louvain, Brussels, Belgium
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24
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Diem HVT, Evrard V, Vinh HT, Sokal EM, Janssen M, Otte JB, Reding R. Pediatric liver transplantation for biliary atresia: results of primary grafts in 328 recipients. Transplantation 2003; 75:1692-7. [PMID: 12777858 DOI: 10.1097/01.tp.0000062570.83203.a3] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE The purpose of this study was to assess the overall results of recipients undergoing transplantation for biliary atresia (BA), according to age, surgical techniques, and transplant eras, and to identify the prognostic factors affecting outcome. METHODS Between 1984 and 2000, 328 pediatric recipients with BA who underwent orthotopic liver transplantation (OLT) were reviewed. Median age at OLT was 1.5 years (range, 0.4-14.5 years). Kasai hepatoportoenterostomy (KHPE) had been previously performed in 285 (87%) children. Regarding surgical techniques, 125 (38%) children received a whole-liver graft, 128 (39%) received a reduced-size graft, 16 (5%) received a split-liver graft, and 59 (18%) received a living-related (LR) donor graft. RESULTS Overall actuarial patient survivals were 87%, 83%, and 81% at 1, 5, and 10 years, respectively. One-year patient survivals in children undergoing transplantation at the different age ranges were 85% (under 1 year), 86% (1-3 years), 83% (3-6 years), 100% (6-10 years), and 100% (beyond 10 years) (not significant). One-year patient survivals for the different transplant eras were 75% (1984-1988), 85% (1989-1992), 93% (1993-1996), and 98% (1997-2000) (P=0.0001). Multivariate analysis demonstrated that pretransplant recipient weight (P=0.004), indication for OLT (P=0.083), and age at OLT (P=0.024) predicted patient survival. The type of baseline calcineurin inhibitor (tacrolimus) and the age at OLT (beyond 6 years) were significantly associated with a better graft survival. CONCLUSIONS Best results in children undergoing transplantation beyond 6 years indicate the importance of performing a KHPE as the first therapeutic step in BA; innovative surgical techniques, particularly LR donor graft, allowed successful transplantation in infants with early failure of KHPE.
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Affiliation(s)
- H Vo Thi Diem
- Pediatric Liver Transplant Program, Saint-Luc University Clinics, Université catholique de Louvain, Brussels, Belgium
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25
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Abstract
The history of pediatric liver transplantation cannot be dissociated from one man, Thomas E. Starzl, whose pioneer efforts contributed more than anyone else to what has become a routinely successful clinical procedure. During the pre-cyclosporine era, the pediatric experience was confined nearly exclusively in Denver: first attempt in 1963, first success with survival beyond one year in 1967, cumulative experience with 84 pediatric cases in the pre-cyclosporine era (1967-1979) with a 2-year patient survival rate of 30%. The stampede for the development of other liver transplant centers came with the introduction of cyclosporine in the early eighties. Besides Pittsburgh, seven centers (Brussels, Cambridge and Hanover in Europe; Boston, Dallas, UCLA, Minneapolis in USA) had performed up to 1986 at least 20 pediatric liver transplants each with a long-term (>1 year) patient survival rate ranging between 57% and 83%. At the moment, a long-term patient survival rate in excess of 90% in elective patients -including infants - is commonly obtained in experienced centers. The shortage of size matched liver donors which was responsible for a high death rate on the cadaveric waiting list stimulated the development or technical innovations based on the segmental anatomy of the liver: reduced ('cutdown') liver graft, split graft and living liver transplantation. Challenging technical aspects in the recipient have been solved in order to reduce the incidence of surgical complications like outflow obstruction, arterial and portal thrombosis, and biliary problems. The indications of liver transplantation have been refined; regarding biliary atresia, which is the most frequent indication, a consensus has developed to propose a sequential strategy with a single attempt at hepatoportoenterostomy followed, when it fails, by liver transplantation. Some contra-indications accepted in the past are not currently valid with better understanding of the pathophysiology and/or increased clinical experience; such is the case of the hepatopulmonary syndrome. A major progress in preoperative management has been achieved through a multidisciplinary approach, particularly regarding nutrition and control of portal hypertension-related bleeding and ascites. Perioperatively, liver transplantation has derived benefit from the expertise of anesthetists managing babies with serious conditions and increased experience of the transplant surgeons regarding the knowledge of all the technical modalities, good strategy, technical skills and meticulous control of bleeding. It is well-recognized that children require more immunosuppression than adults. As in adults, the first breakthrough came with the introduction of cyclosporine which more than doubled the one-year patient survival rate. The next advance during the last decade was afforded by FK 506 - Tacrolimus which allows steroid withdrawal with the first year post-transplant in most patients. Besides its efficacy in reducing the incidence of rejection and absence of cosmetic side-effects, the steroid-sparing effect of Tacrolimus is of utmost importance to preserve the growth potential of children. The use of OKT-3 both for induction and treatment of rejection has been abandoned nearly universally because its use, cumulated with other immunosuppressants, resulted in a high incidence of lymphoproliferative disorder. In contrast, anti-IL2-receptor monoclonal antibodies, will most likely gain an increasing place in induction, with the availability of chimeric or humanized preparations. The side-effects of immunosuppression can endanger both the quality of life and the life expectancy; they are a special source of concern in pediatric recipients whose survival can be expected to be more than a few decades. Children would benefit most from the development of a marker able to identify the patients who have developed graft acceptance, allowing complete wearing of immunosuppression. Also they would benefit most from research protocols of tolerance induction. Since the vast majority of liver-transplanted children will have a reasonably normal life expectancy, the focus should be switched to their long-term rehabilitation and the assessment of their quality of life when they reach adulthood.
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Affiliation(s)
- J B Otte
- Department of Pediatric Surgery and Liver Transplantation, Université Catholique de Louvain, Cliniques Saint-Luc, Brussels, Belgium.
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Noujaim HM, Mayer DA, Buckles JA, Beath SV, Kelly DA, McKiernan PJ, Mirza DF, de Ville De Goyet J. Techniques for and outcome of liver transplantation in neonates and infants weighing up to 5 kilograms. J Pediatr Surg 2002; 37:159-64. [PMID: 11819191 DOI: 10.1053/jpsu.2002.30242] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Neonates and small infants represent less than 5% of paediatric candidates for liver replacement. Most cases present under urgent conditions and receive grafts from large donors. Surgical techniques must be adapted for adequate graft preparation, vascular reconstruction, and abdominal closure. METHODS Technical aspects and outcome of 15 liver transplantations in infants weighing less than 5 kg performed at our unit were analysed retrospectively. RESULTS Liver transplantation was performed under urgent or highly urgent condition in 13 cases. Reduced or split liver grafts were used in all cases (median donor to recipient weight ratio, 9), including a monosegmental graft in 2 cases. In 10 cases, vascular reconstruction was done using a vascular conduit (5, 4, and 1 for artery, portal, and hepatic veins, respectively) and a delayed closure of the abdomen was necessary in 7 children. Postoperative complications were as follows: thrombosis of hepatic artery (n = 1) or portal vein (n = 1), gastrointestinal haemorrhage (n = 2), intraperitoneal bleeding (n = 1), biliary stricture (n = 2), septicaemia (n = 1). Two infants died of brain damage with a functioning graft. One child underwent retransplant for chronic rejection. CONCLUSIONS Overall, survival rate is 60% (median follow-up, 34 months), which compares favourably with older patient groups when case mix is comparable.
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27
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Affiliation(s)
- F Lacaille
- Department of Pediatrics, Necker-Enfants Malades Hospital, Paris, France.
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28
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Andries S, Casamayou L, Sempoux C, Burlet M, Reding R, Bernard Otte J, Buts JP, Sokal E. Posttransplant immune hepatitis in pediatric liver transplant recipients: incidence and maintenance therapy with azathioprine. Transplantation 2001; 72:267-72. [PMID: 11477351 DOI: 10.1097/00007890-200107270-00018] [Citation(s) in RCA: 96] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cases of so-called autoimmune hepatitis (AH) have been reported after liver transplantation. Our aim was to evaluate the incidence in a series of 471 pediatric liver transplant recipients. METHODS Between 1984 and 1998, 471 children had orthotopic liver transplantation (OLT). Children are followed up on a regular basis, with full clinical, biochemical, and histologic evaluation at 6 months, 1, 2, 5, 7, and 10 years after OLT. Children with unexplained abnormal liver tests were screened for autoimmune markers (total gamma-globulins, smooth muscle antibodies [SMA], liver kidney microsome antibodies [LKM], antinuclear factor [ANA]). From January of 1998 until December of 1998, autoimmune markers were prospectively searched in all children admitted for regular posttransplant follow-up (n = 118). RESULTS Eleven of 471 children (2.35%) were found with autoimmune hepatitis, 9 retrospectively and 2 prospectively. None had previous autoimmune liver disease. Patients had a history of steroid-dependent hepatitis. Histology showed variable degree of portal and lobular inflammation, piecemeal necrosis, and bridging collapse. Mean (+/-SDS) aspartate aminotransferase (AST) and alanine aminotransferase (ALT) activities at diagnosis were 173+/-145 and 196+/-157 IU/L, respectively (nl<32). Median gamma-globulin levels reached 1365 mg/dl versus 931 mg/dl in controls (P<0.05). Nine had ANA (titer 1/80 up to 1/10,000), 1 SMA (1/320), and 2 LKM1 antibodies (1/1280). Patients did not respond to increasing charge of cyclosporine (n=10) or tacrolimus (n=1). Eleven received steroids (prednisolone: 2 mg/kg per day, then tapered) and azathioprine (1.5 to 2.5 mg/kg per day). All patients normalized within 3 months (mean AST/ALT levels of 26+/-8 and 30+/-9 IU/L). Three had mild to moderate relapse with increase of ALT thereafter. Gamma-globulins decreased to 1190 mg/dl (ns). Amongst the 116 remaining prospectively evaluated patients, 85 had normal evaluation, despite low titers of autoantibodies in 15 (SMA< or =1/40, ANA 1/80). Thirty-one patients had graft dysfunction, related to well-explained posttransplant causes, among which 7 had similar low levels of autoantibodies. CONCLUSIONS A total of 2.35% of our transplant children present evidence of immune hepatitis after transplantation. Patients do not respond to increasing cyclosporine or tacrolimus levels and require steroid and azathioprine. In view of this specific treatment, systematic screening for "autoimmune" markers is advised in children with liver transplant.
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Affiliation(s)
- S Andries
- Départment de Pédiatrie, Cliniques Universitaires St. Luc, Université Catholique de Louvain, Brussels, Belgium
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29
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Abstract
Successful liver transplantation in a child is often a hard-won victory, requiring all the combined expertise of a dedicated pediatric transplant team. This article outlines the considerable challenges still facing pediatric liver transplant physicians and surgeons. In looking to the future, where should priorities lie to enhance the success already achieved? First, solutions to the donor shortage must be sought aggressively by increasing the use of from split-liver transplants, judicious application of living-donor programs, and increasing the donation rate, perhaps by innovative means. The major immunologic barriers, to successful xenotransplantation make it unlikely that this option will be tenable in the near future. Second, current immunosuppression is nonspecific, toxic, and unable to be individually adjusted to the patient's immune response. The goal of achieving donor-specific tolerance will require new consideration of induction protocols. Developing a clinically applicable method to measure the recipient's immunoreactivity is of paramount importance, for future studies of new immunosuppressive strategies and to address the immediate concern of long-term over-immunosuppression. The inclusion of pediatric patients in new protocols will require the ongoing insistence of pediatric transplant investigators. Third, the current immunosuppressive drugs have a long-term morbidity and mortality of their own. These long-term effects are particularly important in children who may well have decades of exposure to these therapies. There is now some understanding of their long-term renal toxicity and the risk of malignancy. New drugs may obviate renal toxicity, whereas the risk of malignancy is inherent in any nonspecific immunosuppressive regimen. Although progress is being made in preventing and recognizing PTLD, this entity remains an important ongoing concern. The global effect of long-term immunosuppression on the child's growth, development, and intellectual potential is unknown. Of particular concern is the potential for neurotoxicity from the calcineurin inhibitors. Fourth, recurrent disease and new diseases, perhaps potentiated by immunosuppressive drugs, must be considered. Already the recurrence of autoimmune disease and cryptogenic cirrhosis have been documented in pediatric patients. Now, a new lesion, a nonspecific hepatitis, sometimes with positive autoimmune markers, that may progress to cirrhosis has been recognized. It is not known whether this entity is an unusual form of rejection, an unrecognized viral infection, or a response to immunosuppressive drugs themselves. Finally, pediatric transplant recipients, like any other children, must be protected and nourished physically and mentally if they are to fulfill their potential. After liver transplantation the child's growth, intellectual functioning, and psychologic adaptation may all require special attention from parents, teachers, and physicians alike. There is limited understanding of how the enormous physical intervention of a liver transplantation affects a child's cognitive and psychologic function as the child progresses through life. The persons caring for these children have the difficult responsibility of providing services to evaluate these essential measures of children's health over the long term and to intervene if necessary. Part of the transplant physician's our duty to protect and advocate for children is to fight for equal access to health care. In most of the developing world, economic pressures make it impossible to consider liver transplantation a health care priority. In the United States and in other countries with the medical infrastructure to support liver transplantation, however, health care professionals must strive to be sure that the policies governing candidacy for transplantation and allocation of organs are applied justly and uniformly to all children whose lives are threatened by liver disease. In the current regulatory climate that increasingly takes medical decisions out of the hands of physicians, pediatricians must be even more prepared to protect the unique and often complicated needs of children both before and after transplantation. Only in this way can the challenges of the present and the future be met.
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Affiliation(s)
- S V McDiarmid
- Pediatric Liver Transplant Program, University of California Los Angeles Medical Center, Los Angeles, California, USA
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30
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van Mourik ID, Beath SV, Brook GA, Cash AJ, Mayer AD, Buckels JA, Kelly DA. Long-term nutritional and neurodevelopmental outcome of liver transplantation in infants aged less than 12 months. J Pediatr Gastroenterol Nutr 2000; 30:269-75. [PMID: 10749410 DOI: 10.1097/00005176-200003000-00011] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Liver transplantation is established treatment for children with end-stage liver disease and has a 5-year survival rate of 80% to 85%, even in infants under 12 months. Long-term outcome in nutritional rehabilitation and normal development is unknown. This study aimed to prospectively evaluate growth and psychoneurologic performance of children who undergo liver transplantation in infancy. METHODS Twenty-five infants (18 girls, 7 boys) who underwent liver transplantation at less than 12 months of age (median age, 9 months) were evaluated for 4 years. Growth measurements were expressed as standard deviation scores (SDSs; mean +/- SEM), and psychoneurologic performance was assessed with the unrevised Griffiths Mental Ability Scales (normal range, 80-120). RESULTS Four children died during the study (4-year survival, 84%). The children were malnourished before transplantation (SDSs: weight, -1.9 +/- 0.2; midarm muscle area, -0.93 +/- 0.3; midarm fat area, -1.52 +/- 0.3; and height, -0.95 +/- 0.3). Nutritional rehabilitation for all parameters occurred within 12 to 24 months after transplantation, which was most significant for weight (-1.1 +/- 0.2, P = 0.001), midarm muscle area (0.74 +/- 0.3, P = 0.001), and midarm fat area (-0.44 +/- 0.3, P = 0.01). There was some improvement in height (-0.72 +/- 0.3, P = 0.14), which was not significant, although infants who were severely stunted before transplantation (mean height standard deviation score [SDS] -2.46) showed significant catch-up at 1 year after transplantation (mean height SDS -1.2, P = 0.003). Psychoneurologic scores were within normal limits before transplantation and were maintained for the 4-year follow-up period, although individual scores varied during this period. Improved nutritional status was associated with increased muscle bulk and subsequent improvement in motor scores from 90.6 at initial assessment to 97.3 at 4 years (P = 0.28). There was a temporary reduction in social skills and eye-hand coordination in the first year, which may have been an effect of the hospital environment or cyclosporine immunosuppression. Language abilities also regressed during the first year, possibly related to the effect of nasogastric tube feeding in delaying normal speech development. CONCLUSIONS Liver transplantation in infancy has not only a successful outcome but is also associated with long-term catch-up growth and nutrition and maintenance of normal development.
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Affiliation(s)
- I D van Mourik
- The Liver Unit, The Birmingham Children's Hospital NHS Trust, United Kingdom
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31
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Smets F, Bodeus M, Goubau P, Reding R, Otte JB, Buts JP, Sokal EM. Characteristics of Epstein-Barr virus primary infection in pediatric liver transplant recipients. J Hepatol 2000; 32:100-4. [PMID: 10673073 DOI: 10.1016/s0168-8278(00)80195-6] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
BACKGROUND/AIM Pediatric liver transplant recipients are at high risk of Epstein-Barr virus infection. However the incidence of clinical symptoms and the graft function at the time of acute infection remains poorly documented. The aim of this study was to monitor the clinical and biochemical events associated with primary Epstein-Barr virus infection. METHODS Clinical and biological patterns associated with Epstein-Barr virus infection were prospectively searched in 38 liver transplanted children. Polymerase chain reaction and anti-Epstein-Barr virus IgM antibodies were used at regular intervals to detect the timing of primary infection. RESULTS Five children (13%) had pretransplant immunity, 26 (68.5%) developed primary Epstein-Barr virus infection 15 to 90 days after transplantation and seven (18.5%) remained Epstein-Barr virus negative. The four patients with clinical symptoms at the time of infection subsequently developed post-transplant lymphoproliferative disease. A single post-transplant lymphoproliferative disease occurred in non-symptomatic patients (overall incidence 13%). No mortality was associated with post-transplant lymphoproliferative disease. Two asymptomatic patients had abnormal liver function tests possibly related to primary Epstein-Barr virus infection. CONCLUSION Epstein-Barr virus primary infection occurs in 80% of seronegative patients within 3 months after OLT. Clinical symptoms are rare and closely associated with post-transplant lymphoproliferative disease. Outside post-transplant lymphoproliferative disease, the consequences of infection are marginal.
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Affiliation(s)
- F Smets
- Department of Pediatrics, Cliniques Universitaires Saint-Luc, Brussels, Belgium.
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32
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Abstract
To determine growth patterns in a large cohort of unselected children undergoing liver transplantation, the outcomes of 294 orthotopic liver transplantations performed in 221 children at The University of Chicago between October 1984 and October 1992 were retrospectively reviewed; 66% were alive at the time of this analysis. The mean age at transplantation was 4.1 +/- 5.0 years; 44% of the children were male and 16% of the transplants were from living-related donors. The mean height z score at the time of transplantation was -1.6 +/- 1.8, and 39% of children had height z scores of < -2.0 at transplantation. When children with growth retardation at the time of transplantation (height z scores of < -2. 0) were compared with children with more normal growth, there were no significant differences in gender or re-transplantation rates, although children with growth retardation at transplantation were significantly younger than those with more appropriate growth (2.8 +/- 4.1 years vs 4.7 +/- 5.1 years, P <.05). The height z score of all children with biliary atresia at the time of transplantation was -1.9 +/- 1.7 compared with -1.2 +/- 2.0 in those children with underlying diseases other than biliary atresia. Catch-up growth was seen in 37% to 47% of children at any given time point after transplantation. Children with evidence of catch-up growth (growth velocity z score >0) 2 years after transplantation were more likely to be first-time transplant recipients, had more growth retardation at the time of transplantation, and were receiving lower doses of prednisone at 2 years after transplantation. Younger children were most likely to demonstrate catch-up growth after transplantation. In summary, a large proportion of children have growth retardation at the time of liver transplantation. This growth retardation is inversely correlated with age. Before transplantation, children with biliary atresia grow less well than children with other forms of liver disease. Up to one half of children demonstrate catch-up growth after liver transplantation. Growth after transplantation is proportional to the degree of growth retardation at transplantation and inversely correlated to age at transplantation. Children with poor growth after transplantation are more likely to be receiving higher doses of corticosteroid.
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Affiliation(s)
- S M Bartosh
- Department of Pediatrics, Section of Pediatric Nephrology, The University of Wisconsin Medical School, Madison, USA
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Saing H, Fan ST, Chan KL, Lo CM, Wei WI, Tsoi NS, Yuen KY, Ng IL, Chau MT, Tso WK, Chan JK, Wong J. Liver transplantation in infants. J Pediatr Surg 1999; 34:1721-4. [PMID: 10591579 DOI: 10.1016/s0022-3468(99)90653-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE In view of the earlier reports that children below 1 year of age constitute a high-risk group for liver transplantation, the authors reviewed their experience in performing orthotopic liver transplantation in this age group. METHODS The records of 9 children aged less than 1 year who underwent 6 living-related liver transplants and 3 reduced-size liver transplants between December 1993 and June 1997 were reviewed. RESULTS Five reexplorations were required for 3 children who had 1 or more of the following early complications: bleeding from hepatic vein to inferior vena cava anastomosis (n = 1), right hepatic vein stump bleeding (n = 1), intraabdominal hematoma (n = 2), jejuno-jejunostomy leakage (n = 1), and colonic perforation (n = 1). Late complications include stricture at the biliary-enteric anastomosis requiring percutaneous balloon dilatation (n = 3) and hepatitis of undetermined etiology requiring retransplantation (n = 1). There was no hepatic artery thrombosis despite the small arteries available for anastomosis. Follow-up ranged from 19 to 61 months (mean, 40 months). Patient survival rate was 100%, and graft survival with good liver function was 89%. All living donors, 2 fathers and 4 mothers, are well. CONCLUSIONS Liver transplantation in infants less than 1 year of age is technically demanding but feasible and still can be performed with a good outcome. Age alone (under 1 year) should not be considered as a contraindication for liver transplantation.
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Affiliation(s)
- H Saing
- Department of Surgery, University of Hong Kong Medical Center, Queen Mary Hospital, Hong Kong
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Woodle ES, Millis JM, So SK, McDiarmid SV, Busuttil RW, Esquivel CO, Whitington PF, Thistlethwaite JR. Liver transplantation in the first three months of life. Transplantation 1998; 66:606-9. [PMID: 9753340 DOI: 10.1097/00007890-199809150-00010] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pediatric liver transplant recipients have traditionally been grouped according to age. Age-based classification schemes are useful in identifying clinical problems in selected age groups and also for developing solutions to these problems. Although infants in the first 3 months of life have not traditionally been considered a distinct age group, several features of these infants may distinguish them from other pediatric liver transplant recipients. METHODS The experience with liver transplantation in infants during the first 3 months of life in three large pediatric liver transplant programs (University of Chicago, Stanford University, and UCLA) was analyzed in order to characterize this group. RESULTS A total of 23 liver transplants were performed at these three centers in children younger than 3 months of age. This group of patients comprised approximately 37% of the U.S. experience between 1988 and 1994 according to United Network for Organ Sharing statistics. Age distribution at the time of transplantation included the following: <1 month, 28%; 1-2 months, 35%; and 2-3 months, 36%. Median age at the time of transplantation was 37 days (range, 7-90 days), and mean age was 57+/-30 days. Mean weight at the time of transplantation was 3.8+/-1.0 kg. Etiology of liver disease included idiopathic hepatitis, 52%; iron storage disease, 17%; and other causes, 31%. Types of liver allografts used included cadaveric, 85% (reduced size, 60%, and full-size, 25%); living donor, 15%; ABO-identical, 65%; and ABO-compatible, 35%. Actuarial patient and graft survival rates were 60% and 60% at 1 year and 60% and 42% at 2 years, respectively. Median follow-up was 1.5 years. Rejection occurred in 42% of patients, with a median time to first rejection of 13 days. Of these patients, 28% required steroids only and 14% required OKT3. Three patients (14%) were retransplanted at a median time to retransplantation of 1.6 years. Vascular thrombosis occurred in three patients (14%). CONCLUSIONS Liver transplantation performed in infants younger than 3 months of age (1) provides acceptable short- and long-term patient and graft survival, (2) is associated with significant rates of rejection, and (3) is not associated with excessive rates of vascular thrombosis. The etiology of end-stage liver disease occurring in the first 3 months of life is distinct from that in other pediatric liver transplant recipient age groups. These infants should be referred promptly for liver transplantation as reasonable survival can be expected.
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Affiliation(s)
- E S Woodle
- Department of Surgery, University of Chicago, Illinois 60637, USA.
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Abstract
Liver transplantation continues to be successful and effective treatment for acute and chronic liver failure, and many important lessons have been learned. The development of innovative operative techniques has much reduced the waiting list mortality rate and has extended transplantation to younger and sicker children and to those with functionally normal livers who may benefit from auxiliary liver transplantation. The incidence and range of postoperative complications have improved with increased medical and surgical expertise. As information on long-term outcome for liver transplantation is gained, it is clear that many children will benefit from early elective liver transplantation before the development of significant growth or psychosocial retardation. Early transplantation is also indicated in children with cirrhosis and intrapulmonary shunting or cystic fibrosis with moderate lung disease. During the same period, evolving medical therapy has altered the natural history, patient selection, and timing of transplantation in children with tyrosinaemia type I, primary bile acid disorders, neonatal haemochromatosis, and potentially, cystic fibrosis. It is now clear that children with significant multisystem disease, such as mitochondrial disorders or severe systemic oxalosis, are no longer suitable candidates for liver transplantation. The successful development of liver transplantation has brought good quality life to many children and their families. There are still many lessons to learn and there are future challenges such as the ever-increasing problems of donor scarcity and the search for potent but less toxic immunosuppressive agents.
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Affiliation(s)
- D A Kelly
- Birmingham Children's Hospital NHS Trust, United Kingdom
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Goyet JDV, Swielande YS, Reding R, Sokal E, Otte J. Delayed primary closure of the abdominal wall after cadaveric and living related donor liver graft transplantation in children: a safe and useful technique. Transpl Int 1998. [DOI: 10.1111/j.1432-2277.1998.tb00786.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
In this article the diagnostic indications for hepatic transplantation are addressed in detail. The outcome of liver transplantation is also examined, including the impact of the following factors on survival: age and weight at transplantation, type of liver disease, and size of liver allograft, including living related transplantation. Morbidity and quality of life after transplantation are other aspects reviewed in this chapter.
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Affiliation(s)
- C O Esquivel
- Liver Transplant Program, Stanford University Medical Center, Stanford, California, USA
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Affiliation(s)
- R I Holt
- Department of Medicine, King's College School of Medicine and Dentistry, London, UK
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Jara P, Hierro L, Díaz MC, Frauca E, Camarena C, de la Vega A, Santamaría ML, Murcia J, Larrauri J, Sanchez-Peinado C, Prieto C, Zafra M, Gámez M. Comparative results of reduced-size and whole liver transplantation in small children. Transplant Proc 1997; 29:436-8. [PMID: 9123069 DOI: 10.1016/s0041-1345(96)00176-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- P Jara
- Pediatric Hepatology and Liver Transplant Unit, Hospital Infantil La Paz, Madrid, Spain
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Murphy MS, Harrison R, Davies P, Buckels JA, Mayer AD, Hubscher S, Kelly DA. Risk factors for liver rejection: evidence to suggest enhanced allograft tolerance in infancy. Arch Dis Child 1996; 75:502-6. [PMID: 9014603 PMCID: PMC1511799 DOI: 10.1136/adc.75.6.502] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
After liver transplantation, a relatively low intensity immunosuppressive regimen is employed in our unit: after initial triple therapy (prednisolone, azathioprine, cyclosporin), prednisolone is discontinued at three months and azathioprine at one year. A retrospective study was therefore performed to determine the incidence of rejection, and to identify risk factors for rejection in our patient population. Over a 10 year period, 135 transplants were performed on 109 children. Thirty four (25%) were on infants less than 1 year old. Incidences of acute rejection and irreversible chronic rejection were calculated for grafts surviving more than one and four weeks respectively. Acute rejection occurred in 51 of 101 allografts (50%), and irreversible chronic rejection in 11 of 91 allografts (12%). The immunosuppression strategy was not associated with an increased incidence of rejection. Acute rejection occurred in only eight of 28 allografts (29%) in those transplanted during their first year, compared with 43 of 73 (59%) in older children. Logistic and Cox regression analysis supported age at transplantation as a significant risk factor for acute rejection. Irreversible chronic rejection did not occur in any of 24 grafts in patients transplanted before one year, compared with 11 of 67 (16%) in older recipients. This suggests possible enhanced allograft tolerance with transplantation during the first year of life. This unexpected and potentially important finding now requires confirmation in other large patient series, with blind interpretation of post-transplant liver biopsies.
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Affiliation(s)
- M S Murphy
- Department of Child Health, Medical School, University of Birmingham
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Pastore M, Willems M, Cornu C, Buts JP, Reding R, de Ville de Goyet J, Rahier J, Otte JB, Yap SH, Sokal EM. Role of hepatitis C virus in chronic liver disease occurring after orthotopic liver transplantation. Arch Dis Child 1995; 72:403-7. [PMID: 7618905 PMCID: PMC1511101 DOI: 10.1136/adc.72.5.403] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Paediatric orthotopic liver transplant recipients may develop chronic hepatitis after surgery. To investigate the role of hepatitis C virus in this pathology a cohort of 249 paediatric orthotopic liver transplant recipients was studied. Sixteen children (6.4%) were found to have chronic hepatitis C virus hepatitis after orthotopic liver transplantation. All but one of them had serum transaminase values which were persistently raised two to eight times the upper limit of normal. Thirteen were positive for both serology and serum hepatitis C virus RNA. Serum hepatitis C virus RNA detection occurred five to 33 months before hepatitis C virus antibodies. Liver tissue hepatitis C virus RNA and hepatitis C virus core antigen were detected in five. In one patient, tissue hepatitis C virus core antigen was detected when other tests for hepatitis C were negative. Two patients had positive human cytomegalovirus serum antibodies and RNA before transplantation. Although serum hepatitis C virus RNA was not detected after transplantation, serum enzyme immunosorbent assay and tissue core antigen were still detectable in both patients. In another child, serum hepatitis C virus RNA was positive and hepatitis C virus core antigen was found on a liver biopsy specimen but antihepatitis C virus antibodies were negative as well as liver hepatitis C virus RNA. No patient developed severe liver disease or cirrhosis during a follow up of up to 72 months. It is concluded that hepatitis C virus is a significant cause of morbidity after paediatric orthotopic liver transplantation. Diagnosis cannot rely on serological testing only. The patients remained stable on follow up, but longer prospective histological studies remain necessary to establish prognosis.
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Affiliation(s)
- M Pastore
- Department of Paediatrics, Virology, and Surgery, Cliniques St Luc, Catholic University of Louvain, Brussels, Belgium
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Sokal EM. Quality of life after orthotopic liver transplantation in children. An overview of physical, psychological and social outcome. Eur J Pediatr 1995; 154:171-5. [PMID: 7758511 DOI: 10.1007/bf01954265] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Orthotopic liver transplantation is now routinely performed as a cure of numerous untreatable paediatric liver diseases. Evaluation of post-transplant quality of life is subjective and very difficult. It has to take into account the pre-transplant quality of life and the emotional stress to the family. Transplantation saves life in 65%-90% of the patients. Several diseases may, however, recur after transplantation, such as hepatitis B, C or NANB, or tumours. Some metabolic diseases may also progress in other organs. Extra-hepatic manifestations or sequelae may persist after transplantation. Complications of transplantation include renal function impairment, hypertension, viral and opportunistic diseases. Of particular concern is the post-transplant lymphoproliferative syndrome. Liver transplantation is able to restore growth. Children are less frequently admitted to hospital after transplantation, take fewer medications, return to school, are less dependent and interact more normally with their peers. Quality of life may not reach perfection, and depends also on the way our society accepts these imperfections.
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Affiliation(s)
- E M Sokal
- Department of Paediatrics, Cliniques St Luc, Université Catholique de Louvain, Bruxelles, Belgium
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Abstract
Neonatal cholestasis remains a major diagnostic challenge despite increasing knowledge regarding its pathogenesis. The time constraint and urgency in the investigational process is underscored by the age-dependent success rate of the surgical corrective procedures for EHBA. Appropriate interpretation of imaging and pathologic studies requires a pediatric center familiar with the entities causing neonatal cholestasis. When liver failure or progressive hepatic dysfunction is likely to occur, early referral to a liver transplant center is recommended. Despite the increasing experience and excellent results of pediatric liver transplantation, at this point, surgical corrective procedures such as the Kasai procedure remain the first line of treatment for most patients with EHBA.
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Affiliation(s)
- H A Shah
- Department of Pediatrics, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
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Abstract
Biliary atresia is the most frequent cause of chronic cholestasis in infants. When left untreated, this condition leads to death from liver insufficiency within the first 2 yr of life. The modern therapeutic approach consists of a sequential strategy with Kasai portoenterostomy as a first step and, in case of failure, liver transplantation. After portoenterostomy, no more than 20% to 30% of patients will live jaundice-free into adulthood. Illness in another third will be palliated, and these patients have extended survival, delaying liver transplantation to later childhood (2 to 15 yr). The remaining 30% to 40% will not benefit from the Kasai operation and will die of liver failure in infancy. The annual need of liver transplantation for biliary atresia is one case per million people. This indication represents 35% to 67% of the reported series of pediatric liver transplantation and between 5% and 10% of the indications for liver transplantation, all ages included. Approximately four of five children transplanted for biliary atresia will become long-term survivors with good physical and mental development; recurrence of the disease after transplantation has not been observed. Because most candidates are young children (< 3 yr) of small size (< 10 kg), there is a shortage of size-matched donors (which has been alleviated by the use of innovative techniques such as reduced and split livers). The resulting redistribution of the adult donor liver pool is ethically justified by the equal quality of the results after transplantation of a full-size or partial graft.
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Codoner-Franch P, Bernard O, Alvarez F. Long-term follow-up of growth in height after successful liver transplantation. J Pediatr 1994; 124:368-73. [PMID: 8120704 DOI: 10.1016/s0022-3476(94)70357-4] [Citation(s) in RCA: 86] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Quantitative assessment of growth in height during the long-term follow-up of children who underwent orthotopic liver transplantation was done to allay concerns related to the progress of the children in terms of normal relationships with peers. Height curves were constructed for 119 children who received transplants at Bicêtre and Cochin Hospitals and were followed for more than 1 year. Poor linear growth was observed during the first 6 months after transplantation, during which time children received corticosteroids daily. The onset of catch-up growth was observed between 6 and 24 months after transplantation, and its magnitude did not differ between male and female patients. Both boys and girls underwent a normal pubertal growth spurt and normal development of secondary sexual characteristics. All adolescent girls had regular menstrual cycles, and one delivered a normal infant 6 years after transplantation. Patients who received transplants before the age of 2 years had poor average growth velocity by the third year after transplantation. Linear growth improved in almost all children and was not affected by the cause of the liver disease that existed before the liver transplantation except that fulminant hepatic failure was associated with poor growth. Long-term improvement of growth in height usually is obtained after liver transplantation in most children with chronic liver diseases. The use of low doses of corticosteroids, administered on an alternate-day basis, contributes to this improvement. Young age of the patient, but not the cause of the chronic liver disease, appears to influence the long-term outcome of linear growth.
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Affiliation(s)
- P Codoner-Franch
- Service d'Hépatologie Pédiatrique, Hôpital de Bicêtre, Le Kremlin-Bicêtre, France
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46
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Beath SV, Brook GD, Kelly DA, Cash AJ, McMaster P, Mayer AD, Buckels JA. Successful liver transplantation in babies under 1 year. BMJ (CLINICAL RESEARCH ED.) 1993; 307:825-8. [PMID: 8401122 PMCID: PMC1678855 DOI: 10.1136/bmj.307.6908.825] [Citation(s) in RCA: 69] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To review the outcome of liver transplantation in babies aged less than 1 year. DESIGN Prospective evaluation of survival, clinical complications, and nutritional and developmental status before and one year after liver transplantation. SETTING The Children's Hospital and Queen Elizabeth Hospital, Birmingham. SUBJECTS All 25 babies who received liver transplantation from January 1989 to December 1992 were included. Median age was 9 months and median weight was 7.0 kg. Seven babies were assessed but were not given transplants because they died while on the waiting list (two) or had severe extrahepatic disease (five). RESULTS 24 babies had severe decompensated liver disease and 20 were severely malnourished despite nutritional support. Six babies received a whole liver graft and 19 received a reduction hepatectomy. Postoperative complications included primary nonfunction of the transplanted liver (one baby), hepatic artery thrombosis (two), biliary obstruction (seven), acute and chronic rejection (six), and sepsis (18). Three babies required a second transplant; all survived. Three babies, two of whom presented with fulminant hepatic failure, died. The overall actuarial survival rate (4 months to 4 years) is 88%. Review at 12 months showed a dramatic improvement in growth (p < 0.001) and normal psychosocial development with good quality of life. CONCLUSION The improvement in survival rates and quality of life in this group of very sick babies is related not only to the development of reduction hepatectomy but also to advances in medical and nursing expertise. Early referral for liver transplantation is justified even if babies are critically ill.
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Dunn SP, Weintraub W, Vinocur CD, Billmire DF, Falkenstein K. Is age less than 1 year a high-risk category for orthotopic liver transplantation? J Pediatr Surg 1993; 28:1048-50. [PMID: 8229595 DOI: 10.1016/0022-3468(93)90516-n] [Citation(s) in RCA: 29] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The aim of this study was to determine if age less than 1 year is a high risk group for orthotopic liver transplantation (OLT). Retrospective analysis was done of patients with liver failure who received OLT. Comparison was made between patients aged < 1 year and > 1 year with regard to survival, allograft survival, hepatic artery thrombosis, and medical status at OLT. Between January 1, 1987 and September 30, 1991, 46 children received OLT. Fifteen (35%) were < 1 year (average age, 7.93 months). Survival in children < 1 year was 80% and children > 1 year was 91%. Allograft survival in children < 1 year was 57% (21 allografts required for 12 survivors) and 78% in children > 1 year (37 allografts required for 29 survivors). Retransplantation was required in 5 of 15 children < 1 year (33%) and in 5 of 29 children (17%) > 1 year. Medical status in children < 1 year was similar to medical status in children > 1 year at the time of transplant. Children with chronic stable liver disease represented 60% of children < 1 year and 60.1% of children > 1 year. Children requiring hospitalization represented 26% of children < 1 year and 29% of children > 1 year. Children in intensive care represented 13% of children < 1 year and 11% of children > 1 year. Survival for all status groups was similar. Hepatic artery thrombosis occurred in one child < 1 year and in 2 children > 1 year. No statistical difference (chi 2 analysis) was found by age between the categories evaluated.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- S P Dunn
- Department of Pediatric Surgery, St. Christopher's Hospital for Children, Temple University School of Medicine, Philadelphia, PA 19134-1095
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Beath S, Pearmain G, Kelly D, McMaster P, Mayer A, Buckels J. Liver transplantation in babies and children with extrahepatic biliary atresia. J Pediatr Surg 1993; 28:1044-7. [PMID: 8229594 DOI: 10.1016/0022-3468(93)90515-m] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Orthotopic liver transplantation (OLT) is a life-saving procedure for end-stage liver failure. We reviewed 39 children (24 girls, 15 boys) who received OLT for biliary atresia from 1987 to 1991. Twenty had unsuccessful portoenterostomy, 6 were referred too late for a drainage operation, and the remaining 13 achieved bile drainage but developed portal hypertension. At transplant 37 had decompensated liver disease with varices (28), ascites (24), encephalopathy (17), and gastrointestinal bleeding (12). The median weight and age at transplant were 8 kg and 12.6 months, respectively. The median waiting time was 65 days. Forty-eight grafts (30 reduced and 18 whole) were performed; graft loss was 33% and 27%, respectively. Of the 30 segmental grafts, 15 were reduced conserving the left lateral segment and hepatic vein (Brisbane technique)--13 were from the left lobe and 2 from the right lobe. The overall subject survival rate is 72%. Eleven deaths occurred: primary nonfunction (3), sepsis (3), perioperative bleed (3), and other causes (2). Early complications included: hepatic artery thrombosis (5), hepatic vein thrombosis (2), bowel perforation (3), biliary leak (3), and acute rejection (8). Later complications were chronic rejection (4) and biliary stricture requiring reconstruction (3). Follow-up at 12 months confirms good quality of life for both child and family with catch up growth and normal development. Technical advances in reduction hepatectomy have allowed us to treat small babies under 1 year with an urgent requirement for OLT, with comparable results to those obtained with whole grafts. In conclusion, in the future size and age need not be a contraindication to OLT in children with biliary atresia.
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Affiliation(s)
- S Beath
- Liver Unit, Children's Hospital, Birmingham, England
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50
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Ryckman F, Fisher R, Pedersen S, Dittrich V, Heubi J, Farrell M, Balistreri W, Ziegler M. Improved survival in biliary atresia patients in the present era of liver transplantation. J Pediatr Surg 1993; 28:382-5; discussion 386. [PMID: 8468651 DOI: 10.1016/0022-3468(93)90236-e] [Citation(s) in RCA: 52] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Therapy for patients with biliary atresia (BA) has become controversial, with orthotopic liver transplantation (OLTx) suggested in place of portoenterostomy. This is based on the unpredictable success of portoenterostomy, and the increased difficulty of the OLTx procedure following prior extensive liver surgery. The survival rate reported here for infants transplanted after unsuccessful portoenterostomy does not support this approach. OLTx was undertaken in 37 patients when end-stage liver failure followed primary portoenterostomy. Recipient age ranged from 6 months to 14 years (median, 13 months), and weight ranged from 5 to 45 kg (median, 8 kg) at the time of OLTx. Reduced-size allografts were used as the primary allograft in 25 patients (23 left lobe), and 12 received whole-organ allografts. Retransplantation was required in 5 patients, each received a reduced-size allograft. There was no increased incidence of vascular complications, primary nonfunction, irreversible rejection, intestinal perforation, biliary complications, sepsis, or lymphoma comparing the BA patients with all other non-BA patients who had undergone OLTx (all P = .16). There was no statistically significant difference in mean operative blood loss between BA patients (EBL = 1.99 BV) and non-BA patients (1.50 BV) (P = .14). Actuarial survival for the series of BA patients was 89% at 1 year, and 80% at 2 years. Following the introduction of reduced-size allografts, donor organs were selected for use with a priority on donor stability. The actuarial survival for BA patients during this time has improved to 96% at 1 year, and 91% at 2 years.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- F Ryckman
- Liver Transplant Services, Children's Hospital Medical Center, University of Cincinnati, OH 45229
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