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Critical Care and Mechanical Ventilation Practices Surrounding Liver Transplantation in Children: A Multicenter Collaborative. Pediatr Crit Care Med 2023; 24:102-111. [PMID: 36278882 DOI: 10.1097/pcc.0000000000003101] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES We aimed to determine which characteristics and management approaches were associated with postoperative invasive mechanical ventilation (IMV) and with a prolonged course of IMV in children post liver transplant as well as describing the utilization of critical care resources. DESIGN Retrospective, multicenter, cohort study of children who underwent an isolated liver transplantation between January 2017 and December 2018. SETTING Twelve U.S., pediatric, liver transplant centers. PATIENTS Three hundred thirty children post liver transplant admitted to the ICU. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Six patients died in our cohort. The median length of PICU stay was 4.5 days (interquartile range [IQR], 2.9-8.2 d). Most patients were initially monitored with arterial catheters (96%), central venous pressures (95%), and liver ultrasound (93%). Anticoagulation (80%), blood product administration (52.4%), and vasoactive agents (23.0%) were commonly used therapies in the first 7 days. In multivariable logistic regression analysis, age (adjusted odds ratio [aOR] 0.9 [0.86-0.95]), open fascia (aOR 7.0 [95% CI, 2.6-18.9]), large center size (aOR 4.3 [95% CI 2.2-8.3]), and higher Model for End-Stage Liver Disease/Pediatric End-Stage Liver Disease scores (aOR 1.04 [95% CI, 1.01-1.06]) were associated with postoperative IMV. In multivariable logistic regression analysis, postoperative day 0 peak inspiratory pressure (PIP) (aOR 1.2 [95% CI, 1.1-1.3]), large center size (aOR 2.9 [95% CI, 1.6-5.4]), and age (aOR 0.89 [95% CI, 0.85-0.95]) were associated with length of IMV greater than 24 hours. Length of IMV greater than 24 hours was associated with bleeding complications ( p = 0.03), infections ( p = 0.03), graft loss ( p = 0.02), and reoperation ( p = 0.03). CONCLUSIONS Younger age, preoperative hospitalization, large center size, and open fascia are associated with use of IMV, and younger age, large center size, and postoperative day 0 PIP are associated with prolonged IMV on multivariable analysis. Longer IMV is associated with negative outcomes, making it an important clinical marker.
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Slowik V, Lerret SM, Lobritto SJ, Voulgarelis S, Vitola BE. Variation in immunosuppression practices among pediatric liver transplant centers-Society of Pediatric Liver Transplantation survey results. Pediatr Transplant 2021; 25:e13873. [PMID: 33026158 DOI: 10.1111/petr.13873] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 07/28/2020] [Accepted: 09/11/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Variation in IS exists among pediatric liver transplant centers. While individual centers may publish their practice paradigms, current data on practices as a whole are lacking. This study sought to ascertain the IS protocols of pediatric liver transplant centers within the SPLIT to better understand variability and similarities among peer institutions. METHODS A 27-item questionnaire was developed within the SPLIT Quality Improvement and Clinical Care Committee. The survey collected data regarding center demographics, IS practices, and treatment of acute cellular rejection. RESULTS Twenty-eight (64%) SPLIT centers responded with 22 (79%) centers performing more than 10 transplants per year and 17 (61%) following more than 100 post-transplant recipients. All centers use a written protocol, and 25 (89%) have a dedicated transplant pharmacist/PharmD. Twenty-five (89%) centers use steroids for induction alone or in combination with thymoglobulin/interleukin-2 antibodies. All centers use tacrolimus for initial maintenance therapy. Most centers have specialized protocols for ABO-incompatible transplants, recipients with renal dysfunction, autoimmune liver diseases, and liver tumors. Treatment of rejection varied but was associated with escalation in IS. CONCLUSION IS practices among pediatric liver transplant centers are similar including the use of written protocols, pharmacy involvement, steroids for induction, tacrolimus as initial IS, tacrolimus reduction/delay for renal dysfunction, and escalation of IS with rejection severity. However, other IS practices show wide variability including treatment for ABO-incompatible grafts and presumed rejection. This study serves as a foundation to guide prospective research linking IS practice to outcomes to determine best practice.
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Affiliation(s)
- Voytek Slowik
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Children's Mercy Kansas City, University of Missouri - Kansas City School of Medicine, Kansas City, MO, USA
| | - Stacee M Lerret
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, WI, USA
| | - Steven J Lobritto
- Center for Liver Diseases and Transplantation, Department of Pediatrics and Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Stylianos Voulgarelis
- Division of Anesthesiology, Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, WI, USA
| | - Bernadette E Vitola
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, WI, USA
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McLin VA. Cardiovascular Morbidity After Pediatric Liver Transplantation: A Matter of Life Expectancy? Liver Transpl 2019; 25:692-694. [PMID: 30921501 DOI: 10.1002/lt.25461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 03/25/2019] [Indexed: 01/13/2023]
Affiliation(s)
- Valérie A McLin
- Faculty of Medicine, Department of Pediatrics, Gynecology and Obstetrics, University Hospitals Geneva, Geneva, Switzerland
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Rock N, Ansari M, Villard J, Ferrari-Lacraz S, Waldvogel S, McLin VA. Factors associated with immune hemolytic anemia after pediatric liver transplantation. Pediatr Transplant 2018; 22:e13230. [PMID: 29885007 DOI: 10.1111/petr.13230] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/22/2018] [Indexed: 01/27/2023]
Abstract
Immune-mediated hemolytic anemia following SOT is a rare disorder, the risk factors for which are unknown. Our purpose was to analyze a seemingly increased incidence in our center with the aim to identify predisposing factors. This recipients single-center retrospective study reviewed the medical records of 96 pediatric LT between 2000 and 2013. IHA was defined as acute anemia with a positive direct antiglobulin test. Seven cases of immune-mediated hemolytic anemia were identified (incidence 8.5%). Three cases presented during the first 3 months following LT (early IHA), and 4 presented later (late IHA). All patients with late IHA required rituximab. Using univariate analysis, the following factors were associated with IHA onset: BA (P = .04), younger age (P = .04), and the use of IGL-1 preservation solution (P = .05). Late IHA was associated with viral infections occurring beyond 3 months following LT, younger age, and BA (P = .01). Overall, CMV infection was associated with the development of both early and late IHA: CMV-negative recipients who received an organ from a CMV-positive donor were more likely to develop IHA (P = .035), and de novo CMV infection during the first year post-LT was associated with late IHA (P = .03). IHA is a rare complication following pediatric LT, occurring more frequently in younger patients and patients with an initial diagnosis of BA. CMV-negative recipients and patients who experience a de novo CMV infection in the first year following LT seem particularly vulnerable. IGL-1 preservation solution may be associated with an increased likelihood of developing IHA, a novel finding which warrants further investigation.
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Affiliation(s)
- Nathalie Rock
- Swiss Center for Liver Disease in Children, University Hospitals Geneva, Geneva, Switzerland
| | - Marc Ansari
- Pediatric Hematology and Oncology Unit, University Hospitals Geneva, Geneva, Switzerland
| | - Jean Villard
- Transplant Immunology Unit, Division of Immunology and Allergy, University Hospitals Geneva, Geneva, Switzerland
| | - Sylvie Ferrari-Lacraz
- Transplant Immunology Unit, Division of Immunology and Allergy, University Hospitals Geneva, Geneva, Switzerland
| | - Sophie Waldvogel
- Immunology and Hematology Laboratory, University Hospitals Geneva, Geneva, Switzerland
| | - Valérie Anne McLin
- Swiss Center for Liver Disease in Children, University Hospitals Geneva, Geneva, Switzerland
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Hematologic Manifestations of Childhood Illness. Hematology 2018. [DOI: 10.1016/b978-0-323-35762-3.00152-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
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Würdinger M, Modrow S, Plentz A. Impact of Parvovirus B19 Viremia in Liver Transplanted Children on Anemia: A Retrospective Study. Viruses 2017; 9:v9060149. [PMID: 28608818 PMCID: PMC5490825 DOI: 10.3390/v9060149] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 05/30/2017] [Accepted: 06/06/2017] [Indexed: 12/18/2022] Open
Abstract
Acute parvovirus B19 (B19V) infection in immunocompromised patients may lead to severe anemia. However, in adult transplant recipients, B19V reactivations without anemia and low-level viremia are common. The impact of B19V in pediatric transplant patients, with high risk of primary infection, is investigated here. In a six-month period, 159 blood samples of 54 pediatric liver transplant recipients were tested for B19V DNA by quantitative real-time PCR. Viremia was correlated with anemia and immunosuppression and compared with rates in adult transplant recipients. B19V DNA was detected in 5/54 patients. Primary B19V infections were observed in four patients prior to and in one patient after transplantation. Rates of viremia were significantly higher in pediatric recipients than in adults. Prolonged virus shedding after primary infection prior to transplantation accounts for most viremic cases. Anemia was significantly more frequent in samples from viremic patients, but remained mild. In 15% of anemic samples, B19V DNA was detected. Therefore, in anemic pediatric transplant recipients, diagnostics for B19V seem reasonable.
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Affiliation(s)
- Michael Würdinger
- Institute of Medical Microbiology and Hygiene, University of Regensburg, 93053 Regensburg, Germany.
- Department of Surgery and Transplantation, University Hospital of Zurich, 8091 Zürich, Switzerland.
| | - Susanne Modrow
- Institute of Medical Microbiology and Hygiene, University of Regensburg, 93053 Regensburg, Germany.
| | - Annelie Plentz
- Institute of Medical Microbiology and Hygiene, University of Regensburg, 93053 Regensburg, Germany.
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Bass LM, Kim S, Superina R, Mohammad S. Jejunal varices diagnosed by capsule endoscopy in patients with post-liver transplant portal hypertension. Pediatr Transplant 2017; 21. [PMID: 27762481 DOI: 10.1111/petr.12818] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/06/2016] [Indexed: 12/11/2022]
Abstract
Portal hypertension secondary to portal vein obstruction following liver transplant occurs in 5%-10% of children. Jejunal varices are uncommon in this group. We present a case series of children with significant GI blood loss, negative upper endoscopy, and jejunal varices detected by CE. Case series of patients who had CE for chronic GI blood loss following liver transplantation. Three patients who had their initial transplants at a median age of 7 months were identified at our institution presenting at a median age of 8 years (range 7-16 years) with a median Hgb of 2.8 g/dL (range 1.8-6.8 g/dL). Upper endoscopy was negative for significant esophageal varices, gastric varices, and bleeding portal gastropathy in all three children. All three patients had significant jejunal varices noted on CE in mid-jejunum. Jejunal varices were described as large prominent bluish vessels underneath visualized mucosa, one with evidence of recent bleeding. The results led to venoplasty of the portal vein in two patients and a decompressive shunt in one patient with resolution of GI bleed and anemia. CE is useful to diagnose intestinal varices in children with portal hypertension and GI bleeding following liver transplant.
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Affiliation(s)
- Lee M Bass
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Stanley Kim
- Department of Radiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Riccardo Superina
- Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Saeed Mohammad
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Abstract
PURPOSE OF REVIEW Successful outcomes in patient, graft survival, and quality of life depend on the prevention, early detection, and treatment of possible complications. The aim of the study was to highlight the common outcomes focusing on the unique features in children. Medical follow-up of children after liver transplantation includes monitoring of surgical complications: biliary and vascular, rejection, infections, posttransplant lymphoproliferative disease, other malignancies, recurrent disease, graft function, hypertension, diabetes, renal failure, among other conditions. The goal is to maintain normal graft function on minimal immunosuppression to avoid medication-induced side-effects. RECENT FINDINGS Recent findings include the importance of meticulous follow-up of Epstein-Barr virus and Cytomegalic virus viral load, leading to early diagnosis and improved prognosis, increased prevalence of renal toxicity, cognitive dysfunction, autoimmune, atopic and eosinophilic disease, oral hygiene and chronic hepatitis, and fibrosis of allografts. SUMMARY Caring for children after liver transplantation is extremely rewarding; however, careful attention must be paid to a variety of systems with understanding of the distinctiveness of pediatrics to assure optimal outcomes.
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Asfaw M, Mingle J, Hendricks J, Pharis M, Nucci AM. Nutrition management after pediatric solid organ transplantation. Nutr Clin Pract 2014; 29:192-200. [PMID: 24523132 DOI: 10.1177/0884533614521242] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Survival rates for pediatric transplant recipients and organ grafts have increased due to improvements in surgical techniques and with immunosuppressant treatment therapies. Interdisciplinary management after pediatric organ transplantation is essential to assist not only with the complex medical issues and complications that can result from immunosuppressant therapy but also with the achievement of normal growth and development. Impaired growth is a complication frequently experienced by pediatric transplant patients. The presence or absence of impaired growth is affected by the length of illness prior to transplant, graft function, the use of corticosteroids, and the development of infectious complications after surgery. A review of posttransplant nutrition assessment, nutrition requirements, and nutrition goals is provided. In addition, a case series of experiences with nutrition management of pediatric solid organ transplant recipients is described.
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Affiliation(s)
- Meheret Asfaw
- Anita M. Nucci, Department of Nutrition, Georgia State University, PO Box 3995, Atlanta, GA 30302-3995, USA.
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Alonso EM, Ng VL, Anand R, Anderson CD, Ekong UD, Fredericks EM, Furuya KN, Gupta NA, Lerret SM, Sundaram S, Tiao G. The SPLIT research agenda 2013. Pediatr Transplant 2013; 17:412-22. [PMID: 23718800 PMCID: PMC4157303 DOI: 10.1111/petr.12090] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/11/2013] [Indexed: 12/17/2022]
Abstract
This review focuses on active clinical research in pediatric liver transplantation with special emphasis on areas that could benefit from studies utilizing the SPLIT infrastructure and data repository. Ideas were solicited by members of the SPLIT Research Committee and sections were drafted by members of the committee with expertise in those given areas. This review is intended to highlight priorities for clinical research that could successfully be conducted through the SPLIT collaborative and would have significant impact in pediatric liver transplantation.
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Affiliation(s)
- Estella M. Alonso
- Department of Pediatrics; Ann & Robert H. Lurie Children's Hospital of Chicago; Chicago; IL; USA
| | - Vicky L. Ng
- SickKids Transplant Center; The Hospital for Sick Children and University of Toronto; Toronto; ON; Canada
| | | | - Christopher D. Anderson
- Division of Transplant and Hepatobiliary Surgery; University of Mississippi Medical Center; Jackson; MS; USA
| | - Udeme D. Ekong
- Department of Pediatrics; Ann & Robert H. Lurie Children's Hospital of Chicago; Chicago; IL; USA
| | - Emily M. Fredericks
- Division of Child Behavioral Health; Department of Pediatrics and Communicable Diseases; University of Michigan; Ann Arbor; MI; USA
| | - Katryn N. Furuya
- Department of Pediatrics; Thomas Jefferson University; Philadelphia; PA; USA
| | - Nitika A. Gupta
- Department of Pediatrics; Emory University School of Medicine; Atlanta; GA; USA
| | - Stacee M. Lerret
- Department of Pediatrics; Medical College of Wisconsin; Milwaukee; WI; USA
| | - Shikha Sundaram
- Pediatric Liver Center and Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics; University of Colorado Denver School of Medicine; Children's Hospital Colorado; Denver; CO; USA
| | - Greg Tiao
- Departments of Pediatric and Thoracic Surgery; Cincinnati Children's Hospital and Medical Center; Cincinnati; OH; USA
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