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Colmenero J, Gastaca M, Martínez-Alarcón L, Soria C, Lázaro E, Plasencia I. Risk Factors for Non-Adherence to Medication for Liver Transplant Patients: An Umbrella Review. J Clin Med 2024; 13:2348. [PMID: 38673620 PMCID: PMC11051511 DOI: 10.3390/jcm13082348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 04/05/2024] [Accepted: 04/10/2024] [Indexed: 04/28/2024] Open
Abstract
Background/Objectives: Liver Transplantation (LT) is the second most common solid organ transplantation. Medication adherence on LT patients is key to avoiding graft failure, mortality, and important quality of life losses. The aim of this study is to identify risk-factors for non-adherence to treatment of liver transplant patients according to reliable published evidence. Methods: An umbrella review within the context of adherence to immunosuppressant medication of LT patients, was conducted. The review was performed in accordance with the principles of the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines. Results: A total of 11 articles were finally included for the review. Non-adherence factors were identified and allocated using the WHO classification of factors for non-adherence. Each of these groups contains a subset of factors that have been shown to influence adherence to medication, directly or indirectly, according to literature findings. Conclusions: The results of the review indicate that sociodemographic factors, factors related to the patient, factors related to the treatment, condition-related and health system-related factors are good categories of predictors for both adherence and non-adherence to immunosuppressive medication in LT patients. This list of factors may help physicians in the treating and recognizing of patients with a potential risk of non-adherence and it could help in the designing of new tools to better understand non-adherence after LT and targeted interventions to promote adherence of LT patients.
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Affiliation(s)
- Jordi Colmenero
- Liver Transplant Unit, Hospital Clínic, IDIBAPS, CIBERehd, University of Barcelona, 08007 Barcelona, Spain;
| | - Mikel Gastaca
- Hepatobiliary Surgery and Liver Transplantation Unit, Biobizkaia Health Research Institute, Cruces University Hospital, University of the Basque Country, 48940 Bilbao, Spain
| | - Laura Martínez-Alarcón
- Transplant Unit, Surgery Service, IMIB-Virgen de la Arrixaca University Hospital, 30120 Murcia, Spain;
| | | | - Esther Lázaro
- Faculty of Health Sciences, Valencian International University, 46002 Valencia, Spain
| | - Inmaculada Plasencia
- Pharmacy Unit of the University Hospital of Nuestra Señora de Candelaria, 38010 Tenerife, Spain;
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Killian MO, Tian S, Xing A, Hughes D, Gupta D, Wang X, He Z. Prediction of Outcomes After Heart Transplantation in Pediatric Patients Using National Registry Data: Evaluation of Machine Learning Approaches. JMIR Cardio 2023; 7:e45352. [PMID: 37338974 DOI: 10.2196/45352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 04/17/2023] [Accepted: 05/10/2023] [Indexed: 06/21/2023] Open
Abstract
BACKGROUND The prediction of posttransplant health outcomes for pediatric heart transplantation is critical for risk stratification and high-quality posttransplant care. OBJECTIVE The purpose of this study was to examine the use of machine learning (ML) models to predict rejection and mortality for pediatric heart transplant recipients. METHODS Various ML models were used to predict rejection and mortality at 1, 3, and 5 years after transplantation in pediatric heart transplant recipients using United Network for Organ Sharing data from 1987 to 2019. The variables used for predicting posttransplant outcomes included donor and recipient as well as medical and social factors. We evaluated 7 ML models-extreme gradient boosting (XGBoost), logistic regression, support vector machine, random forest (RF), stochastic gradient descent, multilayer perceptron, and adaptive boosting (AdaBoost)-as well as a deep learning model with 2 hidden layers with 100 neurons and a rectified linear unit (ReLU) activation function followed by batch normalization for each and a classification head with a softmax activation function. We used 10-fold cross-validation to evaluate model performance. Shapley additive explanations (SHAP) values were calculated to estimate the importance of each variable for prediction. RESULTS RF and AdaBoost models were the best-performing algorithms for different prediction windows across outcomes. RF outperformed other ML algorithms in predicting 5 of the 6 outcomes (area under the receiver operating characteristic curve [AUROC] 0.664 and 0.706 for 1-year and 3-year rejection, respectively, and AUROC 0.697, 0.758, and 0.763 for 1-year, 3-year, and 5-year mortality, respectively). AdaBoost achieved the best performance for prediction of 5-year rejection (AUROC 0.705). CONCLUSIONS This study demonstrates the comparative utility of ML approaches for modeling posttransplant health outcomes using registry data. ML approaches can identify unique risk factors and their complex relationship with outcomes, thereby identifying patients considered to be at risk and informing the transplant community about the potential of these innovative approaches to improve pediatric care after heart transplantation. Future studies are required to translate the information derived from prediction models to optimize counseling, clinical care, and decision-making within pediatric organ transplant centers.
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Affiliation(s)
- Michael O Killian
- College of Social Work, Florida State University, Tallahassee, FL, United States
| | - Shubo Tian
- Department of Statistics, Florida State University, Tallahassee, FL, United States
| | - Aiwen Xing
- Department of Statistics, Florida State University, Tallahassee, FL, United States
| | - Dana Hughes
- College of Social Work, Florida State University, Tallahassee, FL, United States
| | - Dipankar Gupta
- Congenital Heart Center, Shands Children's Hospital, University of Florida, Gainesville, FL, United States
| | - Xiaoyu Wang
- Department of Statistics, Florida State University, Tallahassee, FL, United States
| | - Zhe He
- School of Information, Florida State University, Tallahassee, FL, United States
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ABO-incompatible Pediatric Liver Transplantation With Antibody and B-cell Depletion-free Immunosuppressive Protocol in High Consanguinity Communities. Transplant Direct 2022; 8:e1353. [PMID: 36479277 PMCID: PMC9722564 DOI: 10.1097/txd.0000000000001353] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 05/27/2022] [Indexed: 01/24/2023] Open
Abstract
UNLABELLED The success of orthotopic liver transplantation as a life-saving treatment has led to new indications and a greater competition for organ grafts. Pediatric patients with acute liver-related crises can benefit from orthotopic liver transplantation, but organ availability in the limited time can be a major obstacle. Crossing ABO blood group barriers could increase the organs available to such patients. METHODS From November 2010 to June 2015, 176 children aged 0.2-to18 y were transplanted in the King Faisal Specialist Hospital and Research Center. Out of those, 19 children were transplanted across blood group barriers (ABO incompatible). The underlying diseases were biliary atresia (n = 6); progressive familial intrahepatic cholestasis type 2 (n = 4); Crigler-Najjar syndrome (n = 3); hepatoblastoma (n = 2); and urea cycle disorder, Caroli disease, cryptogenic cirrhosis, and neonatal sclerosing cholangitis (n = 1 each). Immunosuppression consisted of basiliximab, mycophenolate, tacrolimus, and steroids. Pretransplant prophylactic plasmapheresis, high-dose immunoglobulins, and rituximab were not administered. RESULTS The grafts were from living donors (n = 17) and deceased donors (n = 2). Living donor morbidity was nil. The recipient median age was 21 mo (5-70 mo). After a median follow-up of 44 mo, 2 recipients (10%) died because of sepsis, 1 because of uncontrolled acute myeloid leukemia. The overall rejection rate was 7%, and no grafts were lost because of antibody-mediated rejection (AMR). HLA matching was 3.8 of 6 (A, B, DR), and there were 2 patients presented with acute cellular rejection, 1 patient with AMR, and 1 patient with biliary strictures. CONCLUSIONS ABO incompatible liver transplantation is a feasible and life-saving option even with antibody and B-cell depletion-free protocol without increasing the risks for AMR. We speculate that this excellent result is most likely because of presence of relatively low titer ABO isoagglutinins and the high HLA match compatibility caused by habit of longstanding interfamilial marriages as typical of Saudi Arabia.
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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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Jain AK, Anand R, Lerret S, Yanni G, Chen JY, Mohammad S, Doyle M, Telega G, Horslen S. Outcomes following liver transplantation in young infants: Data from the SPLIT registry. Am J Transplant 2021; 21:1113-1127. [PMID: 32767649 PMCID: PMC7867666 DOI: 10.1111/ajt.16236] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 07/20/2020] [Accepted: 07/20/2020] [Indexed: 02/06/2023]
Abstract
Liver transplantation (LT) in young patients is being performed with greater frequency. We hypothesized that objective analysis of pre-, intra-, and postoperative events would help understand contributors to successful outcomes and guide transplant decision processes. We queried SPLIT registry for pediatric transplants between 2011 and 2018. Outcomes were compared for age groups: 0-<3, 3-<6, 6-<12 months, and 1-<3 years (Groups A, B, C, D respectively) and by weight categories: <5, 5-10, >10 kg; 1033 patients were available for analysis. Cholestatic disease and fulminant failure were highest in group A and those <5 kg; and biliary atresia in group C (72.8%). Group A had significantly higher life support dependence (34.6%; P < .001), listing as United Network for Organ Sharing status 1a/1b (70.4%; P < .001), and shortest wait times (P < .001). The median (interquartile range) for international normalized ratio and bilirubin were highest in group A (3.0 [2.1-3.9] and 16.7 [6.8-29.7] mg/dL) and those <5 kg (2.6 [1.8-3.4] and 13.5 [3.0-28.4] mg/dL). A pediatric end -stage liver disease score ≥40, postoperative hospital stays, rejection, and nonanastomotic biliary strictures were highest in group A with lowest survival at 93.1%. Infants 0 to <3 months and those <5 kg need more intensive care with lower survival and higher complications. Importantly, potential LT before reaching status 1a/1b and aggressive postoperative management may positively influence their outcomes.
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Affiliation(s)
- Ajay K. Jain
- Saint Louis University, Saint Louis, Missouri, USA
| | | | - Stacee Lerret
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Pediatric Gastroenterology, Hepatology and Nutrition, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - George Yanni
- Pediatrics, Children’s Hospital of Los Angeles, Los Angeles, California, USA
| | | | - Saeed Mohammad
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Majella Doyle
- Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Greg Telega
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Pediatric Gastroenterology, Hepatology and Nutrition, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Simon Horslen
- Liver and Small Bowel Transplantation, Seattle Children’s Hospital, Seattle, Washington, USA
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Stormon MO, Hardikar W, Evans HM, Hodgkinson P. Paediatric liver transplantation in Australia and New Zealand: 1985-2018. J Paediatr Child Health 2020; 56:1739-1746. [PMID: 32649047 DOI: 10.1111/jpc.14969] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 05/12/2020] [Indexed: 01/09/2023]
Abstract
Liver transplantation has become the standard of care for children with end-stage liver disease. In Australia and New Zealand, there are four paediatric liver transplant units, in Sydney, Melbourne, Brisbane and Auckland. Over the past 30 years, there have been significant changes to indications for transplant, as well as medical and surgical advances. In this paper, using retrospective data from the Australia and New Zealand Liver Transplant Registry, we review 977 children (less than 16 years of age) who underwent liver transplant from 1985 to 2018. The most common indication was biliary atresia (54%), although there has been an increase in other indications, including inborn errors of metabolism, fulminant hepatic failure and malignant liver tumours. Over the past 3 decades, areas of change and innovation include: the use of 'split grafts' to enable an adult and a child to receive the same donor liver, live donation, improvements in immunosuppressive regimens and infectious prophylaxis protocols and innovative surgical techniques allowing transplantation in smaller infants. The outcomes for children who undergo liver transplant in ANZ are excellent, with current 10-year patient survival rates of 95%, comparable to other larger centres around the world.
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Affiliation(s)
- Michael O Stormon
- Department of Gastroenterology, Children's Hospital Westmead, Sydney, New South Wales, Australia
| | - Winita Hardikar
- Department of Gastroenterology, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Helen M Evans
- Department of Gastroenterology, Starship Children's Hospital Auckland, Auckland, New Zealand
| | - Peter Hodgkinson
- Queensland Liver Transplant Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia
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Elisofon SA, Magee JC, Ng VL, Horslen SP, Fioravanti V, Economides J, Erinjeri J, Anand R, Mazariegos GV, Martin A, Mannino D, Flynn L, Mohammad S, Alonso E, Superina R, Brandt K, Riordan M, Lokar J, Ito J, Elisofon S, Zapata L, Jain A, Foristal E, Gupta N, Whitlow C, Naik K, Espinosa H, Miethke A, Hawkins A, Hardy J, Engels E, Schreibeis A, Ovchinsky N, Kogan‐Liberman D, Cunningham R, Malik P, Sundaram S, Feldman A, Garcia B, Yanni G, Kohli R, Emamaullee J, Secules C, Magee J, Lopez J, Bilhartz J, Hollenbeck J, Shaw B, Bartow C, Forest S, Rand E, Byrne A, Linguiti I, Wann L, Seidman C, Mazariegos G, Soltys K, Squires J, Kepler A, Vitola B, Telega G, Lerret S, Desai D, Moghe J, Cutright L, Daniel J, Andrews W, Fioravanti V, Slowik V, Cisneros R, Faseler M, Hufferd M, Kelly B, Sudan D, Mavis A, Moats L, Swan‐Nesbit S, Yazigi N, Buranych A, Hobby A, Rao G, Maccaby B, Gopalareddy V, Boulware M, Ibrahim S, El Youssef M, Furuya K, Schatz A, Weckwerth J, Lovejoy C, Kasi N, Nadig S, Law M, Arnon R, Chu J, Bucuvalas J, Czurda M, Secheli B, Almy C, Haydel B, Lobritto S, Emand J, Biney‐Amissah E, Gamino D, Gomez A, Himes R, Seal J, Stewart S, Bergeron J, Truxillo A, Lebel S, Davidson H, Book L, Ramstack D, Riley A, Jennings C, Horslen S, Hsu E, Wallace K, Turmelle Y, Nadler M, Postma S, Miloh T, Economides J, Timmons K, Ng V, Subramonian A, Dharmaraj B, McDiarmid S, Feist S, Rhee S, Perito E, Gallagher L, Smith K, Ebel N, Zerofsky M, Nogueira J, Greer R, Gilmour S, Robert C, Cars C, Azzam R, Boone P, Garbarino N, Lalonde M, Kerkar N, Dokus K, Helbig K, Grizzanti M, Tomiyama K, Cocking J, Alexopoulos S, Bhave C, Schillo R, Bailey A, Dulek D, Ramsey L, Ekong U, Valentino P, Hettiarachchi D, Tomlin R. Society of pediatric liver transplantation: Current registry status 2011-2018. Pediatr Transplant 2020; 24:e13605. [PMID: 31680409 DOI: 10.1111/petr.13605] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 08/08/2019] [Accepted: 09/27/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND SPLIT was founded in 1995 in order to collect comprehensive prospective data on pediatric liver transplantation, including waiting list data, transplant, and early and late outcomes. Since 2011, data collection of the current registry has been refined to focus on prospective data and outcomes only after transplant to serve as a foundation for the future development of targeted clinical studies. OBJECTIVE To report the outcomes of the SPLIT registry from 2011 to 2018. METHODS This is a multicenter, cross-sectional analysis characterizing patients transplanted and enrolled in the SPLIT registry between 2011 and 2018. All patients, <18 years of age, received a first liver-only, a combined liver-kidney, or a combined liver-pancreas transplant during this study period. RESULTS A total of 1911 recipients from 39 participating centers in North America were registered. Indications included biliary atresia (38.5%), metabolic disease (19.1%), tumors (11.7%), and fulminant liver failure (11.5%). Greater than 50% of recipients were transplanted as either Status 1A/1B or with a MELD/PELD exception score. Incompatible transplants were performed in 4.1%. Kaplan-Meier estimates of 1-year patient and graft survival were 97.3% and 96.6%. First 30 days of surgical complications included reoperation (31.7%), hepatic artery thrombosis (6.3%), and portal vein thrombosis (3.2%). In the first 90 days, biliary tract complications were reported in 13.6%. Acute cellular rejection during first year was 34.7%. At 1 and 2 years of follow-up, 39.2% and 50.6% had normal liver tests on monotherapy (tacrolimus or sirolimus). Further surgical, survival, allograft function, and complications are detailed.
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Affiliation(s)
- Scott A Elisofon
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts
| | - John C Magee
- Division of Surgery, University of Michigan Transplant Center, Ann Arbor, Michigan
| | - Vicky L Ng
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Transplant and Regenerative Medicine Center, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Simon P Horslen
- Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington
| | - Vicki Fioravanti
- Section of Hepatology and Liver Transplantation, Children's Mercy Hospital, Kansas City, Missouri
| | | | | | | | - George V Mazariegos
- Division of Pediatric Transplant Surgery, Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
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Feldman AG, Sokol RJ. Neonatal cholestasis: emerging molecular diagnostics and potential novel therapeutics. Nat Rev Gastroenterol Hepatol 2019; 16:346-360. [PMID: 30903105 DOI: 10.1038/s41575-019-0132-z] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Neonatal cholestasis is a group of rare disorders of impaired bile flow characterized by conjugated hyperbilirubinaemia in the newborn and young infant. Neonatal cholestasis is never physiological but rather is a sign of hepatobiliary and/or metabolic disorders, some of which might be fatal if not identified and treated rapidly. A step-wise timely evaluation is essential to quickly identify those causes amenable to treatment and to offer accurate prognosis. The aetiology of neonatal cholestasis now includes an expanding group of molecularly defined entities with overlapping clinical presentations. In the past two decades, our understanding of the molecular basis of many of these cholestatic diseases has improved markedly. Simultaneous next-generation sequencing for multiple genes and whole-exome or whole-genome sequencing now enable rapid and affordable molecular diagnosis for many of these disorders that cannot be directly diagnosed from standard blood tests or liver biopsy. Unfortunately, despite these advances, the aetiology and optimal therapeutic approach of the most common of these disorders, biliary atresia, remain unclear. The goals of this Review are to discuss the aetiologies, algorithms for evaluation and current and emerging therapeutic options for neonatal cholestasis.
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Affiliation(s)
- Amy G Feldman
- Pediatric Liver Center, Digestive Health Institute, Children's Hospital Colorado, Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ronald J Sokol
- Pediatric Liver Center, Digestive Health Institute, Children's Hospital Colorado, Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine, Aurora, CO, USA. .,Colorado Clinical and Translational Sciences Institute, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
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Psychosocial outcome and resilience after paediatric liver transplantation in young adults. Clin Res Hepatol Gastroenterol 2019; 43:155-160. [PMID: 30737022 DOI: 10.1016/j.clinre.2018.08.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 08/15/2018] [Accepted: 08/27/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVE The long-term psychosocial outcome of young adults after paediatric liver transplantation (LT) was investigated with the focus on day-to-day living. We aimed to capture patients' subjective perceptions of well-being and autonomy based on key physical outcome parameters. METHODS All patients following paediatric LT at Hannover Medical School born before 2002 with a post-transplant follow-up of at least four years were included in this study. This retrospective observational study compared psychosocial parameters obtained from a self-designed 77-item questionnaire with standard clinical outcome variables. RESULTS Eighty-two patients (male: 57%) aged 13-41 years were included in the survey within a three-month period (response rate: 41%). With an adherence rate of 33%, all but two patients were immunosuppressed. In total, 53 patients had transitioned to adult care largely without problems. Eighty-three percent (n = 68) evaluated their current health status as "(very) good". Sixty-seven patients (82%) did not experience health-related anxiety in daily life. CONCLUSIONS Our results demonstrate psychological stability and high self-esteem of young patients, as well as good integration into society and a high degree of normality during daily life after LT. Adherence rates are lower than anticipated and do not correlate with patients' understanding of their medical condition.
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10
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Naeser V, Brandt AH, Nyhuus B, Borgwardt L, Jørgensen MH, Rasmussen A. Risk markers for later cardiovascular diseases in liver-transplanted children and adolescents. Pediatr Transplant 2018; 22:e13298. [PMID: 30338616 DOI: 10.1111/petr.13298] [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] [Received: 04/07/2018] [Revised: 08/15/2018] [Accepted: 09/04/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Increased risk of cardiovascular diseases is well described after adult liver transplantation, whereas the risk in the pediatric population still is discussed. The aim of this study was to investigate the prevalence of metabolic syndrome in pediatric liver transplant recipients and whether measurements of carotid intima media thickness and pulse wave velocity were increased compared to healthy controls. METHODS We included 42 pediatric liver transplantation recipients and examined them for markers of metabolic syndrome, liver fibrosis measured by shear wave velocity, body fat measured by DXA scans and carotid intima-media thickness, and pulse wave velocity (n = 41 for the carotid scans). The ultrasound measurements of carotid intima-media thickness and pulse wave velocity were also conducted on 82 healthy children and adolescents matched on height and age, respectively. RESULTS Participants had a median age of 13.03 years, and median time since transplantation was 8.54 years. Compared to healthy controls, liver-transplanted patients had significantly increased intima-media thickness measurements in both control groups whereas there was no significant difference with regard to pulse wave velocity. Two patients (6.25%) were diagnosed with metabolic syndrome. Within the group of liver-transplanted pediatric patients, only elevated body mass index was associated with elevated carotid intima-media thickness measurement. Elevated pulse wave velocity was only associated with abdominal obesity. Factors not significantly correlated with either were age, sex, metabolic syndrome, hyperglycemia, triglycerides, years since transplantation, fibrosis of the liver, body fat content, smoking habits, HDL cholesterol levels, hypertension, and mono-drug versus multi-drug therapies. CONCLUSION Pediatric liver transplant recipients do have an increased risk of increased carotid intima-media thickness.
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Affiliation(s)
- Vibeke Naeser
- Department of Surgical Gastroenterology and Transplantation, Rigshospitalet, Copenhagen, Denmark
| | | | - Bo Nyhuus
- Department of Radiology, Rigshospitalet, Copenhagen, Denmark
| | - Lise Borgwardt
- Department of Clinical Physiology and Nuclear Medicine, Rigshospitalet, Copenhagen, Denmark
| | | | - Allan Rasmussen
- Department of Surgical Gastroenterology and Transplantation, Rigshospitalet, Copenhagen, Denmark
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11
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Perito ER, Phelps A, Vase T, Feldstein VA, Lustig RH, Rosenthal P. Subclinical Atherosclerosis in Pediatric Liver Transplant Recipients: Carotid and Aorta Intima-Media Thickness and Their Predictors. J Pediatr 2018; 193:119-127.e1. [PMID: 29224938 PMCID: PMC5794603 DOI: 10.1016/j.jpeds.2017.10.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 08/21/2017] [Accepted: 10/10/2017] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To investigate prevalence and predictors of cardiovascular risk in pediatric liver transplant recipients using noninvasive markers of subclinical atherosclerosis: carotid intima-media thickness (cIMT) and aorta intima-media thickness (aIMT). STUDY DESIGN Cross-sectional study of 88 pediatric liver transplant recipients. The cIMT and aIMT were measured by ultrasound imaging using standardized protocol. RESULTS Participants were 15.4 ± 4.8 years of age, and 11.2 ± 5.6 years post-transplantation. The cIMT and aIMT were both higher in males than females. In analyses adjusted for sex, age, and height, the cIMT was higher in subjects transplanted for chronic/cirrhotic liver disease and lower in subjects on cyclosporine (n = 9) than tacrolimus (n = 71). The cIMT was not associated with rejection history or current corticosteroid use. The cIMT increased with increasing diastolic blood pressure and triglycerides. The aIMT (n = 83) also increased with age, and its rate of increase post-transplant varied by age at transplantation. In adjusted analyses, aIMT was higher in subjects with glucose intolerance. In analysis of patients ≤20 years of age for whom blood pressure percentiles could be calculated (n = 66), aIMT increased with increasing diastolic blood pressure percentile (0.010 mm per 5-percentile; 95% CI, 0.000-0.021; P = 0.05). Neither the cIMT nor the aIMT was associated with obesity, systolic hypertension, or other dyslipidemia at study visit. CONCLUSION Measures of long-term cardiovascular risk were associated with conditions that are more common in pediatric liver transplant recipients than nontransplanted peers, namely, diastolic hypertension and glucose intolerance. Larger, longitudinal studies are warranted to investigate whether cIMT could be useful for stratifying these patients' cardiovascular risk-and potential need for proactive intervention-during long-term follow-up.
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Affiliation(s)
- Emily R. Perito
- Department of Pediatrics, UCSF Benioff Children’s Hospital, University of California, San Francisco, San Francisco, CA,Department of Epidemiology and Biostatistics, UCSF Benioff Children’s Hospital, University of California, San Francisco, San Francisco, CA
| | - Andrew Phelps
- Department of Radiology and Biomedical Imaging, UCSF Benioff Children’s Hospital, University of California, San Francisco, San Francisco, CA
| | - Tabitha Vase
- School of Medicine, UCSF Benioff Children’s Hospital, University of California, San Francisco, San Francisco, CA
| | - Vickie A. Feldstein
- Department of Radiology and Biomedical Imaging, UCSF Benioff Children’s Hospital, University of California, San Francisco, San Francisco, CA
| | - Robert H. Lustig
- Department of Pediatrics, UCSF Benioff Children’s Hospital, University of California, San Francisco, San Francisco, CA
| | - Philip Rosenthal
- Department of Pediatrics, UCSF Benioff Children’s Hospital, University of California, San Francisco, San Francisco, CA,Department of Surgery, UCSF Benioff Children’s Hospital, University of California, San Francisco, San Francisco, CA
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12
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Alobaidi R, Anton N, Cave D, Moez EK, Joffe AR. Predicting early outcomes of liver transplantation in young children: The EARLY study. World J Hepatol 2018; 10:62-72. [PMID: 29399279 PMCID: PMC5787685 DOI: 10.4254/wjh.v10.i1.62] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 12/20/2017] [Accepted: 12/29/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To determine potentially modifiable predictors of early outcomes after liver transplantation in children of age < 3 years.
METHODS This study was a retrospective chart review including all consecutive children of age less than 3-years-old having had a liver transplant done at the Western Canadian referral center from June 2005 to June 2015. Pre-specified potential predictor variables and primary and secondary outcomes were recorded using standard definitions and a case report form. Associations between potential predictor variables and outcomes were determined using univariate and multiple logistic [odds ratio (OR); 95%CI] or linear (effect size, ES; 95%CI) regressions.
RESULTS There were 65 children, of mean age 11.9 (SD 7.1) mo and weight 8.5 (2.1) kg, with biliary-atresia in 40 (62%), who had a living related donor [LRD; 29 (45%)], split/reduced [21 (32%)] or whole liver graft [15 (23%)]. Outcomes after liver transplant included: ventilator-days of 12.5 (14.1); pediatric intensive care unit mortality of 5 (8%); re-operation in 33 (51%), hepatic artery thrombosis (HAT) in 12 (19%), portal vein thrombosis (PVT) in 11 (17%), and any severe complication (HAT, PVT, bile leak, bowel perforation, intraabdominal infection, retransplant, or death) in 32 (49%) patients. Predictors of the prespecified primary outcomes on multiple regression were: (1) HAT: split/reduced (OR 0.06; 0.01, 0.76; P = 0.030) or LRD (OR 0.16; 0.03, 0.95; P = 0.044) vs whole liver graft; and (2) ventilator-days: surgeon (P < 0.05), lowest antithrombin (AT) postoperative day 2-5 (ES -0.24; -0.47, -0.02; P = 0.034), and split/reduced (ES -12.5; -21.8, -3.2; P = 0.009) vs whole-liver graft. Predictors of the pre-specified secondary outcomes on multiple regression were: (1) any thrombosis: LRD (OR 0.10; 0.01, 0.71; P = 0.021) or split/reduced (OR 0.10; 0.01, 0.85; P = 0.034) vs whole liver graft, and lowest AT postoperative day 2-5 (OR 0.93; 0.87, 0.99; P = 0.038); and (2) any severe complication: surgeon (P < 0.05), lowest AT postoperative day 2-5 (OR 0.92; 0.86-0.98; P = 0.016), and split/reduced (OR 0.06; 0.01, 0.78; P = 0.032) vs whole-liver graft.
CONCLUSION In young children, whole liver graft and surgeon was associated with more complications, and higher AT postoperative day 2-5 was associated with fewer complications early after liver transplantation.
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Affiliation(s)
- Rashid Alobaidi
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Alberta and Stollery Children’s Hospital, Edmonton, Alberta T6G 1C9, Canada
| | - Natalie Anton
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Alberta and Stollery Children’s Hospital, Edmonton, Alberta T6G 1C9, Canada
| | - Dominic Cave
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Alberta and Stollery Children’s Hospital, Edmonton, Alberta T6G 1C9, Canada
| | - Elham Khodayari Moez
- School of Public Health, University of Alberta, Edmonton, Alberta T6G 2B7, Canada
| | - Ari R Joffe
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Alberta and Stollery Children’s Hospital, Edmonton, Alberta T6G 1C9, Canada
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Disparities in Waitlist and Posttransplantation Outcomes in Liver Transplant Registrants and Recipients Aged 18 to 24 Years: Analysis of the UNOS Database. Transplantation 2017; 101:1616-1627. [PMID: 28230640 DOI: 10.1097/tp.0000000000001689] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND We evaluated liver transplantation waitlist and posttransplantation outcomes in those aged 18 to 24 years compared with both younger (0-17 years) and older (25-34 years) registrants and recipients. METHODS Using national data from the United Network for Organ Sharing, competing risk, Cox regression and Kaplan-Meier analyses were performed on first-time liver transplant registrants (n = 13 979) and recipients (n = 8718) ages 0 to 34 years between 2002 and 2015. RESULTS Nonstatus 1A registrants, registrants aged 0 to 17 and 25 to 34 years were less likely to experience dropout from the waiting list compared with those aged 18 to 24 years (adjusted hazard ratio, 0-5 years = 0.36; 6-11 = 0.29; 12-17 = 0.48; 18-24 = 1.00; 25-34 = 0.82). Although there was no difference in risk of graft failure across all age groups, both younger and older age groups had significantly lower risk of posttransplant mortality compared with those aged 18 to 24 years (adjusted hazard ratio, for 0-5 years = 0.53, 6-11 = 0.48, 12-17 = 0.70, 18-24 = 1.00, 25-34 = 0.77). This may be related to lower likelihood of retransplantation after graft failure in those aged 18 to 24 years. CONCLUSIONS This national registry study demonstrates for the first time poorer waitlist and postliver transplant outcomes in young adults ages 18 to 24 years at the time of listing and transplantation compared to older and younger age groups. Given the potential survival benefit in transplanting young adults and the shortage of solid organs for transplant, future studies are critical to identify and target modifiable risk factors to improve waitlist and long-term posttransplant outcomes in 18- to 24-year-old registrants and recipients.
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14
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Early and Late Factors Impacting Patient and Graft Outcome in Pediatric Liver Transplantation: Summary of an ESPGHAN Monothematic Conference. J Pediatr Gastroenterol Nutr 2017; 65:e53-e59. [PMID: 28319600 DOI: 10.1097/mpg.0000000000001564] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
As pediatric liver transplantation comes of age, experts gathered to discuss current paradigms and define gaps in knowledge warranting research to further improve patient and graft outcomes. Identified areas ripe for collaborative research include understanding the molecular and cellular mechanisms of tolerance and the role of donor-specific antibodies, considering ways to expand donor pool, minimizing long-term side effects of immunosuppression, and fine-tuning surgical techniques to minimize biliary and vascular complications.
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15
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Prediabetes in Pediatric Recipients of Liver Transplant: Mechanism and Risk Factors. J Pediatr 2017; 182:223-231.e3. [PMID: 28041666 PMCID: PMC5328850 DOI: 10.1016/j.jpeds.2016.11.070] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 10/17/2016] [Accepted: 11/28/2016] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To investigate the role of calcineurin inhibitor exposure and states of insulin resistance-obesity and adolescence-in prediabetes after pediatric liver transplant via oral glucose tolerance testing, which previously has not been done systematically in these at-risk youths. STUDY DESIGN This was a cross-sectional study of 81 pediatric recipients of liver transplant. Prediabetes was defined as impaired glucose tolerance (IGT; glucose ≥140 mg/dL at 2 hours) or impaired fasting glucose (IFG, ≥100 mg/dL). Corrected insulin response (CIR) was calculated as measure of insulin secretion, corrected for glucose (CIR30, CIR60, CIR120). RESULTS Subjects were aged 8.1-30.0 years and 1.1-24.7 years post-transplant; 44% had prediabetes-27% IGT, 14% IFG, and 3% both. IGT was characterized by insulin hyposecretion, with lower CIR60 and CIR120 in IGT than subjects with normal glucose tolerance. Subjects with tacrolimus trough >6 µg/mL at study visit had lower CIR120 than those with trough ≤6 µg/mL and those off calcineurin-inhibitors. Mean of tacrolimus troughs preceding the study visit, years since transplant, and rejection episodes were not associated significantly with lower CIR. CIR suppression by tacrolimus was most pronounced >6 years from transplant. Overweight/obese subjects and adolescents who retained normal glucose tolerance had greater CIR than those who were IGT. CONCLUSION IGT after pediatric liver transplant is driven by inadequate insulin secretion. It is quite common but not detectable with fasting laboratory values-the screening recommended by current guidelines. Calcineurin inhibitors suppress insulin secretion in these patients in a dose-dependent manner. Given the recent focus on long-term outcomes and immunosuppression withdrawal in these children, longitudinal studies are warranted to investigate whether IGT is reversible with calcineurin inhibitor minimization.
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16
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Minneman JA, Grijalva JL, LaQuaglia MJ, Kim HB, Rangel SJ, Vakili K. Variation in resource utilization in liver transplantation at freestanding children's hospitals. Pediatr Transplant 2016; 20:921-925. [PMID: 27762480 DOI: 10.1111/petr.12783] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/21/2016] [Indexed: 11/30/2022]
Abstract
We sought to examine the relationship between liver transplant-related total cost, patient outcome, and hospital resource utilization at freestanding children's hospitals. Using the PHIS database, a retrospective study of 374 patients that underwent liver transplantation at 15 freestanding children's hospitals from July 2010 to December 2012 was performed. One-year graft failure and patient mortality rates from July 2010 to December 2012 for each center were also obtained from the SRTR. There was a 5.1-fold difference in median cost (median $146 444, range $59 487-302 058, P<.001) between all centers. A 2.4-fold difference existed in median LOS (median 15 days, range 9-22 days, P<.001) across centers. Median postoperative ICU stay varied from 0 to 7 days (median 4 days, P<.001). Overall, 30-day readmission rate was 55% (31.3%-100%, P<.001). One-year graft failure varied from 0% to 19.1%, with an overall rate of 5.5% (P=.279). One-year patient mortality for all centers was 2.3% (range 0%-11.1%, P=.016). Higher total cost did not correlate with lower readmission rates, patient mortality, graft failure, or any other variable. These data suggest that identifying practice patterns at low-cost centers and implementing them at higher-cost centers may decrease the cost of pediatric liver transplantation without compromising outcomes.
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Affiliation(s)
| | - James L Grijalva
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | | | - Heung Bae Kim
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Shawn J Rangel
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Khashayar Vakili
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA.
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17
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Konidis SV, Hrycko A, Nightingale S, Renner E, Lilly L, Therapondos G, Fu A, Avitzur Y, Ng VL. Health-related quality of life in long-term survivors of paediatric liver transplantation. Paediatr Child Health 2015; 20:189-94. [PMID: 26038635 DOI: 10.1093/pch/20.4.189] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2015] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Long-term survival after paediatric liver transplantation is now the rule rather than the exception. Improving long-term outcomes after transplantation must consider not only the quantity but also the quality of life years restored. OBJECTIVES To characterize health-related quality of life (HRQOL) of LT recipients ≥15 years after paediatric LT. METHODS Recipients of a paediatric LT performed before December 1996 in a single institution with continuous follow-up at either the paediatric or adult partner centre were identified. Patients with severe developmental or neurological impairment were excluded. HRQOL was assessed using the Pediatric Quality of Life Inventory 4.0, the Medical Outcomes Study Short Form-36 version 2 and the Pediatric Liver Transplant Quality of Life Tool. RESULTS A total of 27 (67% male) subjects (mean age 24.3±6.7 years [median 23.2 years; range 16.6 to 40.3 years]) participated. The median age at transplant was 1.7 years (range 0.5 to 17.0 years). Seven (26%) participants underwent retransplantation. Seventeen (63%) participants were engaged in full-time work/study. Mean Short Form-36 version 2 scores included physical (49.6±11.1) and mental (45.3±12.5) subscale scores. The mean score for the disease-specific quality of life tool for paediatric liver transplant recipients (the Pediatric Liver Transplant Quality of Life Tool) was 64.70±15.2. The physical health of the young adults strongly correlated with level of involvement in work/study (r=0.803; P<0.05). CONCLUSIONS The self-reported HRQOL of participants <18 years of age was comparable with a standardized healthy population. In contrast, participants between 18 and 25 years of age had HRQOL scores that were more similar to a group with chronic illness. Participants engaged in full-time work/study experienced enhanced physical health.
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Affiliation(s)
- Stacey V Konidis
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto; ; Multi-Organ Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario
| | - Alexander Hrycko
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto
| | - Scott Nightingale
- Department of Gastroenterology, John Hunter Children's Hospital, Newcastle, New South Wales, Australia
| | - Eberhard Renner
- Multi-Organ Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario
| | - Leslie Lilly
- Multi-Organ Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario
| | - George Therapondos
- Multi-Organ Transplant Institute, Ochsner Clinic Foundation, Ochsner Medical Center, New Orleans, Louisiana, USA
| | - Ann Fu
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto
| | - Yaron Avitzur
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto
| | - Vicky Lee Ng
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto
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18
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"Current state and prospects in managing liver transplanted children". Clin Res Hepatol Gastroenterol 2015; 39:292-5. [PMID: 25241997 DOI: 10.1016/j.clinre.2014.08.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2014] [Revised: 08/27/2014] [Accepted: 08/27/2014] [Indexed: 02/04/2023]
Abstract
Pediatric liver transplantation (LTx) has revolutionized life chances and perspectives of children with liver disease. Following rapid establishment of the therapeutic concept in the early years of pediatric transplant medicine, more aspects beyond plain survival become increasingly important. In addition to improving the short to medium-term survival rates, researchers are focusing on themes such as rehabilitation, adherence and quality of life, long-term graft fibrosis and dysfunction, as well as the consequences of long-term immunosuppression. Also, more protocol biopsy data are available to evaluate increasing graft fibrosis. To manage their conditions, patients will need access to highly experienced pediatric liver transplant centers where clinical research will examine modulators of renal disease, endocrine and cardiovascular comorbidity and the development of graft fibrosis and malignancies. Assessment and evaluation of health-related quality of life and factors which influence clinical tolerance, adherence and transition from child to adult care will also be investigated. The analysis of multi-national registry data and more than 40years of experience with large patient cohorts will provide important clues to treatment and will thus get increasing attention. In the future, longitudinal assessment of the outcome for pediatric LTx patients should include more functional aspects than plain survival rates or laboratory parameters.
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19
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20
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Perito ER, Mohammad S, Rosenthal P, Alonso EM, Ekong UD, Lobritto SJ, Feng S. Posttransplant metabolic syndrome in the withdrawal of immunosuppression in Pediatric Liver Transplant Recipients (WISP-R) pilot trial. Am J Transplant 2015; 15:779-85. [PMID: 25648649 PMCID: PMC4426259 DOI: 10.1111/ajt.13024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Revised: 09/04/2014] [Accepted: 09/15/2014] [Indexed: 01/25/2023]
Abstract
Posttransplant metabolic syndrome (PTMS)-obesity, hypertension, elevated triglycerides, low HDL and glucose intolerance-is a major contributor to morbidity after adult liver transplant. This analysis of the Withdrawal of Immunosuppression in Pediatric Liver Transplant Recipients (WISP-R) pilot trial is the first prospective study of PTMS after pediatric liver transplant. Twenty children were enrolled in WISP-R, at median age 8.5 years (IQR 6.4-10.8), and weaned from calcineurin-inhibitor monotherapy. The 12 children who tolerated complete immunosuppression withdrawal were compared to matched historical controls. At baseline, 45% of WISP-R subjects and 58% of controls had at least one component of PTMS. Calcineurin-inhibitor withdrawal in the WISP-R subjects did not impact the prevalence of PTMS components compared to controls. At 5 years, despite weaning off of immunosuppression, 92% of the 12 tolerant WISP-R subjects had at least one PTMS component and 58% had at least two; 33% were overweight or obese, 50% had dyslipidemia, 33% glucose intolerance and 42% systolic hypertension. Overweight/obesity increased the risk of hypertension in all children. Compared to controls, WISP-R tolerant subjects had similar GFR at baseline but did have higher GFR at 2, 3 and 4 years. Further study of PTMS and immunosuppression withdrawal after pediatric liver transplant is warranted.
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Affiliation(s)
- E. R. Perito
- Department of Pediatrics, UCSF Benioff Children's Hospital, University of California, San Francisco, CA
| | - S. Mohammad
- Department of Pediatrics, Children's Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - P. Rosenthal
- Department of Pediatrics, UCSF Benioff Children's Hospital, University of California, San Francisco, CA,Department of Surgery, University of California, San Francisco, CA
| | - E. M. Alonso
- Department of Pediatrics, Children's Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - U. D. Ekong
- Department of Pediatrics, Children's Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - S. J. Lobritto
- Department of Pediatrics, Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, NY,Department of Surgery, Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, NY
| | - S. Feng
- Department of Surgery, University of California, San Francisco, CA,Corresponding author: Sandy Feng,
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21
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Perito ER, Rhee S, Roberts JP, Rosenthal P. Pediatric liver transplantation for urea cycle disorders and organic acidemias: United Network for Organ Sharing data for 2002-2012. Liver Transpl 2014; 20:89-99. [PMID: 24136671 PMCID: PMC3877181 DOI: 10.1002/lt.23765] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Accepted: 09/30/2013] [Indexed: 02/07/2023]
Abstract
Decision making concerning liver transplantation is unique for children with urea cycle disorders (UCDs) and organic acidemias (OAs) because of their immediate high priority on the waiting list, which is not related to the severity of their disease. There are limited national outcome data on which recommendations about liver transplantation for UCDs or OAs can be based. This study was a retrospective analysis of United Network for Organ Sharing data for liver recipients who underwent transplantation at an age < 18 years in 2002-2012. Repeat transplants were excluded. Among the pediatric liver transplants, 5.4% were liver-only for UCDs/OAs. The proportion of transplants for UCDs/OAs increased from 4.3% in 2002-2005 to 7.4% in 2010-2012 (P < 0.001). Ninety-six percent were deceased donor transplants, and 59% of these patients underwent transplantation at <2 years of age. Graft survival improved as the age at transplant increased (P = 0.04). Within 5 years after transplantation, the graft survival rate was 78% for children < 2 years old at transplant and 88% for children ≥ 2 years old at transplant (P = 0.06). Vascular thrombosis caused 44% of the graft losses, and 65% of these losses occurred in children < 2 years old. Patient survival also improved as the age at transplant increased: the 5-year patient survival rate was 88% for children with UCDs/OAs who were <2 years old at transplant and 99% for children who were ≥2 years old at transplant (P = 0.006). At the last-follow-up (54 ± 34.4 months), children who underwent transplantation for UCDs/OAs were more likely to have cognitive and motor delays than children who underwent transplantation for other indications. Cognitive and motor delays for children with UCDs/OAs were associated with metabolic disorders, but they were not predicted by age or weight at transplant, sex, ethnicity, liver graft type (split versus whole), or hospitalization at transplant in univariate and multivariate analyses. In conclusion, most liver transplants for UCDs/OAs occur in early childhood. Further research on the benefits of early transplantation for patients with UCDs/OAs is needed because a younger age may increase posttransplant morbidity.
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Affiliation(s)
- Emily R. Perito
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Francisco
| | - Sue Rhee
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Francisco
| | - John Paul Roberts
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco
| | - Philip Rosenthal
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Francisco,Division of Transplant Surgery, Department of Surgery, University of California, San Francisco
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