Sustained linear growth and preserved renal function in 10-year survivors of pediatric liver transplantation

Long-term Outcome of Pediatric Liver Transplant Recipients Who Have Reached Adulthood: A Single-center Experience

BACKGROUND

As long-term survival of pediatric liver transplant recipients increases, the assessment of physical, psychological, and social well-being becomes more important.

METHODS

In this retrospective analysis, 120 young adult patients (age ≥18 y) who underwent liver transplantation in childhood were studied. Patients with ideal outcome were defined as patients with perfect graft function, with no complications from the immunosuppressive medication, no late retransplantation, and no steroid treatment. Also, the patients' drug adherence and their psychosocial situation were assessed.

RESULTS

After a median follow-up of 19 y, only 16.7% of the patients (mean age: 26.5 y) were considered patients with ideal outcome. The main reasons precluding ideal outcome were chronic kidney disease (38.3%), elevated liver enzymes (33.3%), and arterial hypertension (31.7%). Ideal outcome decreased over time from 54% to 42%, 26%, and 8% at 10-, 15-, 20-, and 25-y follow-up, respectively. Reduced drug adherence was noted in 24.8% of patients and associated with a significantly higher prevalence of donor-specific antibodies class II ( P  = 0.015), elevated transaminases ( P  = 0.010), and chronic rejection ( P  < 0.001). Also, 15% of patients had a psychiatric disease, mainly depression.

CONCLUSIONS

The morbidity of young adults who underwent liver transplantation as children was high and increased over time. The majority developed complications from immunosuppression or chronic graft dysfunction. More than 1 in 7 patients had a psychiatric disease and 1 in 4 was not perfectly drug adherent. Therefore, immunosuppressive treatment and psychological care should be optimized for these particularly vulnerable patients.

Long-Term Survival and Kidney Function in Pediatric Patients Following Liver Transplantation: A 15-Year Retrospective Cohort Study

Long-term preservation of kidney function after liver transplantation (LT) has not been well studied. We thus evaluated the rates of kidney function preservation and long-term survival after pediatric LT. We also investigated the risk factors associated with the progression of chronic kidney disease (CKD). We conducted a retrospective study of 184 pediatric patients who had undergone LT from 2003 to 2018 at a university hospital. We collected demographics, primary indications for LT, liver disease scores, renal function test results, immunosuppressive drug prescriptions, and diagnosis of post-LT complications. The 15-year survival rate was 90.8%. Furthermore, the rate of kidney function preservation at 14 years post-LT in patients at high risk of renal disease was 79.3%, and that in those with less risk of kidney diseases was 96.0%. Arterial hypertension was an independent risk factor associated with CKD progression. However, when arterial hypertension was excluded, the use of cyclosporine and liver disease with renal involvement were risk factors for CKD progression. We found that kidney function after pediatric LT was well preserved. We encourage the early detection of underlying kidney involvement, routine monitoring of renal function for high-risk patients, active control of hypertension, and appropriate immunosuppressive regimens for pediatric patients with LT.

Social and Educational Outcomes in Patients With Biliary Atresia: A Systematic Review

OBJECTIVES

To systematically review the social outcomes of patients with biliary atresia (BA), including educational, employment and family outcomes.

METHODS

We conducted a systematic review of Medline, EMBASE, Global Health, Maternity and Infant Care Database, supplemented by reference searching. National Heart, Lung and Blood Institute scoring was conducted for quality assessment. The PROSPERO registration ID was CRD42020178846.

RESULTS

Fifty-one studies were included (41 cohort, 10 cross-sectional), including 4631 participants across 16 countries. Cohorts were BA post-liver transplant (LT) (18 studies), native liver survivors (NLS) (16 studies), mixed (13 studies) and four other cohorts. Outcomes covered; education (n = 35), employment (n = 16), family outcomes (n = 22), and social functioning (n = 22). BA patients had lower school functioning scores than controls, with no difference between NLS versus post-LT. Between 2% and 48% of children required additional educational support. Between 60% and 100% of adult patients with BA were employed. Pregnancies were described in 17 studies, with small samples, and some noted complications. Social functioning scores were similar to healthy controls in 8 of 11 comparisons.

CONCLUSIONS

Despite BA being the primary indication for liver transplantation in childhood, social outcomes for children and adolescents are predominantly reported in non-controlled, single-centre survey-based studies. School functioning is lower compared to peer groups, with no evidence of a difference for those having a liver transplant. We recommend routine psychosocial assessment of these patients during follow-up, alongside multi-centre collaborations, to maximise the quality of evidence for future patients.

Factors Associated With Growth After Deceased and Live Donor Pediatric Liver Transplantation

BACKGROUND

There are limited data on predictors of growth after pediatric liver transplantation.

METHODS

We reviewed the impact of graft type, ethnicity, and biliary complications (BC) on growth after pediatric liver transplantation (LT). We compared preoperative and 6-, 12-, and 24-month weight, height, and body mass index (BMI) percentiles between living donor (LD), deceased donor full-size (DD-full), and deceased donor split (DD-split) graft recipients. We also compared length of stay (LOS) between groups.

RESULTS

We had 98 patients (DD-split: 32; DD-full: 43, LD: 23). The Median Pediatric End-stage Liver Disease (PELD) scores, exception points, albumin, bilirubin, failure to thrive, and presence of ascites were similar among groups. The DD-full group had the lowest preoperative percentiles in all categories and exceeded these at 24 months. The DD-split group was at preoperative percentiles at 24 months. The LD group had parallel weight curves compared to the DD-full group and exceeded only the preoperative weight percentile at 24 months. Black patients had the lowest percentiles in all categories (P < .01). The BC group caught up weight and BMI percentile at 24 months but had persistent decrease in height percentiles. Patients without BC exceeded preoperative height percentiles. The longer LOS group had lower height and BMI percentiles at 24 months; however, there was no statistical difference.

CONCLUSION

DD-full and black patients seem to benefit the most from LT in terms of growth. BC seems to affect height percentiles. Patients with longer LOS had lower height and BMI percentiles (P>.05). Longer follow up and larger cohorts are necessary to improve the power of these findings.

Long-term outcome of liver transplantation in childhood: A study of 20-year survivors

We report the results of a study of survival, liver and kidney functions, and growth with a median follow-up of 24 years following liver transplantation in childhood. From 1988 to 1993, 128 children underwent deceased donor liver transplantation (median age: 2.5 years). Twenty-year patient and graft survival rates were 79% and 64%, respectively. Raised serum aminotransferase and/or γ-glutamyl transferase activities were present in 42% of survivors after a single transplantation. Graft histology (35 patients) showed signs of chronic rejection in 11 and biliary obstruction in 5. Mean total fibrosis scores were 4.5/9 and 3/9 in patients with abnormal and normal serum liver tests, respectively. Glomerular filtration rate was <90 mL·min^-1 in 35 survivors, including 4 in end-stage renal disease who were undergoing dialysis or had undergone renal transplantation. Median final heights were 159 cm for women and 172 cm for men; final height was below the target height in 37 patients. Twenty-year survival after childhood liver transplantation may be close to 80%, and final height is within the normal range for most patients. However, chronic kidney disease or altered liver biochemistries are present in over one third of patients, which is a matter of concern for the future.

Long-term Follow-up After Pediatric Liver Transplantation: Predictors of Growth

OBJECTIVES

The aim of the study was to describe long-term growth postpediatric liver transplantation and to conduct bivariate and multivariate analysis of factors that may predict post-transplantation growth in children who received a liver transplant from January 1999 to December 2008 at the Hospital for Sick Children.

METHODS

A retrospective cohort study was conducted with follow-up of up-to 10 years post-transplantation. Mean height and weight z scores and annual differences in mean z scores were plotted against time after transplantation. A 1-way analysis of variance was conducted. Multivariate and univariate Cox proportional hazards analyses were conducted to determine factors associated with reaching the 50th and 25th percentiles for height.

RESULTS

A total of 127 children met eligibility criteria. The mean height z score at time of transplantation was -2.21 which by the second year post-transplantation increased significantly to -0.66 (mean increase of 1.55 standard deviation units). There were no further significant increases in mean height z score from 2 years post-transplantation until the end of follow-up at year 10. In multivariate analysis, height at transplant was the most important predictor of linear growth post-transplantation.

CONCLUSIONS

Children who underwent liver transplantation had significant catch-up growth in the first 2 years post-transplantation followed by a plateau phase. Increased height z-score at transplantation is the most important predictor of long-term growth.

De novo hepatitis b prophylaxis with hepatitis B virus vaccine and hepatitis B immunoglobulin in pediatric recipients of core antibody-positive livers

The use of hepatitis B core antibody-positive (HBcAb+) grafts for liver transplantation (LT) has the potential to safely expand the donor pool, as long as proper prophylaxis against de novo hepatitis B (DNHB) is employed. The aim of this study was to characterize the longterm outcome of pediatric LT recipients of HBcAb + liver grafts under a prophylaxis regimen against DNHB using hepatitis B virus (HBV) vaccine and hepatitis B immunoglobulin (HBIG). From June 1996 to February 2013, 49 patients receiving pediatric LT at our center were from HBcAb + donors. Forty-one patients who received DNHB prophylaxis according to our protocol were included in this analysis. Our DNHB prophylaxis protocol consists of HBV vaccine intramuscular injections given intermittently to maintain anti-hepatitis B surface antibody (HBsAb) titers above 100 IU/L. HBIG was also used during the first posttransplant year with a target anti-HBsAb titer level above 200 IU/L. There were 19 boys and 22 girls. Median age was 1.0 year (range, 4 months to 16 years). Median follow-up time was 66 months after transplant. Median annual number of HBV vaccine injections was 0.8 per year (range, 0-1.8 per year). Four patients did not require any HBV vaccine injections during follow-up. One patient with DNHB was encountered during the follow-up period (1/41, 2.4%). DNHB was diagnosed at 3.5 years after transplant, when hepatitis B surface antigen was positive upon routine follow-up serologic testing. Anti-HBsAb titer was 101.5 IU/L at the time. No grafts were lost because of DNHB-related events. Overall survival of the 41 recipients of HBcAb + grafts who received DNHB prophylaxis was 92.3% at 10 years after transplant. In conclusion, longterm prophylaxis against DNHB with HBV vaccine in pediatric LT recipients of HBcAb + grafts was safe and effective in terms of DNHB incidence as well as graft and patient survival.