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Muncner S, Dell AJ, Mwita C, Bigam D, Saleh A. Examining need and capacity for the development of a pediatric liver transplantation program in Kenya. Pediatr Transplant 2023; 27:e14462. [PMID: 36604852 DOI: 10.1111/petr.14462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 10/02/2022] [Accepted: 12/09/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND In Africa, pediatric liver transplantation (PLT) is currently only performed in Egypt and South Africa, leaving those who require treatment in Kenya to travel abroad. The aim of this study was to determine whether sufficient capacity and need exists in Kenya to establish a safe and sustainable PLT program. METHODS A descriptive analysis of the intensive care unit (ICU) beds, surgical workforce, current hepatobiliary volume, and estimated prevalence of pediatric liver disease (PLD) was conducted across 17 hospitals in Kenya between July and September 2020. Data were collected from medical superintendents, directors of surgical departments, or nominated proxies at Kenyan Level 5 and 6 hospitals via a web-based survey. RESULTS A total of 165 ICU beds were reported at 17 facilities, with 15 facilities reporting five or more beds. About 39% of general surgeons at responding hospitals performed hepatobiliary procedures, and 30% performed pediatric surgeries. Only 10% of surgeons had pediatric training. Over half (57%) of hospitals performed hepatobiliary procedures; at the maximum, 1-5 cases were performed per week including cholecystectomy to Kasai portoenterostomy and hepatectomy. Across 13 hospitals, there were an estimated 192-570 cases of PLD seen per month. The most common PLDs were hepatitis B, neonatal hepatitis, cirrhosis, and acute hepatic failure. Overall, two hospitals possessed the minimum workforce and resources to attempt PLT. CONCLUSIONS In Kenya, ICU bed availability, pediatric surgical training, and hepatobiliary volume are limited. However, the high prevalence of PLD demonstrated a significant need for PLT across all Kenyan hospitals.
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Affiliation(s)
- Susan Muncner
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Angela J Dell
- Department of Surgery, University of Cape Town Health Sciences Faculty, Groote Schuur Hospital, Observatory, Cape Town, South Africa
| | - Clifford Mwita
- Afya Research Africa, Nairobi, Kenya.,Department of Surgery, Gatundu Level 5 Hospital, Gatundu, Kenya
| | - David Bigam
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Abdullah Saleh
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.,Office of Global Surgery, University of Alberta, Edmonton, Alberta, Canada
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Bruckmann EK, Beretta M, Demopolous D, Brannigan L, Bouter C, Maher H, Etheredge HR, Fabian J, Haeri Mazanderani A, Britz R, Loveland J, Botha JF. Minding the gap-Providing quality transplant care for South African children with acute liver failure. Pediatr Transplant 2020; 24:e13827. [PMID: 32871038 DOI: 10.1111/petr.13827] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 06/26/2020] [Accepted: 07/26/2020] [Indexed: 11/28/2022]
Abstract
Pediatric ALF is rare but life-threatening and may require urgent transplantation. In low and middle-income countries, access to transplantation is limited, deceased organ donation rates are low, and data on outcomes scarce. The Wits Donald Gordon Medical Centre, in Johannesburg, is one of only two centers in South Africa that perform pediatric liver transplant. We describe the etiology, clinical presentation, and outcomes of children undergoing liver transplant for ALF at our center over the past 14 years. We performed a retrospective chart review of all children undergoing liver transplantation for ALF from November 2005 to September 2019. Recipient data included demographics, clinical and biochemical characteristics pretransplant, post-operative complications, and survival. We conducted descriptive data analysis and used the Kaplan-Meier method for survival analysis. We performed 182 primary pediatric liver transplants. Of these, 27 (15%) were for ALF, mostly from acute hepatitis A infection (11/27;41%). Just over half of the grafts were from living donors (15/27;56%), and five grafts (5/27;19%) were ABO-incompatible. The most frequent post-transplant complications were biliary leaks (9/27;33%). There were two cases of hepatic artery thrombosis (2/27;7%), one of whom required re-transplantation. Unadjusted patient and graft survival at one and 3 years were the same, at 81% (95% CI 61%-92%) and 78% (95% CI 57%-89%), respectively. At WDGMC, our outcomes for children who undergo liver transplantation for ALF are excellent. We found workable solutions that effectively addressed our pervasive organ shortages without compromising patient outcomes.
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Affiliation(s)
- Eduard K Bruckmann
- Faculty of Health Sciences, Wits Donald Gordon Medical Centre, University of the Witwatersrand, Johannesburg, South Africa.,Faculty of Health Sciences, Department of Pediatric Intensive Care, University of the Witwatersrand, Johannesburg, South Africa
| | - Marisa Beretta
- Faculty of Health Sciences, Wits Donald Gordon Medical Centre, University of the Witwatersrand, Johannesburg, South Africa
| | - Despina Demopolous
- Faculty of Health Sciences, Wits Donald Gordon Medical Centre, University of the Witwatersrand, Johannesburg, South Africa
| | - Lliam Brannigan
- Faculty of Health Sciences, Wits Donald Gordon Medical Centre, University of the Witwatersrand, Johannesburg, South Africa
| | - Carolyn Bouter
- Faculty of Health Sciences, Wits Donald Gordon Medical Centre, University of the Witwatersrand, Johannesburg, South Africa
| | - Heather Maher
- Faculty of Health Sciences, Wits Donald Gordon Medical Centre, University of the Witwatersrand, Johannesburg, South Africa
| | - Harriet R Etheredge
- Faculty of Health Sciences, Wits Donald Gordon Medical Centre, University of the Witwatersrand, Johannesburg, South Africa.,Faculty of Health Sciences, Department of Internal Medicine, University of the Witwatersrand, Parktown, South Africa
| | - June Fabian
- Faculty of Health Sciences, Wits Donald Gordon Medical Centre, University of the Witwatersrand, Johannesburg, South Africa
| | - Ahmad Haeri Mazanderani
- National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
| | - Russel Britz
- Faculty of Health Sciences, Wits Donald Gordon Medical Centre, University of the Witwatersrand, Johannesburg, South Africa
| | - Jerome Loveland
- Faculty of Health Sciences, Wits Donald Gordon Medical Centre, University of the Witwatersrand, Johannesburg, South Africa.,Faculty of Health Sciences, Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Jean F Botha
- Faculty of Health Sciences, Wits Donald Gordon Medical Centre, University of the Witwatersrand, Johannesburg, South Africa.,Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Parktown, South Africa
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Botha J, Demetriou G, Fabian J, Etheredge H. Liver Transplant for Nonresectable Colorectal Cancer Liver Metastases in South Africa: A Single-Center Case Series. EXP CLIN TRANSPLANT 2020; 18:842-846. [PMID: 32967602 DOI: 10.6002/ect.2020.0064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Publication in 2013 of the first Secondary Cancer cohort study returned attention to liver transplant for nonresectable colorectal cancer, demonstrating excellent outcomes for a procedure that was historically contraindicated. The Wits Donald Gordon Medical Centre in Johannesburg, South Africa, hosts the largest liver transplant program in sub-Saharan Africa. The persistent shortage of deceased donor organs in our setting has compelled us to innovate solutions unique to our context, which allows us to perform as many transplants as possible and maximize our resource utilization. Therefore, we initiated a research study to transplant organs in patients with nonresectable colorectal carcinoma with expanded criteria using marginal deceased donor organs that would otherwise have been discarded. MATERIALS AND METHODS Institutional Review Board approval was obtained for this study. We used criteria from the 2013 Secondary Cancer cohort study to determine eligibility of patients with nonresectable colorectal carcinoma for liver transplant. Unlike the study from 2013, we utilized expanded criteria and marginal liver allografts for transplant. RESULTS Five patients have undergone liver transplant for nonresectable colorectal carcinoma. At a median follow-up of 36 months (range, 10-52 months), 4 of the 5 (80%) patients are alive. The patient who died had progressive disease on chemotherapy pretransplant and was the only patient who tested positive for the Kirsten rat sarcoma viral oncogene homolog mutant. Recurrence occurred in all patients at a median time of 6 months after transplant (range, 3-13 months). CONCLUSIONS To our knowledge, this is the only published case series of patients undergoing liver transplant for nonresectable colorectal carcinoma in Africa and is internationally unique in its use of expanded criteria and marginal grafts for this type of transplant. Despite the use of such grafts in our recipients, thus far, these outcomes align with those of the 2013 Secondary Cancer cohort studies from Norway.
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Affiliation(s)
- Jean Botha
- From the Wits Donald Gordon Medical Centre and the Department of Surgery, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Duncan M, DeVoll-Zabrocki A, Etheredge HR, Maher HA, Bouter C, Gaylard P, Loveland J, Fabian J, Botha JF. Blood stream infections in children in the first year after liver transplantation at Wits Donald Gordon Medical Centre, South Africa. Pediatr Transplant 2020; 24:e13660. [PMID: 31985168 DOI: 10.1111/petr.13660] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 12/10/2019] [Accepted: 01/03/2020] [Indexed: 12/18/2022]
Abstract
Children who undergo liver transplantation and subsequently develop BSI are at risk for adverse outcomes. Research from high-income settings contrasts the dearth of information from transplant centers in low- and middle-income countries, such as South Africa. Therefore, this study from Johannesburg aimed to describe the clinical and demographic profile of children undergoing liver transplantation, and determine the incidence and pattern of BSI and associated risk factors for BSI during the first year after liver transplant. Pediatric liver transplants performed from 2005 to 2014 were reviewed. Descriptive analyses summarized donor, recipient, and post-transplant infection characteristics. Association between BSI and sex, cause of liver failure, age, nutritional status, PELD/MELD score, graft type, biliary complications, and acute rejection was determined by Fisher's exact test; and association with length of stay by Cox proportional hazards regression analysis. Survival estimates were determined by the Kaplan-Meier method. Sixty-five children received one transplant and four had repeat transplants, totaling 69 procedures. Twenty-nine BSI occurred in 19/69 (28%) procedures, mostly due to gram-negative organisms, namely Klebsiella species. Risk for BSI was independently associated with biliary atresia (44% BSI in BA compared to 17% in non-BA transplants; P = .014) and post-operative biliary complications (55% BSI in transplants with biliary complications compared to 15% in those without; P = .0013). One-year recipient and graft survival was 78% (CI 67%-86%) and 77% (CI 65%-85%), respectively. In Johannesburg, incident BSI, mostly from gram-negative bacteria, were associated with biliary atresia and post-operative biliary complications in children undergoing liver transplantation.
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Affiliation(s)
- Mary Duncan
- Wits Donald Gordon Medical Centre, University of the Witwatersrand, Johannesburg, South Africa
| | - AnneMarie DeVoll-Zabrocki
- College of Nursing, 985330 Nebraska Medical Center, University of Nebraska Medical Center, Omaha, NE, USA
| | - Harriet R Etheredge
- Wits Donald Gordon Medical Centre, University of the Witwatersrand, Johannesburg, South Africa.,Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Heather A Maher
- Wits Donald Gordon Medical Centre, University of the Witwatersrand, Johannesburg, South Africa
| | - Carolyn Bouter
- Wits Donald Gordon Medical Centre, University of the Witwatersrand, Johannesburg, South Africa
| | - Petra Gaylard
- Data Management and Statistical Analysis (DMSA), Johannesburg, South Africa
| | - Jerome Loveland
- Wits Donald Gordon Medical Centre, University of the Witwatersrand, Johannesburg, South Africa.,Department of Pediatric Surgery, Faculty of Health Sciences, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - June Fabian
- Wits Donald Gordon Medical Centre, University of the Witwatersrand, Johannesburg, South Africa.,Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jean F Botha
- Wits Donald Gordon Medical Centre, University of the Witwatersrand, Johannesburg, South Africa.,Department of Surgery, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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