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Dalzell C, Vargas PA, Soltys K, Dipaola F, Mazariegos G, Oberholzer J, Goldaracena N. Living Donor Liver Transplantation vs. Split Liver Transplantation Using Left Lateral Segment Grafts in Pediatric Recipients: An Analysis of the UNOS Database. Transpl Int 2022; 36:10437. [PMID: 35391900 PMCID: PMC8980223 DOI: 10.3389/ti.2022.10437] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 03/03/2022] [Indexed: 12/12/2022]
Abstract
Split and LDLT in pediatric patients have the potential to decrease wait times and waitlist mortality. Using UNOS-STAR data, we compared outcomes of pediatric patients undergoing LDLT and SLT using LLS grafts. The baseline characteristics and post-operative outcomes were compared between groups. Actuarial graft and patient survival were analyzed with Kaplan-Meier curves. Between 2010 and 2019, 911 pediatric LT were included in the analysis (LD graft group, n = 508, split graft group, n = 403). LD graft recipients spent more time on the waitlist vs. the split graft group (60 (22–138) days vs. 46 (16–108) days; p = 0.007). LD recipients had a lower rate of graft failure, found in 9.8% of patients compared with 14.6% in the split graft group (p = 0.02). HAT was the most common graft failure cause, with similar rates. Graft and patient survival at 1-, 3-, and 5-years was comparable between LDLT and SLT. In subgroup analyses, patients with biliary atresia, those ≤10 kg or ≤10 years old receiving an LD graft showed improved graft survival. In conclusion, LDLT is associated with a lower rate of graft failure in pediatric patients. The use of LLS regardless of the type of donor is a safe way to facilitate access to transplantation to pediatric patients with acceptable short and long-term outcomes.
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Affiliation(s)
- Christina Dalzell
- School of Medicine, University of Virginia, Charlottesville, VA, United States
| | - Paola A Vargas
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, VA, United States
| | - Kyle Soltys
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, VA, United States.,Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh and Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Frank Dipaola
- Division of Pediatric Gastroenterology, Department of Pediatrics, University of Virginia, Charlottesville, VA, United States
| | - George Mazariegos
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, VA, United States.,Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh and Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Jose Oberholzer
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, VA, United States
| | - Nicolas Goldaracena
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, VA, United States
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Alnagar A, Daradka K, Kyrana E, Mtegha M, Palaniswamy K, Rajwal S, Mulla J, O'meara M, Karam M, Shawky A, Hakeem AR, Upasani V, Dhakshinamoorthy V, Prasad R, Attia M. Predictors of patient and graft survival following pediatric liver transplantation: Long-term analysis of more than 300 cases from single centre. Pediatr Transplant 2022; 26:e14139. [PMID: 34545678 DOI: 10.1111/petr.14139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 08/04/2021] [Accepted: 08/28/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Pediatric liver transplant (PLT) activity has flourished over time although with limited expansion in the graft pool. The study aims to identify pre-transplant factors that predict post-transplant patient and graft survival in the PLT population. METHODS Retrospective review of PLTs at a single tertiary transplant unit from 2000 to 2019. Univariate and multivariate analyses of pre-transplant factors were performed to identify predictors of patient and graft survival. RESULTS Two hundred and seventy-six patients received 320 PLTs. The most common cause of graft loss was hepatic artery thrombosis (n = 13, 29.6%). The most common cause of mortality was sepsis (n = 11, 29.7%). Univariate analysis showed that the following variables had a significant (p < .05) impact on patient survival: recipient age, weight, height, graft type (technical variant graft), transplant category (acute liver failure), the era of transplant, and invasive ventilation. The following variables had a significant (p < .05) impact on graft survival: recipient age, weight, height, transplant category (acute liver failure), and the era of transplant. Multivariate analysis precluded the era of transplant as the only significant factor for patient survival; patients transplanted after 2005 had significantly higher patient survival. No independent factor predicting graft survival was identified. For children transplanted after 2005, the only factor that predicted patient survival was pre-transplant invasive ventilation. CONCLUSIONS Our study suggests that the learning curve and pre-transplant invasive ventilation in the recipient have a significant impact on patient survival. The traditional view of worse outcomes of smaller PLT candidates should be changed.
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Affiliation(s)
- Amr Alnagar
- The Leeds Teaching Hospitals, NHS Foundation Trust, Leeds, UK.,General Surgery Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Khaled Daradka
- The Leeds Teaching Hospitals, NHS Foundation Trust, Leeds, UK.,Department of General Surgery, Jordan University Hospital, The University of Jordan- Queen Rania Street, Amman, Jordan
| | - Eirini Kyrana
- The Leeds Teaching Hospitals, NHS Foundation Trust, Leeds, UK
| | - Marumbo Mtegha
- The Leeds Teaching Hospitals, NHS Foundation Trust, Leeds, UK
| | | | - Sanjay Rajwal
- The Leeds Teaching Hospitals, NHS Foundation Trust, Leeds, UK
| | - Jamila Mulla
- The Leeds Teaching Hospitals, NHS Foundation Trust, Leeds, UK
| | - Moira O'meara
- The Leeds Teaching Hospitals, NHS Foundation Trust, Leeds, UK
| | - Mohamed Karam
- General Surgery Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Ahmed Shawky
- General Surgery Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | | | - Vivek Upasani
- The Leeds Teaching Hospitals, NHS Foundation Trust, Leeds, UK
| | | | - Raj Prasad
- The Leeds Teaching Hospitals, NHS Foundation Trust, Leeds, UK
| | - Magdy Attia
- The Leeds Teaching Hospitals, NHS Foundation Trust, Leeds, UK
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Béranger A, Capito C, Lacaille F, Ferroni A, Bouazza N, Girard M, Oualha M, Renolleau S, Debray D, Chardot C, Frange P, Moulin F. Early Bacterial Infections After Pediatric Liver Transplantation in the Era of Multidrug-resistant Bacteria: Nine-year Single-center Retrospective Experience. Pediatr Infect Dis J 2020; 39:e169-75. [PMID: 32251259 DOI: 10.1097/INF.0000000000002662] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Early bacterial infection is a major and severe complication after liver transplantation (LT). The rise of antimicrobial resistance, especially extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE), is a growing concern for these patients. This study aimed to assess the epidemiology of early bacterial infections in a pediatric population, including those caused by multidrug-resistant (MDR) pathogens, and to identify risk factors for infection. METHODS We conducted a monocentric retrospective study including 142 consecutive LTs performed in 137 children between 2009 and 2017. RESULTS Ninety-three bacterial infections occurred after 67 (47%) LTs. Among the 82 isolated pathogens, the most common was Klebsiella pneumoniae (n = 19, 23%). Independent risk factors for early bacterial infection were low weight [odds ratio (OR) = 0.96; 95% confidence interval (CI): 0.9-0.99; P = 0.03] and the presence of a prosthetic mesh (OR = 2.4; 95% CI: 1.1-5.4; P = 0.046). Sixty-one children (45%) carried MDR bacteria and 16 infections were caused by MDR pathogens, especially ESBL-producing K. pneumoniae (n = 12). ESBL-PE stool carriage was associated with ESBL-PE infection (OR = 4.5; 95% CI: 1.4-17.4; P = 0.02). Four children died from an infection, three due to ESBL-producing K. pneumoniae. CONCLUSIONS This study confirmed a shift toward a predominance of Gram-negative early bacterial infections after pediatric LT. The risk factors for infection were low weight and the presence of a prosthetic mesh. ESBL-PE stool carriage was associated with ESBL-PE infection. Adapted antimicrobial prophylaxis and personalized antibiotherapy are mandatory to reduce infection prevalence and mortality.
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Balcı Sezer O, Barış Z, Ecevit Z, Özçay F, Haberal M. Prevalence of Infections in Infants Within the First 6 Months of Liver Transplant. EXP CLIN TRANSPLANT 2020; 18:93-95. [PMID: 32008506 DOI: 10.6002/ect.tond-tdtd2019.p33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES In this retrospective study, we aimed to determine the most common infectious agents in infants within the first 6 months of liver transplant. MATERIALS AND METHODS Thirty-four infant patients with median age of 8 months (range, 4-12 mo) at the time of liver transplant were retrospectively evaluated. We evaluated causative organisms in bloodstream cultures and in subclavian catheter, urine, and intra-abdominal drainage fluid cultures. We also evaluated Epstein-Barr and cytomegalovirus infections by polymerase chain reaction in all recipients. RESULTS The most common isolated bacteria from the bloodstream were Klebsiella pneumoniae, Staphylococcus epidermidis, and Enterococcus faecium. Staphylococcus epidermidis was the most common isolated bacteria from subclavian catheter cultures. Klebsiella pneumoniae was the most common bacteria isolated from intra-abdominal drainage fluid. Only 1 recipient had cytomegalovirus infection during this period. CONCLUSIONS Our study showed a high incidence of Klebsiella pneumoniae infections in infants after liver transplant. New prophylactic antibiotic strategies can be promoted to prevent Klebsiella pneumoniae infections in infants.
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Affiliation(s)
- Oya Balcı Sezer
- From the Department of Pediatric Gastroenterology, Baskent University Faculty of Medicine, Ankara, Turkey
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Song Z, Ma N, Dong C, Sun C, Meng X, Zhang W, Wang K, Wu B, Li S, Qin H, Han C, Li H, Gao W, Shen Z. Feasibility and safety of using low-body-weight donors in pediatric liver transplantation. J Pediatr Surg 2019; 54:2382-2386. [PMID: 31109730 DOI: 10.1016/j.jpedsurg.2019.04.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 04/06/2019] [Accepted: 04/23/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Donors with low-body-weight were previously reported to be related to inferior recipient outcomes in pediatric liver transplantation. However, the scarce availability of age and size-matched organs has encouraged us to re-evaluate the feasibility and safety of using low-body-weight donors. METHODS We retrospectively analyzed 91 deceased donor pediatric liver transplantation between January 2014 and December 2016, donor weight less than 5 kg was defined as low-body-weight donors. The recipients were divided into two groups according to donor weight. (≤5 kg and 5 kg < to ≤20 kg). Donor and recipient characteristics, perioperative data, postoperative complications as well as graft and recipient survival rate were compared RESULTS: The recipients and grafts recovery after transplantation were comparable between two groups. The recipients receiving low-body-weight donors showed higher risk of hepatic artery thrombosis and small-for-size syndrome, however, these complications can effectively be treated by our strategies. The 2-year patient survival rates were 92.9% and 95.2%, 2-year graft survival rates were 92.9% and 93.7% in Groups 1 and 2, without significant difference. CONCLUSIONS Our finding suggested that the utility of livers from low-body-weight donors is a potential strategy to increase donor availability in well-selected pediatric recipients. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Zhuolun Song
- Organ Transplantation Center, Tianjin First Center Hospital, Tianjin Key Laboratory for Organ Transplantation, Tianjin, China
| | - Nan Ma
- Organ Transplantation Center, Tianjin First Center Hospital, Tianjin Key Laboratory for Organ Transplantation, Tianjin, China
| | - Chong Dong
- Organ Transplantation Center, Tianjin First Center Hospital, Tianjin Key Laboratory for Organ Transplantation, Tianjin, China
| | - Chao Sun
- Organ Transplantation Center, Tianjin First Center Hospital, Tianjin Key Laboratory for Organ Transplantation, Tianjin, China
| | - Xingchu Meng
- Organ Transplantation Center, Tianjin First Center Hospital, Tianjin Key Laboratory for Organ Transplantation, Tianjin, China
| | - Wei Zhang
- Organ Transplantation Center, Tianjin First Center Hospital, Tianjin Key Laboratory for Organ Transplantation, Tianjin, China
| | - Kai Wang
- Organ Transplantation Center, Tianjin First Center Hospital, Tianjin Key Laboratory for Organ Transplantation, Tianjin, China
| | - Bin Wu
- Organ Transplantation Center, Tianjin First Center Hospital, Tianjin Key Laboratory for Organ Transplantation, Tianjin, China
| | - Shanni Li
- Organ Transplantation Center, Tianjin First Center Hospital, Tianjin Key Laboratory for Organ Transplantation, Tianjin, China
| | - Hong Qin
- Organ Transplantation Center, Tianjin First Center Hospital, Tianjin Key Laboratory for Organ Transplantation, Tianjin, China
| | - Chao Han
- Organ Transplantation Center, Tianjin First Center Hospital, Tianjin Key Laboratory for Organ Transplantation, Tianjin, China
| | - Haohao Li
- Organ Transplantation Center, Tianjin First Center Hospital, Tianjin Key Laboratory for Organ Transplantation, Tianjin, China
| | - Wei Gao
- Organ Transplantation Center, Tianjin First Center Hospital, Tianjin Key Laboratory for Organ Transplantation, Tianjin, China.
| | - Zhongyang Shen
- Organ Transplantation Center, Tianjin First Center Hospital, Tianjin Key Laboratory for Organ Transplantation, Tianjin, China
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Ren X, Guan J, Gao N, Niu H, Tang J. Evaluation of Pediatric Liver Transplantation-Related Artery Complications Using Intra-Operative Multi-Parameter Ultrasonography. Med Sci Monit 2016; 22:4495-4502. [PMID: 27870825 PMCID: PMC5126936 DOI: 10.12659/msm.897408] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background This article discusses the value of using multi-parameter evaluation of intra-operative ultrasonography in evaluating pediatric liver transplantation-related arterial complications. Material/Methods Sixty-eight children receiving a liver transplant underwent intraoperative ultrasonography for monitoring of artery hemodynamics. The ultrasonic measurement parameters included the diameters of the hepatic artery (HA) of the donor and anastomotic stoma, peak systolic velocity (PSV), resistance index (RI), acceleration time (SAT), and blood flow volume. Results After being treated immediately using surgery or other means, blood flow returned to normal in 8 cases, and did not in 3 cases, of whom 2 experienced postoperative HAT. There was a significant difference in HA diameter of the donor, anastomotic stoma diameter, PSV, RI, SAT, and blood flow volume before and after treatment of the donor in the complications group. Postoperative complications occurred in 7 of 68 recipients, including the 2 cases exhibiting complications during the surgery (complication group) and 5 without complications during the surgery (no complication group). There was a statistically significant difference (P<0.05) between the 2 groups in intraoperative ultrasonography parameters of HA diameter, anastomotic stoma diameter, RI, and blood flow volume. Conclusions Through intraoperative multi-parameter ultrasonic measurement, a definite diagnosis of hepatic artery complications can be made in liver transplantation patients. HA diameter of the donor, anastomotic stoma diameter, PSV, RI, SAT, and blood flow volume are important in assessing intraoperative artery complications.
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Affiliation(s)
- Xiuyun Ren
- Department of Ultrasound, The General Hospital of Chinese People's Liberation Army, Beijing, China (mainland).,Department of Ultrasound, General Hospital of Chinese People's Armed Police Forces, Beijing, China (mainland)
| | - Junhui Guan
- Department of Ultrasound, General Hospital of Chinese People's Armed Police Forces, Beijing, China (mainland)
| | - Nong Gao
- Department of Ultrasound, General Hospital of Chinese People's Armed Police Forces, Beijing, China (mainland)
| | - Hong Niu
- Department of Ultrasound, General Hospital of Chinese People's Armed Police Forces, Beijing, China (mainland)
| | - Jie Tang
- Department of Ultrasound, The General Hospital of Chinese People's Liberation Army, Beijing, China (mainland)
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Schukfeh N, Holland AC, Hoyer DP, Gallinat A, Paul A, Schulze M. Liver transplantation in infants with biliary atresia: comparison of primary versus temporary abdominal closure. Langenbecks Arch Surg 2016; 402:135-141. [DOI: 10.1007/s00423-016-1525-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Accepted: 10/09/2016] [Indexed: 02/07/2023]
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Yang SC, Huang CJ, Chen CL, Wang CH, Wu SC, Shih TH, Juang SE, Lee YE, Jawan B, Cheng YF, Cheng KW. Living donor liver transplantation with body-weight more or less than 10 kilograms. World J Gastroenterol 2015; 21:7248-7253. [PMID: 26109812 PMCID: PMC4476887 DOI: 10.3748/wjg.v21.i23.7248] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Revised: 03/27/2015] [Accepted: 05/04/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the outcomes of pediatric patients weighing less than or more than 10 kg who underwent liver transplantation.
METHODS: Data for 196 pediatric patients who underwent living donor liver transplantation between June 1994 and February 2011 were reviewed retrospectively. The information for each patient was anonymized and de-identified before analysis. The data included information regarding the pre-transplant conditions, intraoperative fluid replacement and outcomes for each patient. The 196 patients were divided into two groups: those with body weights of less than 10 kg were included in group 1 (G1; n = 101), while those with body weights of more than 10 kg were included in group 2 (G2; n = 95). For each group, the patients’ ages, body weights, heights, pediatric end stage liver disease scores, anesthesia times, and warm and cold ischemic times were analyzed. In addition, between-group comparisons were also made. Mann-Whitney U tests were used to compare all the variables except for complications and survival rates, which were analyzed using χ2 tests and Kaplan-Meier tests, respectively.
RESULTS: The general medical conditions of the G1 patients were worse than those of the G2 patients, as shown by the higher pediatric end stage liver disease scores and poorer Z-scores. In addition, the pre-operative Hb and serum albumin levels were all lower for the G1 patients than for the G2 patients. The G1 patients also had significantly more intraoperative blood loss than the G2 patients. In addition, the intraoperative fluid requirements for the G1 patients, including leukocyte poor red blood cell transfusions, 5% albumin infusions and crystalloid infusions, were significantly higher than those for the G2 patients. The risk of intraoperative portal vein thrombosis was higher for the patients in G1 than for those in G2. However, the one-year survival rates (95.9% and 96.8% for G1 and G2, respectively) and three-year survival rates (94.9% and 94.6% for G1 and G2, respectively) for both groups were similar.
CONCLUSION: Patients weighing less than 10 kg typically have poorer conditions, but their survival rates are comparable to those of children weighing more than 10 kg.
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