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Baranwal P, Sathe M, Lobritto SJ, Vittorio J. The impact of health literacy on adolescent and young adult pediatric liver transplant recipients. Liver Transpl 2024; 30:386-394. [PMID: 37812071 DOI: 10.1097/lvt.0000000000000283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 09/26/2023] [Indexed: 10/10/2023]
Abstract
Pediatric liver transplant recipients have increased rates of morbidity and mortality following transfer to adult health care providers. The role of health literacy (HL) has not been adequately assessed in this population and may be an unrecognized barrier to successful health care transition. We sought to determine the impact of HL for patients and their caregivers on measures of transition readiness (TR), adherence, health-related quality of life, and medical outcomes following pediatric liver transplant. This is a single-center study of pediatric liver transplant recipients transplanted between the ages of 12 and 26 from October 2016 through August 2020. Patients and caregivers completed 4 surveys to evaluate TR, health-related quality of life, and HL. Clinical outcomes were stratified based on the presence or absence of adequate HL. Limited HL was identified in 57.0% of recipients and 47.4% of caregivers. Patients with limited HL were more likely to be younger in age ( p = 0.004), Hispanic ( p = 0.003), and less likely to have obtained a high school diploma or equivalent ( p < 0.001). Patients with adequate HL demonstrated significantly higher levels of TR ( p < 0.001). Patient HL did not impact health-related quality of life, adherence, or medical outcomes. Caregiver HL did not impact patient outcomes or adherence, though higher levels of caregiver education were associated with adequate patient HL ( p = 0.049). This study demonstrates that limited HL is associated with decreased measures of TR. Inadequate HL may be an unrecognized barrier to a successful health care transition. Regular assessment of HL may provide an opportunity for intervention prior to transfer of care. Future studies should investigate the impact of these interventions on long-term medical outcomes.
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Affiliation(s)
- Prerana Baranwal
- Division of Pediatric Gastroenterology, Nutrition, and Liver Diseases, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Mihika Sathe
- Departments of Internal Medicine and Pediatrics, Inova Health, Annandale, Virginia, USA
| | - Steven J Lobritto
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Columbia University Irving Medical Center, New York, New York, USA
| | - Jennifer Vittorio
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, New York University (NYU) Langone Health, New York University School of Medicine, New York, New York, USA
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2
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Sabapathy DG, Hosek K, Lam FW, Desai MS, Williams EA, Goss J, Raphael JL, Lopez MA. Identifying drivers of cost in pediatric liver transplantation. Liver Transpl 2024:01445473-990000000-00349. [PMID: 38535617 DOI: 10.1097/lvt.0000000000000367] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 03/13/2024] [Indexed: 05/09/2024]
Abstract
Understanding the economics of pediatric liver transplantation (LT) is central to high-value care initiatives. We examined cost and resource utilization in pediatric LT nationally to identify drivers of cost and hospital factors associated with greater total cost of care. We reviewed 3295 children (<21 y) receiving an LT from 2010 to 2020 in the Pediatric Health Information System to study cost, both per LT and service line, and associated mortality, complications, and resource utilization. To facilitate comparisons, patients were stratified into high-cost, intermediate-cost, or low-cost tertiles based on LT cost. The median cost per LT was $150,836 [IQR $104,481-$250,129], with marked variance in cost within and between hospital tertiles. High-cost hospitals (HCHs) cared for more patients with the highest severity of illness and mortality risk levels (67% and 29%, respectively), compared to intermediate-cost (60%, 21%; p <0.001) and low-cost (51%, 16%; p <0.001) hospitals. Patients at HCHs experienced a higher prevalence of mechanical ventilation, total parental nutrition use, renal comorbidities, and surgical complications than other tertiles. Clinical (27.5%), laboratory (15.1%), and pharmacy (11.9%) service lines contributed most to the total cost. Renal comorbidities ($69,563) and total parental nutrition use ($33,192) were large, independent contributors to total cost, irrespective of the cost tertile ( p <0.001). There exists a significant variation in pediatric LT cost, with HCHs caring for more patients with higher illness acuity and resource needs. Studies are needed to examine drivers of cost and associated outcomes more granularly, with the goal of defining value and standardizing care. Such efforts may uniquely benefit the sicker patients requiring the strategic resources located within HCHs to achieve the best outcomes.
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Affiliation(s)
- Divya G Sabapathy
- Department of Pediatrics, Baylor College of Medicine, Division of Critical Care Medicine, Houston, Texas, USA
| | - Kathleen Hosek
- Texas Children's Hospital, Department of Quality, Houston, Texas, USA
| | - Fong W Lam
- Department of Pediatrics, Baylor College of Medicine, Division of Critical Care Medicine, Houston, Texas, USA
| | - Moreshwar S Desai
- Department of Pediatrics, Baylor College of Medicine, Division of Critical Care Medicine, Houston, Texas, USA
| | - Eric A Williams
- Department of Pediatrics, Division of Critical Care Medicine, University of Cincinnati School of Medicine, Cincinnati, Ohio, USA
| | - John Goss
- Division of Abdominal Transplantation, Baylor College of Medicine, Houston, Texas, USA
| | - Jean L Raphael
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Center for Child Health Policy and Advocacy, Houston, TX, USA
| | - Michelle A Lopez
- Center for Child Health Policy and Advocacy, Houston, TX, USA
- Department of Pediatrics, Baylor College of Medicine, Division of Hospital Medicine, Houston, Texas, USA
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Shpoliansky M, Chavhan GB, Zhou A, Ng VL, Kamath BM. A pilot feasibility study of an ultrasound-based tool to assess muscle mass in children with liver disease. Hepatol Commun 2023; 7:e0211. [PMID: 37506186 PMCID: PMC10389755 DOI: 10.1097/hc9.0000000000000211] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 05/22/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Sarcopenia is associated with adverse outcomes following liver transplantation, and at-risk children must be identified and prehabilitated. The gold standard for assessing sarcopenia in end-stage liver disease (ESLD) is CT assessment of the total Psoas Muscle Area (tPMA). However, radiation exposure and sedation requirements make this approach impractical for children. The bilateral anterior thigh thickness (BATT) is the cumulative measurement of the rectus femoris and vastus intermedius muscles by ultrasound and has been used to identify sarcopenia in adults. There are no studies assessing muscle mass in children using ultrasound. We hypothesized that measuring BATT with ultrasound in children with ESLD is feasible and is associated with sarcopenia. METHODS A prospective pilot feasibility study of patients with ESLD on the liver transplantation waitlist and age-matched healthy controls. BATT was measured by a single operator using ultrasound. tPMA indices were determined by CT imaging, along with clinical and anthropometric data. RESULTS Thirty children were studied between September 2021 and December 2022, 15 listed patients aged 4-30 months, and 15 controls aged 4-32 months. No major technical challenges or complications were encountered while performing the ultrasounds. Median BATTs of 30.8 mm (interquartile range: 27.9-32.8 mm) versus 32.7 mm (interquartile range: 31.8-36.9 mm) were demonstrated in the ESLD and control groups, respectively, and p = 0.01. A positive correlation (R = 0.603) was demonstrated between BATT and tPMA at the L4-5 level among patients with ESLD. No correlation was observed between BATT and anthropometrics. CONCLUSIONS This study yields novel data on the feasibility of ultrasound to measure mid-thigh thickness in children with ESLD and suggests a correlation between BATT and tPMA, the gold standard for diagnosing sarcopenia. It sets the stage for ultrasound as a simple, noninvasive, and easily repeatable tool for assessing sarcopenia in children.
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Affiliation(s)
- Michael Shpoliansky
- Division of Gastroenterology, Department of Pediatrics, Hepatology and Nutrition, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Govind B Chavhan
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Alex Zhou
- Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Vicky L Ng
- Division of Gastroenterology, Department of Pediatrics, Hepatology and Nutrition, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Binita M Kamath
- Division of Gastroenterology, Department of Pediatrics, Hepatology and Nutrition, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
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Yeh H. Moving the Goalpost: From "Alive" to "Ideal". Transplantation 2023; 107:1667-1668. [PMID: 36814092 DOI: 10.1097/tp.0000000000004557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Affiliation(s)
- Heidi Yeh
- Department of Surgery, Massachusetts General Hospital, Boston, MA
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Balbale SN, Cho M, Raval MV, Close SM. Role of patient and family engagement in quality improvement for pediatric surgery. Semin Pediatr Surg 2023; 32:151281. [PMID: 37094531 DOI: 10.1016/j.sempedsurg.2023.151281] [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: 04/26/2023]
Abstract
In recent decades, the role of quality improvement (QI) in pediatric surgery has grown substantially. Patient and family engagement can help to maximize the impact of QI by enhancing safety and patient outcomes. Yet, broader, systematic efforts to actively involve patients and families in QI initiatives remain a persistent gap in pediatric surgery. To address this gap, we propose an agenda centered on three key goals for future quality improvement efforts: (1) building partnerships with patients and their families; (2) expanding the use of patient-reported outcomes (PROs) and novel, cross-disciplinary research methods; and (3) engaging patients and families consistently across all stages of pediatric surgical care. Fulfilling this agenda will be essential in shifting our mindset to view QI as a collective that involves patients, families, clinicians, and payers in continuous, system-wide opportunities to evaluate and improve care. Actively listening to and collaborating with patients and families may also help renew our focus on narrowing the gap between current practice and the best possible practice for children undergoing surgery.
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Affiliation(s)
- Salva N Balbale
- Division of Gastroenterology and Hepatology, Department of Medicine; Department of Medical Social Sciences; Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Department of Surgery; & Center for Health Services and Outcomes Research, Institute of Public Health and Medicine (IPHAM), Northwestern University Feinberg School of Medicine, Chicago, IL; Center of Innovation for Complex Chronic Healthcare, Health Services Research & Development, Edward Hines, Jr. VA Hospital, Hines, IL.
| | | | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Sharron M Close
- Department of Pediatric Advanced Practice Nursing, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA
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Yoeli D, Feldman AG, Choudhury RA, Moore HB, Sundaram SS, Nydam TL, Wachs ME, Pomfret EA, Adams MA, Jackson WE. Can non-directed living liver donation help improve access to grafts and correct socioeconomic disparities in pediatric liver transplantation? Pediatr Transplant 2023; 27:e14428. [PMID: 36329627 PMCID: PMC10132215 DOI: 10.1111/petr.14428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 08/18/2021] [Revised: 02/10/2022] [Accepted: 05/05/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Each year, children die awaiting LT as the demand for grafts exceeds the available supply. Candidates with public health insurance are significantly less likely to undergo both deceased donor LT and D-LLD LT. ND-LLD is another option to gain access to a graft. The aim of this study was to evaluate if recipient insurance type is associated with likelihood of D-LLD versus ND-LLD LT. METHODS The SRTR/OPTN database was reviewed for pediatric LDLT performed between January 1, 2014 (Medicaid expansion era) and December 31, 2019 at centers that performed ≥1 ND-LLD LDLT during the study period. A multivariable logistic regression was performed to assess relationship between type of living donor (directed vs. non-directed) and recipient insurance. RESULTS Of 299 pediatric LDLT, 46 (15%) were from ND-LLD performed at 18 transplant centers. Fifty-nine percent of ND-LLD recipients had public insurance in comparison to 40% of D-LLD recipients (p = .02). Public insurance was associated with greater odds of ND-LLD in comparison to D-LLD upon multivariable logistic regression (OR 2.37, 95% CI 1.23-4.58, p = .01). CONCLUSIONS ND-LLD allows additional children to receive LTs and may help address some of the socioeconomic disparity in pediatric LDLT, but currently account for only a minority of LDLT and are only performed at a few institutions. Initiatives to improve access to both D-LLD and ND-LLD transplants are needed.
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Affiliation(s)
- Dor Yoeli
- Division of Transplantation, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA.,Division of Abdominal Transplant Surgery, Department of Surgery, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Amy G Feldman
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatric Medicine, The Digestive Health Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Rashikh A Choudhury
- Division of Transplantation, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Hunter B Moore
- Division of Transplantation, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Shikha S Sundaram
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatric Medicine, The Digestive Health Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Trevor L Nydam
- Division of Transplantation, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Michael E Wachs
- Division of Transplantation, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA.,Division of Abdominal Transplant Surgery, Department of Surgery, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Elizabeth A Pomfret
- Division of Transplantation, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Megan A Adams
- Division of Transplantation, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA.,Division of Abdominal Transplant Surgery, Department of Surgery, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Whitney E Jackson
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
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7
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Ng VL, Dunphy C, Shemesh E, Lobritto S, Eisenberg E, Pomponi C, Szolna J, Wilkerson D, Gupta N, Romero R, Perito ER, DiPaola F, Gonzalez-Peralta RP, Hsu E, Saarela K, Mohammad S, Superina R, Logan S, Miller DW, Krise-Confair C, Swami N, Mazariegos G. Feasibility of using a patient-reported outcome measure into clinical practice following pediatric liver transplantation: The Starzl Network experience. Pediatr Transplant 2023; 27:e14409. [PMID: 36272132 DOI: 10.1111/petr.14409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 04/22/2022] [Revised: 09/19/2022] [Accepted: 09/23/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Patient-reported outcome measures (PROMs) are not routinely used in clinical care by pediatric liver transplant (LT) teams. The Starzl Network for Excellence in Pediatric Transplantation (SNEPT) assessed feasibility of using a disease-specific Quality of Life (QoL) questionnaire in the ambulatory setting at 10 SNEPT sites. METHODS A mixed methods feasibility project assessing administration processes, barriers, and user experiences with the Pediatric Liver Transplant Quality of Life (PeLTQL) tool. Iterative processes sought stakeholder feedback across four phases (Pilot, Extended Pilot, Development of a Mobile App PeLTQL version, and Pilot App use). RESULTS A total of 149 patient-parent dyads completed the PeLTQL during LT clinic follow-up. Clinicians, parents, and patients evaluated and reported on feasibility of operationalization. Only two of 10 SNEPT sites continued PeLTQL administration after the initial two pilot phases. Reasons include limited clinical time and available personnel aggravated by the COVID-19 pandemic. In response, a mobile application version of the PeLTQL was initiated. Providing PeLTQL responses electronically was "very easy" or "easy" as reported by 96% (22/23) parents. CONCLUSIONS Administration of a PROM into post-pediatric LT clinical care was feasible, but ongoing utilization stalled. Use of a mobile app towards facilitating completion of the PeLTQL outside of clinic hours may address the time and work-flow barriers identified.
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Affiliation(s)
- Vicky Lee Ng
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Claire Dunphy
- Icahn School of Medicine at Mount Sinai, Mount Sinai Kravis Children's Hospital, New York, New York, USA
| | - Eyal Shemesh
- Icahn School of Medicine at Mount Sinai, Mount Sinai Kravis Children's Hospital, New York, New York, USA
| | - Steven Lobritto
- Columbia University Medical Center, Morgan Stanley Children's Hospital of New York, New York, New York, USA
| | - Elizabeth Eisenberg
- Patient and Family Voice, Starzl Network for Excellence in Pediatric Transplantation, Pittsburgh, Pennsylvania, USA
| | - Claudia Pomponi
- Icahn School of Medicine at Mount Sinai, Mount Sinai Kravis Children's Hospital, New York, New York, USA
| | - Jonathan Szolna
- Children's Hospital of Pittsburgh, UPMC, Pittsburgh, Pennsylvania, USA
| | - Dawn Wilkerson
- Children's Hospital of Pittsburgh, UPMC, Pittsburgh, Pennsylvania, USA
| | - Nitika Gupta
- Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, Georgia, USA
| | - Rene Romero
- Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, Georgia, USA
| | - Emily R Perito
- Benioff Children's Hospital, University of California San Francisco, San Francisco, California, USA
| | - Frank DiPaola
- Division of Pediatric Gastroenterology, Department of Pediatrics, University of Virginia, Charlottesville, Virginia, USA
| | | | - Evelyn Hsu
- Division of Gastroenterology and Hepatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington, USA
| | - Katelyn Saarela
- Division of Gastroenterology and Hepatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington, USA
| | - Saeed Mohammad
- Feinberg School of Medicine, The Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois, USA.,Vanderbilt Unversity Medical Center, Nashville, Tennessee, USA
| | - Riccardo Superina
- Feinberg School of Medicine, The Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois, USA
| | - Sherrie Logan
- Patient and Family Voice, Starzl Network for Excellence in Pediatric Transplantation, Pittsburgh, Pennsylvania, USA
| | - Daniel W Miller
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | | | - George Mazariegos
- Children's Hospital of Pittsburgh, UPMC, Pittsburgh, Pennsylvania, USA
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Sakhuja S, Himes R, Carreker C, Guffey D, Beer S, Amin M, Hiremath G, Mysore K. Impact of psychosocial factors on medication level variability index and outcomes in pediatric liver transplant recipients. Pediatr Transplant 2023; 27:e14425. [PMID: 36325588 DOI: 10.1111/petr.14425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 05/12/2022] [Revised: 09/20/2022] [Accepted: 10/16/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Caregivers play an important role in maintaining a functioning graft after pediatric liver transplantation. Therefore, the psychosocial factors of both patients and caregivers can have a critical impact on transplant outcomes. Appropriate assessment and recognition of these factors pre-transplantation may allow transplant teams to better define the needs of pediatric organ recipients and develop specific countermeasures, which may then contribute toward improving transplant outcomes. METHODS We studied 136 pediatric LT recipients followed at Texas Children's Hospital. Licensed social workers conducted comprehensive pre-transplant assessments on each patient, consisting of 22 psychosocial variables that were thought to impact adherence, which were reviewed during our study period. Non-adherence was determined using the MLVI for up to 4 years after transplantation. Biopsy-confirmed rejection episodes were assessed in the first 3 years after liver transplantation. RESULTS Factors significantly associated with non-adherence (defined as MLVI >2) included parental age and parental education level at assessment, type of insurance, and household income. The number of ACR episodes trended higher in patients with non-adherence, and these patients had a higher number of moderate to severe rejection episodes but this trend was not statistically significant. CONCLUSIONS Psychosocial characteristics such as parental age, education level, insurance, and household income may contribute significantly to suboptimal adherence to medications after transplantation. Identification of these psychosocial factors and early intervention is essential to the success and equitable care of our pediatric LT recipients.
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Affiliation(s)
- Shruti Sakhuja
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Ryan Himes
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA.,Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Ochsner Health, New Orleans, Louisiana, USA
| | - Colleen Carreker
- Department of Patient and Family Services, Texas Children's Hospital, Houston, Texas, USA
| | - Danielle Guffey
- Institution for Clinical and Translational Research, Baylor College of Medicine, Houston, Texas, USA
| | - Stacey Beer
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Mansi Amin
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA.,Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Duke University, Durham, North Carolina, USA
| | - Girish Hiremath
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA.,Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Vanderbilt Children's, Nashville, Tennessee, USA
| | - Krupa Mysore
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
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9
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McElroy LM, Martin AE, Feldman AG, Ng VL, Kato T, Reichman T, Valentino PL, Anand R, Anderson SG, Sudan DL. An appraisal of technical variant grafts compared to whole liver grafts in pediatric liver transplant recipients: Multicenter analysis from the SPLIT registry. Pediatr Transplant 2023; 27:e14415. [PMID: 36303260 PMCID: PMC10184704 DOI: 10.1111/petr.14415] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 01/19/2022] [Revised: 08/08/2022] [Accepted: 08/10/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Shortages of liver allografts for children awaiting transplantation have led to high LT waitlist mortality. Prior studies have shown that usage of TVG can reduce waiting time and waitlist mortality, but their use is not universal. We sought to compare patient and graft survival between WLG and TVG and to identify potential associated risk factors in a contemporary pediatric LT cohort. METHODS We performed a retrospective analysis of patient survival, graft survival, and biliary and vascular complications for LT recipients <18 years old entered into the Society of Pediatric Liver Transplantation prospective multicenter database. RESULTS Of 1839 LT recipients, 1029 received a WLG and 810 received a TVG from either a LD or a DD. There was no difference in patient survival or graft survival by graft type. Three-year patient survival and graft survival were 96%, 93%, and 96%, and 95%, 89%, and 92% for TVG-LD, TVG-DD, and WLG, respectively. Biliary complications were more frequent in TVG. Hepatic artery thrombosis was more frequent in WLG. Multivariate analysis revealed primary diagnosis was the only significant predictor of patient survival. Predictors for graft survival included time-dependent development of biliary and vascular complications. CONCLUSIONS There were no significant differences in patient and graft survival based on graft types in this North American multi-center pediatric cohort. Widespread routine use of TVG should be strongly encouraged to decrease mortality on the waitlist for pediatric LT candidates.
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Affiliation(s)
- Lisa M McElroy
- Division of Abdominal Transplant Surgery, Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Abigail E Martin
- Division of Solid Organ Transplantation, Department of Surgery, Nemours Children's Hospital Delaware, Wilmington, Delaware, USA
| | - Amy G Feldman
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Digestive Health Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Vicky L Ng
- Division of Gastroenterology, Hepatology and Nutrition, Transplant and Regenerative Medicine Center, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Tomoaki Kato
- Division of Abdominal Organ Transplantation, Department of Surgery, New York Presbyterian-Morgan Stanley Children's Hospital, Columbia University, New York, New York, USA
| | - Trevor Reichman
- Multi Organ Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Pamela L Valentino
- Division of Gastroenterology and Hepatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
| | | | | | - Debra L Sudan
- Division of Abdominal Transplant Surgery, Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
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10
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Kortbeek S, Pawaria A, Ng VL. Equivalence of Paper and Electronic-Based Patient Reported Outcome Measures for Children: A Systematic Review. J Pediatr Gastroenterol Nutr 2023; 76:128-36. [PMID: 36240491 DOI: 10.1097/MPG.0000000000003636] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Patient-reported outcome measures (PROMs) exist for a variety of chronic gastrointestinal disorders in children. The availability of electronic (e-)formats of PROMs enhance the accessibility of these tools. The International Society for Pharmacoeconomic and Outcomes Research (ISPOR) defines measurement equivalence (ME) as "comparability of the psychometric properties of data" obtained from the administration of original and adapted versions of PROMs. Consideration of proxy PROM versions is unique to pediatrics and must be included in ME evaluations. We conducted a systematic review (SR) of the literature evaluating ME of e-versions adapted from pediatric paper-based PROMs. A literature search was conducted through Medline, Embase, APA PsychInfo, and the Cochrane Library. Titles, abstracts, and manuscripts were reviewed by 2 independent reviewers. The search yielded 19 studies meeting pre-defined criteria. Just over half (52.6%) of 19 PROMs were disease-specific ones. ME between paper- and e-PROM versions was reported as present in all 19 studies evaluating 5653 participants under the age of 18 years. However, only 6 (31.6%) studies evaluated ME in proxy reported e-versions. Despite the use of PROMs for children with a variety of chronic gastrointestinal disorders, only 1 study evaluated a PROM in this population (IMPACT III for inflammatory bowel disease). Findings from this SR highlight strategic opportunities for the pediatric gastroenterologist to broaden the clinical and research armamentarium to include e-PROMs.
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11
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Squires JE, Bilhartz J, Soltys K, Hafberg E, Mazariegos GV, Gupta NA, Anand R, Anderson SG, Miloh T. Factors associated with improved patient and graft survival beyond 1 year in pediatric liver transplantation. Liver Transpl 2022; 28:1899-1910. [PMID: 35555876 DOI: 10.1002/lt.26502] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 03/29/2022] [Accepted: 04/04/2022] [Indexed: 01/13/2023]
Abstract
With advances in surgical techniques, medical management, and more equitable allocation systems, children who receive a liver transplantation (LT) today can expect remarkable outcomes early after LT. However, beyond 1 year after transplant, attrition rates have not improved. We reviewed two separate eras (Era 1: January 1995-June 2004 vs. Era 2: July 2004-March 2018) of the Society of Pediatric Liver Transplantation registry to explore the evolution and associated factors contributing to late graft loss (LGL) and late mortality (LM). The fraction of long-term pediatric LT recipients surviving after 1 year with their first graft significantly improved (81.5% in Era 1 vs. 85.7% in Era 2; p < 0.0001). This improvement occurred despite significant changes in patient selection toward higher risk populations (p < 0.001) and without notable improvement in perioperative complications such as hepatic artery thrombosis (p = 0.24) and early posttransplant reoperation (p = 0.94) that have historically contributed to poor late-allograft outcomes. Improved outcomes were associated with changes in patient characteristics and perioperative practices, which subsequently impacted both early post-LT complications as well as other sequalae known to contribute to adverse events in long-term pediatric LT recipients. In conclusion, despite significant changes in patient selection toward higher risk populations, and without notable improvement in several perioperative complications known to contribute to poor late-allograft outcomes, significant improvements in LGL and a trend toward improvement in LM was seen in a more contemporary cohort of children receiving an LT.
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Affiliation(s)
- James E Squires
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jacob Bilhartz
- C. S. Mott Children's Hospital, University of Michigan Health, Ann Arbor, Michigan, USA
| | - Kyle Soltys
- Hillman Center for Pediatric Transplantation, Thomas E. Starzl Transplantation Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Einar Hafberg
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - George V Mazariegos
- Hillman Center for Pediatric Transplantation, Thomas E. Starzl Transplantation Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Nitika A Gupta
- Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, Georgia, USA
| | | | | | - Tamir Miloh
- Department of Pediatrics, University of Miami, Miami, Florida, USA
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12
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Wadhwani SI, Barrera AG, Shifman HP, Baker E, Bucuvalas J, Gottlieb LM, Kotagal U, Rhee SJ, Lai JC, Lyles CR. Caregiver perspectives on the everyday medical and social needs of long-term pediatric liver transplant patients. Liver Transpl 2022; 28:1735-1746. [PMID: 35524767 PMCID: PMC9949888 DOI: 10.1002/lt.26498] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/22/2022] [Accepted: 04/28/2022] [Indexed: 02/05/2023]
Abstract
Using in-depth interviews, we sought to characterize the everyday medical and social needs of pediatric liver transplant caregivers to inform the future design of solutions to improve care processes. Participants (parents/caregivers of pediatric liver transplant recipients) completed a survey (assessing socioeconomic status, economic hardship, health literacy, and social isolation). We then asked participants to undergo a 60-min virtual, semistructured qualitative interview to understand the everyday medical and social needs of the caregiver and their household. We intentionally oversampled caregivers who reported a social or economic hardship on the survey. Transcripts were analyzed using thematic analysis and organized around the Capability, Opportunity, Motivation-Behavior model. A total of 18 caregivers participated. Of the participants, 50% reported some form of financial strain, and about half had less than 4 years of college education. Caregivers had high motivation and capability in executing transplant-related tasks but identified several opportunities for improving care. Caregivers perceived the health system to lack capability in identifying and intervening on specific family social needs. Caregiver interviews revealed multiple areas in which family supports could be strengthened, including (1) managing indirect costs of prolonged hospitalizations (e.g., food, parking), (2) communicating with employers to support families' needs, (3) coordinating care across hospital departments, and (4) clarifying care team roles in helping families reduce both medical and social barriers. This study highlights the caregiver perspective on barriers and facilitators to posttransplant care. Future work should identify whether these themes are present across transplant centers. Caregiver perspectives should help inform future interventions aimed at improving long-term outcomes for children after liver transplantation.
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Affiliation(s)
| | | | - Holly P. Shifman
- Oakland University William Beaumont School of Medicine, Rochester, MI
| | - Ethel Baker
- University of California, San Francisco, San Francisco, CA
| | - John Bucuvalas
- Icahn School of Medicine at Mount Sinai, New York, NY
- Kravis Children’s Hospital, New York, NY
| | | | - Uma Kotagal
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Sue J. Rhee
- University of California, San Francisco, San Francisco, CA
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13
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Anderson MS, Taylor C, Englesbe MJ. From Survival to Survivorship in Pediatric Liver Transplantation. Pediatrics 2022; 150:189500. [PMID: 36111448 DOI: 10.1542/peds.2022-057753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/23/2022] [Indexed: 11/24/2022] Open
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14
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Hübscher SG, Feng S, Gouw ASH, Haga H, Kang HJ, Kelly DA, Komuta M, Lesniak A, Popp BA, Verkade HJ, Yu E, Demetris AJ. Standardizing the histological assessment of late posttransplantation biopsies from pediatric liver allograft recipients. Liver Transpl 2022; 28:1475-1489. [PMID: 35429359 DOI: 10.1002/lt.26482] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 03/30/2022] [Accepted: 03/30/2022] [Indexed: 02/07/2023]
Abstract
Excellent short-term survival after pediatric liver transplantation (LT) has shifted attention toward the optimization of long-term outcomes. Despite considerable progress in imaging and other noninvasive modalities, liver biopsies continue to be required to monitor allograft health and to titrate immunosuppression. However, a standardized approach to the detailed assessment of long-term graft histology is currently lacking. The aim of this study was to formulate a list of histopathological features relevant for the assessment of long-surviving liver allograft health and to develop an approach for assessing the presence and severity of these features in a standardized manner. Whole-slide digital images from 31 biopsies obtained ≥4 years after transplantation to determine eligibility for an immunosuppression withdrawal trial were selected to illustrate a range of typical histopathological findings seen in children with clinically stable grafts, including those associated with alloantibodies. Fifty histological features were independently assessed and, where appropriate, scored semiquantitatively by six pathologists to determine inter- and intraobserver reproducibility of the histopathological features using unweighted and weighted kappa statistics; the latter metric enabled distinction between minor and major disagreements in parameter severity scoring. Weighted interobserver kappa statistics showed a high level of agreement for various parameters of inflammation, interface activity, fibrosis, and microvascular injury. Intraobserver agreement for these features was even more substantial. The results of this study will help to standardize the assessment of biopsies from long-surviving liver allografts, aid the recognition of important histological features, and facilitate international comparisons and clinical trials aiming to improve outcomes for children undergoing LT.
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Affiliation(s)
- Stefan G Hübscher
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.,Department of Cellular Pathology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Sandy Feng
- Division of Transplantation, Department of Surgery, University of California, San Francisco, California, USA
| | - Annette S H Gouw
- Department of Pathology and Medical Biology, University Medical Center Groningen, Groningen, the Netherlands
| | - Hironori Haga
- Department of Diagnostic Pathology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hyo Jeong Kang
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Deirdre A Kelly
- Liver Unit, Birmingham Women's & Children's NHS Trust and University of Birmingham, Birmingham, UK
| | - Mina Komuta
- Department of Pathology, Keio University, Tokyo, Japan
| | - Andrew Lesniak
- Division of Liver and Transplantation Pathology, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Benjamin A Popp
- Division of Liver and Transplantation Pathology, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Henkjan J Verkade
- Pediatric Gastroenterology/Hepatology, Department of Pediatrics, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Eunsil Yu
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Anthony J Demetris
- Division of Liver and Transplantation Pathology, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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15
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Ebel NH, Lai JC, Bucuvalas JC, Wadhwani SI. A review of racial, socioeconomic, and geographic disparities in pediatric liver transplantation. Liver Transpl 2022; 28:1520-1528. [PMID: 35188708 PMCID: PMC9949889 DOI: 10.1002/lt.26437] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 01/21/2022] [Accepted: 02/15/2022] [Indexed: 02/07/2023]
Abstract
Equity is a core principle in both pediatrics and solid organ transplantation. Health inequities, specifically across race, socioeconomic position, or geography, reflect a moral failure. Ethical principles of prudential life span, maximin principle, and fair innings argue for allocation priority to children related to the number of life years gained, equal access to transplant, and equal opportunity for ideal posttransplant outcomes. Iterative policy changes have aimed to narrow these disparities to achieve pediatric transplant equity. These policy changes have focused on modifying pediatric priority for organ allocation to eliminate mortality on the pediatric transplant waiting list. Yet disparities remain in pediatric liver transplantation at all time points: from access to referral for transplantation, likelihood of living donor transplantation, use of exception narratives, waitlist mortality, and inequitable posttransplant outcomes. Black children are less likely to be petitioned for exception scores, have higher waitlist mortality, are less likely to be the recipient of a living donor transplant, and have worse posttransplant outcomes compared with White children. Children living in the most socioeconomically deprived neighborhoods have worse posttransplant outcomes. Children living farther from a transplant center have higher waitlist mortality. Herein we review the current knowledge of these racial and ethnic, socioeconomic, and geographic disparities for these children. To achieve equity, stakeholder engagement is required at all levels from providers and health delivery systems, learning networks, institutions, and society. Future initiatives must be swift, bold, and effective with the tripartite mission to inform policy changes, improve health care delivery, and optimize resource allocation to provide equitable transplant access, waitlist survival, and posttransplant outcomes for all children.
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Affiliation(s)
- Noelle H Ebel
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, Department of Pediatrics Stanford University Stanford California USA Division of Gastroenterology, Hepatology & NutritionDepartment of Medicine University of California San Francisco California USA Division of Pediatric HepatologyDepartment of Pediatrics Icahn School of Medicine at Mount Sinai New York New York USA Division of Pediatric Gastroenterology, Hepatology & Nutrition, Department of PediatricsUniversity of CaliforniaSan Francisco California USA
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16
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Ebel NH, Dike PN, Hsu EK. Addressing Racism in Pediatric Liver Transplantation: A Moral Imperative. J Pediatr 2022; 246:8-10. [PMID: 35504347 DOI: 10.1016/j.jpeds.2022.04.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 04/20/2022] [Accepted: 04/27/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Noelle H Ebel
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Stanford University School of Medicine, Lucile Packard Children's Hospital, Stanford, California.
| | - Peace N Dike
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Evelyn K Hsu
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington
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17
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de Ville de Goyet J, Illhardt T, Chardot C, Dike PN, Baumann U, Brandt K, Wildhaber BE, Pakarinen M, di Francesco F, Sturm E, Cornet M, Lemoine C, Pfister ED, Calinescu AM, Hukkinen M, Harpavat S, Tuzzolino F, Superina R. Variability of Care and Access to Transplantation for Children with Biliary Atresia Who Need a Liver Replacement. J Clin Med 2022; 11. [PMID: 35456234 DOI: 10.3390/jcm11082142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 02/24/2022] [Accepted: 03/09/2022] [Indexed: 02/04/2023] Open
Abstract
Background & Aims: Biliary atresia (BA) is the commonest single etiology indication for liver replacement in children. As timely access to liver transplantation (LT) remains challenging for small BA children (with prolonged waiting time being associated with clinical deterioration leading to both preventable pre- and post-transplant morbidity and mortality), the care pathway of BA children in need of LT was analyzed—from diagnosis to LT—with particular attention to referral patterns, timing of referral, waiting list dynamics and need for medical assistance before LT. Methods: International multicentric retrospective study. Intent-to-transplant study analyzing BA children who had indication for LT early in life (aged < 3 years at the time of assessment), over the last 5 years (2016−2020). Clinical and laboratory data of 219 BA children were collected from 8 transplant centers (6 in Europe and 2 in USA). Results: 39 patients underwent primary transplants. Children who underwent Kasai in a specialist -but not transplant- center were older at time of referral and at transplant. At assessment for LT, the vast majority of children already were experiencing complication of cirrhosis, and the majority of children needed medical assistance (nutritional support, hospitalization, transfusion of albumin or blood) while waiting for transplantation. Severe worsening of the clinical condition led to the need for requesting a priority status (i.e., Peld Score exception or similar) for timely graft allocation for 76 children, overall (35%). Conclusions: As LT currently results in BA patient survival exceeding 95% in many expert LT centers, the paradigm for BA management optimization and survival have currently shifted to the pre-LT management. The creation of networks dedicated to the timely referral to a pediatric transplant center and possibly centralization of care should be considered, in combination with implementing all different graft type surgeries in specialist centers (including split and living donor LTs) to achieve timely LT in this vulnerable population.
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18
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Steinberg Christofferson E, Ruzicka EB, Bolt M, Lyons E, Wachs M, Buchanan CL, Schmiege SJ, Monnin K. Understanding disparities and barriers associated with pediatric transplant evaluation and time to listing: Moving toward a more comprehensive picture. Pediatr Transplant 2022; 26:e14182. [PMID: 34738706 DOI: 10.1111/petr.14182] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 09/25/2021] [Accepted: 10/14/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND Delayed time to listing (TTL) for pediatric transplant patients is associated with increased risks of mortality and morbidity. The full range of health disparities, sociodemographic factors, and other barriers associated with delays in listing in the pediatric transplant candidate evaluation process has not been fully examined. METHODS Retrospective chart reviews were conducted for 183 kidney, liver, and heart transplant candidates ages 0-18 who were referred for evaluation during 2012-2015. Demographic information and potential barriers (e g., social/medical factors, financial concerns) were gathered from pre-transplant evaluations and included in a comprehensive model to evaluate mechanisms that explain differences in TTL. Descriptive statistics, logistic regression models, Cox proportional hazards models, and path analysis were used for analyses. RESULTS Candidates included 26.8% heart, 33.3% liver, and 39.9% kidney patients. The most common barrier to listing was financial (71.6%), followed by caregiver psychological or substance use (57.9%), and medical problems (49.7%). Higher age, kidney, and liver organ type (relative to the heart), and presence of social, medical, administrative/motivation, and financial barriers were all directly associated with longer TTL. Public insurance was indirectly associated with TTL through social, administrative/motivation, and financial barriers. Organ type was indirectly associated with TTL through financial barriers. CONCLUSIONS Results suggest social problems, administrative issues, and financial issues act as mechanisms through which insurance type and liver transplant candidates face increased risk of delays in transplant listing time. There are numerous clinical implications and interventions that are warranted to reduce TTL among pediatric transplant candidates with co-occurring barriers.
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Affiliation(s)
- Elizabeth Steinberg Christofferson
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Pediatric Mental Health Institute, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Elizabeth B Ruzicka
- Pediatric Mental Health Institute, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Matthew Bolt
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Emma Lyons
- Pediatric Mental Health Institute, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Michael Wachs
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Cindy L Buchanan
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Pediatric Mental Health Institute, Children's Hospital Colorado, Aurora, Colorado, USA
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Sarah J Schmiege
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Kara Monnin
- Department of Psychology, Nationwide Children's Hospital, Columbus, Ohio, USA
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19
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Kanneganti M, Xu Y, Huang YS, Kitt E, Fisher BT, Abt PL, Rand EB, Schaubel DE, Bittermann T. Center Variability in Acute Rejection and Biliary Complications After Pediatric Liver Transplantation. Liver Transpl 2022; 28:454-465. [PMID: 34365719 PMCID: PMC8821725 DOI: 10.1002/lt.26259] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 03/23/2021] [Revised: 07/09/2021] [Accepted: 07/28/2021] [Indexed: 01/13/2023]
Abstract
Transplant center performance and practice variation for pediatric post-liver transplantation (LT) outcomes other than survival are understudied. This was a retrospective cohort study of pediatric LT recipients who received transplants between January 1, 2006, and May 31, 2017, using United Network for Organ Sharing (UNOS) data that were merged with the Pediatric Health Information System database. Center effects for the acute rejection rate at 1 year after LT (AR1) using UNOS coding and the biliary complication rate at 1 year after LT (BC1) using inpatient billing claims data were estimated by center-specific rescaled odds ratios that accounted for potential differences in recipient and donor characteristics. There were 2216 pediatric LT recipients at 24 freestanding children's hospitals in the United States during the study period. The median unadjusted center rate of AR1 was 36.92% (interquartile range [IQR], 22.36%-44.52%), whereas that of BC1 was 32.29% (IQR, 26.14%-40.44%). Accounting for recipient case mix and donor factors, 5/24 centers performed better than expected with regard to AR1, whereas 3/24 centers performed worse than expected. There was less heterogeneity across the center effects for BC1 than for AR1. There was no relationship observed between the center effects for AR1 or BC1 and center volume. Beyond recipient and allograft factors, differences in transplant center management are an important driver of center AR1 performance, and less so of BC1 performance. Further research is needed to identify the sources of variability so as to implement the most effective solutions to broadly enhance outcomes for pediatric LT recipients.
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Affiliation(s)
- Mounika Kanneganti
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Yuwen Xu
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA
| | - Yuan-Shung Huang
- Center for Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Eimear Kitt
- Division of Infectious Diseases, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Brian T Fisher
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA,Division of Infectious Diseases, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Peter L Abt
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Elizabeth B Rand
- Division of Gastroenterology, Hepatology and Nutrition, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Douglas E Schaubel
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA
| | - Therese Bittermann
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA,Division of Gastroenterology, Hepatology and Nutrition, The Children’s Hospital of Philadelphia, Philadelphia, PA,Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, PA
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20
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Ewing CB, Soltys KA, Strauss KA, Sindhi R, Vockley J, McKiernan P, Squires RH, Bond G, Ganoza A, Khanna A, Mazariegos GV, Squires JE. Metabolic Control and "Ideal" Outcomes in Liver Transplantation for Maple Syrup Urine Disease. J Pediatr 2021; 237:59-64.e1. [PMID: 34153280 PMCID: PMC9795541 DOI: 10.1016/j.jpeds.2021.06.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/12/2021] [Accepted: 06/15/2021] [Indexed: 12/30/2022]
Abstract
OBJECTIVES To assess outcomes following liver transplantation for maple syrup urine disease by determining attainment and sustainability of metabolic control and apply an "ideal" outcome composite in long-term survivors. STUDY DESIGN A single center, retrospective review collected clinical data including branched-chain amino acid (leucine, isoleucine, and valine) levels following liver transplant and determined achievement of an ideal long-term outcome profile of a first allograft stable on immunosuppression monotherapy, normal growth, and absence of common transplant-related sequelae. RESULTS Of 77 patients meeting inclusion criteria identified, 23 were long-term (≥10-year) survivors and were additionally assessed for ideal outcome attainment. Patient and graft survival were 100% and 99%, respectively, and all patients were on an unrestricted protein intake diet. Although significant variation was noted in mean isoleucine (P < .01) and leucine (P < .05) levels postliver transplantation, no difference was seen in valine (P = .29) and overall clinical impact was likely negligible as metabolic stability was achieved and sustained beyond 3 years postliver transplantation and no metabolic crises were identified. Of 23 long-term survivors with available data, 9 (39%) achieved all composite metrics determined to define "ideal" outcomes in pediatric postliver transplantation populations. CONCLUSIONS Liver transplant enables long-term metabolic stability for patients with maple syrup urine disease. A combination of experience and improvement in both pre- and postliver transplantation care has enabled excellent survival and minimal comorbidities following transplant.
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Affiliation(s)
| | - Kyle A. Soltys
- Thomas E. Starzl Transplantation Institute, Hillman Center for Pediatric Transplantation, Department of Transplant Surgery, University of Pittsburgh Medical Center (UPMC) Children’s Hospital of Pittsburgh, Pittsburgh
| | | | - Rakesh Sindhi
- Thomas E. Starzl Transplantation Institute, Hillman Center for Pediatric Transplantation, Department of Transplant Surgery, University of Pittsburgh Medical Center (UPMC) Children’s Hospital of Pittsburgh, Pittsburgh
| | - Jerry Vockley
- Center for Rare Disease Therapy, University of Pittsburgh Medical Center (UPMC) Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Patrick McKiernan
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center (UPMC) Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Robert H. Squires
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center (UPMC) Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Geoffrey Bond
- Thomas E. Starzl Transplantation Institute, Hillman Center for Pediatric Transplantation, Department of Transplant Surgery, University of Pittsburgh Medical Center (UPMC) Children’s Hospital of Pittsburgh, Pittsburgh
| | - Armando Ganoza
- Thomas E. Starzl Transplantation Institute, Hillman Center for Pediatric Transplantation, Department of Transplant Surgery, University of Pittsburgh Medical Center (UPMC) Children’s Hospital of Pittsburgh, Pittsburgh
| | - Ajai Khanna
- Thomas E. Starzl Transplantation Institute, Hillman Center for Pediatric Transplantation, Department of Transplant Surgery, University of Pittsburgh Medical Center (UPMC) Children’s Hospital of Pittsburgh, Pittsburgh
| | - George V. Mazariegos
- Thomas E. Starzl Transplantation Institute, Hillman Center for Pediatric Transplantation, Department of Transplant Surgery, University of Pittsburgh Medical Center (UPMC) Children’s Hospital of Pittsburgh, Pittsburgh
| | - James E. Squires
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center (UPMC) Children’s Hospital of Pittsburgh, Pittsburgh, PA
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21
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Ohlendorf J, Stasch L, Baumann U, Konietzny C, Pfister E, Ernst G, Lange K, Sautmann K, Goldschmidt I. Two Sides of a Coin: Parental Disease-Specific Training as Seen by Health Care Practitioners and Parents in Pediatric Liver Transplantation. Children 2021; 8:827. [PMID: 34572259 PMCID: PMC8469562 DOI: 10.3390/children8090827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 09/03/2021] [Accepted: 09/15/2021] [Indexed: 12/04/2022]
Abstract
In the absence of widely accepted education standards for parents of children after liver transplantation (LTx), the content and structure of parental training are influenced by health care practitioners’ (HCP) individual knowledge and assessment of the relevance of its contents. This study examines the hypothesis that expectations towards training differ between HCPs and parents, and that the quality of parental training affects the job-satisfaction of HCPs. Attitudes towards disease-specific education were assessed by tailor-made questionnaires in HCPs (n = 20) and parents of children with chronic liver disease or after LTx (n = 113). These were supplemented by focused interviews in n = 7 HCPs and n = 16 parents. Parents were more satisfied with current counseling than HCP. Language barriers and low parental educational background were perceived as obstacles by 43% of HCPs. The quality of parental knowledge was felt to have a strong influence on HCPs job satisfaction. The expectations towards the content of disease-specific education largely overlap but are not synonymous. HCP and parents agreed with regards to the importance of medication knowledge. Parents rated the importance about the meaning of laboratory values and diagnostic procedures significantly higher (3.50 vs. 2.85, p < 0.001 and 3.42 vs. 2.80, p < 0.001) than HCPs. Parents and HCPs would prefer a structured framework with sufficient staff resources for disease-specific counseling.
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22
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Leiskau C, Samuel S, Pfister ED, Junge N, Beneke J, Stupak J, Richter N, Vondran F, Schrem H, Baumann U. Low-dose steroids do make a difference: Independent risk factors for impaired linear growth after pediatric liver transplantation. Pediatr Transplant 2021; 25:e13989. [PMID: 33689189 DOI: 10.1111/petr.13989] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 08/28/2020] [Revised: 01/14/2021] [Accepted: 01/31/2021] [Indexed: 01/31/2023]
Abstract
Growth failure persists after pediatric liver transplantation and impairs pediatric development and quality of life. Steroid dose minimization attempts to prevent growth impairment, yet long-term assessment in pediatric liver recipients is lacking. We identified risk factors for impaired linear growth after pediatric liver transplantation, with a special focus on low-dose steroid therapy. This is a single-center retrospective analysis of height development in pediatric liver recipients up to 5 years after transplantation. Risk factors for impaired linear growth (height Z-scores≤-2) at transplantation, after two (n = 347) and five years (n = 210) were identified by univariate and multivariate logistic regression. At transplantation, growth retardation was found in 52.2%, predominantly younger children. Height Z-scores improved from -2.23 to -1.40 (SE 0.11; 95%CI 0.74-1.16; p < .001) two years and -1.19 (SE 0.07;0.08-0.34; p = .017) five years post-transplant. Multivariate analysis showed previous growth impairment (OR=1.484; 95%-CI=1.107-1.988; p = .004), graft loss (49.006;2.232-1076; p = .006), and prolonged cold ischemic time (1.034;1.007-1.061; p = .011) as main long-term risk factors; steroid use was a significant predictor of 2-year but not 5-year growth impairment. In univariate analysis, impaired growth after 2 and 5 years was associated with continuous low-dose (2.5 mg/m2 BSA) steroid therapy (OR=3.323;1.578-6.996; p < .001/OR=8.352;1.089-64.07; p = .006)and graft loss (OR=2.513;1.395-4.525; p = .003/OR=3.378;1.815-7.576; p < .001). Furthermore, indication and era of transplantation affected growth. Our results show significant catch-up growth after pediatric liver transplantation, yet growth failure strongly affects particularly young liver recipients. The main influenceable long-term risk factor is pre-existing growth failure, emphasizing the importance of early aggressive nutritional therapy. Moreover, low-dose steroid therapy might impair growth and should therefore be critically questioned in long-term immunosuppression.
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Affiliation(s)
- Christoph Leiskau
- Division of Pediatric Gastroenterology, Hepatology and Liver Transplantation, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany.,Core Facility Quality Management & Health Technology Assessment in Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Saskia Samuel
- Division of Pediatric Gastroenterology, Hepatology and Liver Transplantation, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany.,Core Facility Quality Management & Health Technology Assessment in Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany.,Department of Internal Medicine, Military Hospital Hamburg, Germany
| | - Eva-Doreen Pfister
- Division of Pediatric Gastroenterology, Hepatology and Liver Transplantation, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Norman Junge
- Division of Pediatric Gastroenterology, Hepatology and Liver Transplantation, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Jan Beneke
- Core Facility Quality Management & Health Technology Assessment in Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Julia Stupak
- Core Facility Quality Management & Health Technology Assessment in Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Nicolas Richter
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Germany
| | - Florian Vondran
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Germany
| | - Harald Schrem
- Core Facility Quality Management & Health Technology Assessment in Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany.,Department of General, Visceral and Transplant Surgery, Hannover Medical School, Germany.,Division of Transplant Surgery, Department of Surgery, Medical University Graz, Austria
| | - Ulrich Baumann
- Division of Pediatric Gastroenterology, Hepatology and Liver Transplantation, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
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23
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Woolfson JP, Perez M, Chavhan GB, Johara FT, Lurz E, Kamath BM, Ng VL. Sarcopenia in Children With End-Stage Liver Disease on the Transplant Waiting List. Liver Transpl 2021; 27:641-651. [PMID: 33460522 PMCID: PMC8248423 DOI: 10.1002/lt.25985] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 12/08/2020] [Accepted: 12/28/2020] [Indexed: 12/15/2022]
Abstract
Sarcopenia predicts morbidity and mortality in adults with end-stage liver disease (ESLD) and is determined by total psoas muscle area (tPMA) measurement from computed tomography (CT) imaging. Recently developed pediatric age- and sex-specific tPMA growth curves provide the opportunity to ascertain prevalence and impact of sarcopenia in children awaiting liver transplantation (LT). This retrospective single-center study evaluated sarcopenia in children between 1 and 16 years with ESLD and a clinically indicated abdominal CT less than 3 months before first isolated LT. Sarcopenia was defined as tPMA z score less than -2 measured at the intervertebral L4-5 level. Patient demographic, biochemical, and outcome data were recorded. tPMA was compared with other measures of nutritional status using univariate and multivariate logistic analyses. Outcome measures included 1-year morbidity events and mortality after LT. CT images from 25 (64% female) children with median age of 5.50 (interquartile range [IQR], 3.75-11.33) years were reviewed. Ten children (40%) had a tPMA z score less than -2. Sarcopenia was associated with lower z scores for weight (odds ratio [OR], 0.38; P = 0.02), height (OR, 0.32; P = 0.03), and nutritional support before LT (OR, 12.93; P = 0.01). Sarcopenic children had a longer duration of pediatric intensive care unit (PICU) stay (3.50 [IQR, 3.00-6.00] versus 2.00 [IQR, 2.00-3.50] days; P = 0.03). Sarcopenia was prevalent in 40% of children with ESLD awaiting LT, and lower tPMA z score was associated with deficient anthropometrics and need for nutritional support before LT. Post-LT PICU duration was increased in children with sarcopenia, reflecting adverse outcomes associated with muscle loss. Further studies are needed to elucidate the underlying mechanisms of sarcopenia in children with ESLD.
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Affiliation(s)
- Jessica P. Woolfson
- Division of Gastroenterology, Hepatology, and Nutritionthe Hospital for Sick ChildrenTorontoOntarioCanada
- University of TorontoTorontoOntarioCanada
| | - Manuela Perez
- University of TorontoTorontoOntarioCanada
- Department of Diagnostic Imaging and Department of Medical Imagingthe Hospital for Sick ChildrenTorontoOntarioCanada
| | - Govind B. Chavhan
- University of TorontoTorontoOntarioCanada
- Department of Diagnostic Imaging and Department of Medical Imagingthe Hospital for Sick ChildrenTorontoOntarioCanada
| | - Fatema T. Johara
- Division of Gastroenterology, Hepatology, and Nutritionthe Hospital for Sick ChildrenTorontoOntarioCanada
- University of TorontoTorontoOntarioCanada
| | - Eberhard Lurz
- Division of Gastroenterology, Hepatology, and Nutritionthe Hospital for Sick ChildrenTorontoOntarioCanada
- University of TorontoTorontoOntarioCanada
| | - Binita M. Kamath
- Division of Gastroenterology, Hepatology, and Nutritionthe Hospital for Sick ChildrenTorontoOntarioCanada
- University of TorontoTorontoOntarioCanada
- Transplant and Regenerative Medicine Centrethe Hospital for Sick ChildrenTorontoOntarioCanada
| | - Vicky L. Ng
- Division of Gastroenterology, Hepatology, and Nutritionthe Hospital for Sick ChildrenTorontoOntarioCanada
- University of TorontoTorontoOntarioCanada
- Transplant and Regenerative Medicine Centrethe Hospital for Sick ChildrenTorontoOntarioCanada
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24
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Perito ER, Squires JE, Bray D, Bucuvalas J, Krise-Confair C, Eisenberg E, Gonzalez-Peralta RP, Gupta N, Hsu EK, Kosmach-Park B, Lobritto S, Logan B, Mohammad S, Ng VL, Pillari T, Rasmussen S, Shemesh E, Soltys K, Szolna J, Superina R, Tunno J, Mazariegos GV. A Learning Health System for Pediatric Liver Transplant: The Starzl Network for Excellence in Pediatric Transplantation. J Pediatr Gastroenterol Nutr 2021; 72:417-424. [PMID: 33560758 DOI: 10.1097/mpg.0000000000002974] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE Learning health systems (LHS) integrate research, improvement, management, and patient care, such that every child receives "the right care at the right time...every time," that is, evidence-based, personalized medicine. Here, we report our efforts to establish a sustainable, productive, multicenter LHS focused on pediatric liver transplantation. METHODS The Starzl Network for Excellence in Pediatric Transplantation (SNEPT) is the first multicenter effort by pediatric liver transplant families and providers to develop shared priorities and a shared agenda for innovation in clinical care. This report outlines SNEPT's structure, accomplishments, and challenges as an LHS. RESULTS We prioritized 4 initial projects: immunosuppression, perioperative anticoagulation, quality of life, and transition of care. We shared center protocols/management to identify areas of practice variability between centers. We prioritized actionable items that address barriers to providing "the right care at the right time" to every pediatric liver transplant recipient: facilitating transparency of practice variation and the connection of practices to patient outcomes, harnessing existing datasets to reduce the burden of tracking outcomes, incorporating patient-reported outcomes into outcome metrics, and accelerating the implementation of knowledge into clinical practice. This has allowed us to strengthen collaborative relationships, design quality improvement projects, and collect pilot data for each of our priority projects. CONCLUSIONS The field of pediatric liver transplantation can be advanced through application of LHS principles. Going forward, SNEPT will continue to unite patient advocacy, big data, technology, and transplant thought leaders to deliver the best care, while developing new, scalable solutions to pediatric transplantation's most challenging problems.
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Affiliation(s)
- Emily R Perito
- University of California San Francisco, Benioff Children's Hospital, San Francisco, CA
| | - James E Squires
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - David Bray
- Patient and Family Voice. Starzl Network for Excellence in Pediatric Transplantation
| | - John Bucuvalas
- Recanati Miller Transplant Institute, Icahn School of Medicine at Mount Sinai, Mount Sinai Kravis Children's Hospital, New York, NY
| | - Cassandra Krise-Confair
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Elizabeth Eisenberg
- Patient and Family Voice. Starzl Network for Excellence in Pediatric Transplantation
| | | | - Nitika Gupta
- Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA
| | - Evelyn K Hsu
- University of Washington School of Medicine, Department of Pediatrics, Division of Gastroenterology and Hepatology, Seattle Children's Hospital, Seattle, WA
| | - Beverly Kosmach-Park
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Steven Lobritto
- Columbia University Medical Center, Children's Hospital of New York, New York, NY
| | - Beth Logan
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Saeed Mohammad
- Northwestern University Feinberg School of Medicine, Lurie Children's Hospital, Chicago, IL
| | - Vicky L Ng
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Eyal Shemesh
- Recanati Miller Transplant Institute, Icahn School of Medicine at Mount Sinai, Mount Sinai Kravis Children's Hospital, New York, NY
| | - Kyle Soltys
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Jonathan Szolna
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Riccardo Superina
- Northwestern University Feinberg School of Medicine, Lurie Children's Hospital, Chicago, IL
| | - John Tunno
- Patient and Family Voice. Starzl Network for Excellence in Pediatric Transplantation
| | - George V Mazariegos
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
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25
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Wadhwani SI, Beck AF, Bucuvalas J, Gottlieb L, Kotagal U, Lai JC. Neighborhood socioeconomic deprivation is associated with worse patient and graft survival following pediatric liver transplantation. Am J Transplant 2020; 20:1597-1605. [PMID: 31958208 PMCID: PMC7261648 DOI: 10.1111/ajt.15786] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [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: 10/29/2019] [Revised: 12/10/2019] [Accepted: 01/08/2020] [Indexed: 01/25/2023]
Abstract
Long-term outcomes remain suboptimal following pediatric liver transplantation; only one third of children have normal biochemical liver function without immunosuppressant comorbidities 10 years posttransplant. We examined the association between an index of neighborhood socioeconomic deprivation with graft and patient survival using the Scientific Registry of Transplant Recipients. We included children <19 years who underwent liver transplantation between January 1, 2008 to December 31, 2013 (n = 2868). Primary exposure was a neighborhood socioeconomic deprivation index-linked via patient home ZIP code-with a range of 0-1 (values nearing 1 indicate neighborhoods with greater socioeconomic deprivation). Primary outcome measures were graft failure and death, censored at 10 years posttransplant. We modeled survival using Cox proportional hazards. In univariable analysis, each 0.1 increase in the deprivation index was associated with a 14.3% (95% confidence interval [CI]): 3.8%-25.8%) increased hazard of graft failure and a 12.5% (95% CI: 2.5%-23.6%) increased hazard of death. In multivariable analysis adjusted for race, each 0.1 increase in the deprivation index was associated with a 11.5% (95% CI: 1.6%-23.9%) increased hazard of graft failure and a 9.6% (95% CI: -0.04% to 20.7%) increased hazard of death. Children from high deprivation neighborhoods have diminished graft and patient survival following liver transplantation. Greater attention to neighborhood context may result in improved outcomes for children following liver transplantation.
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Affiliation(s)
| | - Andrew F. Beck
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH,University of Cincinnati College of Medicine, Cincinnati, OH
| | - John Bucuvalas
- Icahn School of Medicine at Mount Sinai, New York, NY,Mount Sinai Kravis Children’s Hospital, New York, NY
| | - Laura Gottlieb
- University of California San Francisco, San Francisco, CA
| | - Uma Kotagal
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH,University of Cincinnati College of Medicine, Cincinnati, OH
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26
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Covarrubias K, Luo X, Massie A, Schwarz KB, Garonzik-Wang J, Segev DL, Mogul DB. Determinants of length of stay after pediatric liver transplantation. Pediatr Transplant 2020; 24:e13702. [PMID: 32212292 PMCID: PMC7260078 DOI: 10.1111/petr.13702] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 01/07/2020] [Accepted: 03/04/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND We sought to identify factors that are associated with LOS following pediatric (<18 years) liver transplantation in order to provide personalized counseling and discharge planning for recipients and their families. METHODS We identified 2726 infants (≤24 months) and 3210 children (>24 months) who underwent pediatric liver-only transplantation from 2002-2017 using the Scientific Registry of Transplant Recipients. We used multilevel multivariable negative binomial regression to analyze associations between LOS and recipient and donor characteristics and calculated the MLOSR to quantify heterogeneity in LOS across centers. RESULTS In infants, the median LOS (IQR) was 19 (13-32) days. Hospitalization prior to transplant (ICU ratio:1.46 1.591.70 ; non-ICU ratio:1.08 1.161.23 ), public insurance (ratio:1.03 1.091.15 ), and a segmental graft (ratio:1.08 1.151.22 ) were associated with a longer LOS; thus, we would expect a 1.59-fold longer LOS in an infant admitted to the ICU compared to a non-hospitalized infant with similar characteristics. In children, the median LOS (IQR) was 13 (9-21) days. Hospitalization prior to transplant (ICU ratio:1.49 1.621.77 ; non-ICU ratio:1.34 1.441.56 ), public insurance (ratio:1.02 1.071.13 ), a segmental graft (ratio:1.20 1.271.35 ), a living donor graft (ratio:1.27 1.381.51 ), and obesity (ratio:1.03 1.101.17 ) were associated with a longer LOS. The MLOSR was 1.25 in infants and 1.26 in children, meaning if an infant received a transplant at another center with a longer LOS, we would expect a 1.25-fold difference in LOS driven by center practices alone. CONCLUSIONS While center-level practices account for substantial variation in LOS, consideration of donor and recipient factors can help clinicians provide more personalized counseling for families of pediatric liver transplant candidates.
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Affiliation(s)
- Karina Covarrubias
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Xun Luo
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Allan Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins University School of Public Health, Baltimore, MD
| | - Kathleen B. Schwarz
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins University School of Public Health, Baltimore, MD
| | - Douglas B. Mogul
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
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