Time is of the essence: A single-center experience of hepatic arterial supply impairment management in pediatric liver transplant recipients

BACKGROUND

Impairment of hepatic arterial flow including hepatic arterial thrombosis (HAT), hepatic arterial stenosis (HAS), and splenic artery steal syndrome (SASS) is potentially life-threatening complications. The proposed early diagnosis and urgent treatment strategy of graft arterial flow reduction aim to decrease morbidity and mortality.

METHODS

Pediatric patients with known hepatic arterial flow impairment were retrospectively reviewed. Patients were grouped by occlusive (HAT) and non-occlusive (HAS/SASS) arterial flow reduction. Patients with HAT were further divided in two groups based on the estimated maximal hepatic artery occlusion time ≤8 and >8 hours.

RESULTS

Impairment of hepatic arterial flow developed in 32 of 416 pediatric liver transplant recipients. HAT, HAS, and SASS incidences were 4.1% (n = 17), 2.2% (n = 9), and 1.4% (n = 6), respectively. Neither graft loss nor death occurred in the non-occlusive group. The probabilities of sepsis (OR, 1.7; 95% CI, 1.14-2.53; P=.008) and graft loss or death (OR, 1.42; 95% CI, 1.04-1.92; P=.046) were higher in the occlusive group. Patients with estimated maximal duration of hepatic artery occlusion ≤ 8 hours (n = 7; 41.2%) did not have ischemic-type biliary lesions and sepsis (P=.044 and 0.010, respectively) but had excellent 3-year graft survival compared with > 8 hours group (100% vs 40%; P=.037). Multivariate analysis revealed HAT manifestation by fever was associated with increased chances of graft loss or death.

CONCLUSION

Occlusive arterial complications impose higher risks of graft loss and death. Thorough arterial supply monitoring by Doppler ultrasonography and urgent endovascular arterial flow restoration may salvage both graft and the recipient.

Transforming growth factor beta 1 levels in the blood of pediatric liver recipients: Clinical and biochemical correlations

TGF-β1 is a cytokine with profibrogenic and immunosuppressive activities, which suggest the clinical significance of TGF-β1 for the assessment of graft function after LT. We analyzed the dynamics of TGF-β1 levels in the blood after LDLT in 135 pediatric liver recipients and examined the relationship between the cytokine levels and the laboratory and clinical variables. We found that TGF-β1 levels in the blood of patients with ESLD were lower than that in healthy children of the same age, P = .001. Moreover, blood levels of TGF-β1 were associated with liver disease etiology (r = .23) and hepatic fibrosis severity (r = .33). Before LDLT, TGF-β1 levels were significantly higher in children with good outcomes than in recipients who developed graft dysfunction early in the post-transplant period, P = .047. One month after LDLT, TGF-β1 levels in blood plasma increased in pediatric recipients, P = .002. Cytokine levels were significantly correlated with gender (r = .21) and HLA (r = -.24) mismatches, as well as with TAC dosage (r = -.32) later in the post-transplant period. One year after LDLT, TGF-β1 plasma levels were higher (P = .01) than those before LDLT and did not correlate with most of the investigated biochemical and clinical variables. Conclusion: Blood levels of TGF-β1 are associated with hepatic fibrosis severity, graft dysfunction development, and TAC dosage and can be regarded as a potential prognostic biomarker for the assessment of graft function and the optimization of immunosuppressant dosage in pediatric recipients after LDLT.

Deceased vs living donor grafts for pediatric simultaneous liver-kidney transplantation: A single-center experience

Introduction

In conditions of limited experience of pediatric simultaneous liver‐kidney transplantation (SLKT) using grafts from living and deceased donors, there is a certain need to validate the approach.

Patients

The retrospective study of 18 pediatric patients who received SLKT between 2008 and 2019.

Results

Grafts were obtained from both living and deceased donors. The patients’ age ranged from 2 to 16 years (9 years ±4). The body weight of the children varied from 9.5 to 39 kg (22 kg ±9). The follow‐up period lasted from 1 to 109 months (median 38 months ±35). The various graft combinations were used in both groups. There was no mortality during the follow‐up. There was no significant difference in baseline parameters in recipients who received grafts from living and deceased donors except age (7.5 years ±2.2 vs 11.8 years ±4.1; P = .038). Rate of complications > grade II was higher among recipients of deceased donor SLKT (7.7% vs 60%; OR, 7.8; 95% CI, 1.04‐58.48; P = .044). All the patients are alive with both grafts functioning. All the living donors returned to the normal life.

Conclusion

SLKT is a safe and effective procedure for children with both simultaneous end‐stage liver disease and end‐stage renal disease. Both living donor partial liver and kidney transplantation and deceased donor liver‐kidney transplantation can be considered as safe and feasible options.

P6318Survival rate in patients with the identification of predictors for antibody mediated rejection

Introduction

Antibody mediated rejection (AMR) is still an important issue in heart transplantation (HT). The standard methods of diagnosis and treatment remain controversial, whereas immunosuppressive therapy is mainly used to prevent cellular rejection.

Purpose

To determine predictors of AMR using the routine investigations in clinical practice.

Methods

During 7 years we conducted a single center study of 181 HT recipients. Patients were divided into 5 groups based on AMR and detected anti-HLA, such as DSA and non-DSA antibodies. Recipients underwent immunology screening and HLA antibodies tests, DSA; 2D-speckle-tracking echocardiography using the Kruskal-Wallis and Wilcoxon signed-rank tests; Spearman correlation, the table of critical values for the Pearson correlation. Kaplan-Meier curves were used to estimate the survival rate. Roc-analysis was used to measure the diagnostic accuracy. Statistical analysis was performed with the STATISTICA 10 (Tibco, USA).

Results

The study demonstrated the lowest survival in patients with anti-HLA antibodies, such as anti-HLA and non-DSA antibodies versus recipients without anti-HLA de novo. Survival in patients with DSA is 40%, and in patients without DSA is 68%. It should be noted that comparing of survival in patients with HLA identified in different post-transplant period showed that patients with HLA-antibodies identified in late post-transplant period had worse survival (50%) than recipients who developed antibodies in the early post-transplant period (75%). On the second stage of the study we conducted 2D-speckle-tracking echocardiography. At first we estimated 2D-STE parameters for the selected groups of patients in the first period of our study, and then during AMR and the late period of the study. AMR effectively reduces the parameters of deformation and mechanics, GLPS LV,%i = −9,94±1,37, RadS LV,% 19,36±3,66, Cir SLV,% −17,83±4,89, ROT APEX°,4,51±1,46, ROT BASE°, −4,75±2,12, ROT MID° 1,94±1,41, TWIST,% 8,90±1,85, RV-FWS,% −15,89±0,89. The possible criteria for diagnosis of AMR include global peak systolic strain, sensitivity (S) 86,2%, specificity (Sp) 90,4%, radial systolic strain, S 75,8%, Sp 84,5% circular systolic strain, S 78,6%, Sp 84,4%; left ventricular twist S 66,7%, Sp 94,2% (p<0,001).

Conclusions

There is a correlation between changes and parameters of 2D-speckle-tracking echocardiography. DSA limits the survival and increases the risk for AMR.