A262 NEONATAL ACUTE LIVER FAILURE DUE TO PRESUMED GESTATIONAL ALLOIMMUNE LIVER DISEASE - A CASE REPORT

Background

Neonatal acute liver failure (NALF) is a rare disease that is distinct from acute liver failure seen in older children and adults. Gestational alloimmune liver disease (GALD) is the most frequent cause, is initiated in utero by sensitization of the maternal immune system to a fetal hepatocyte antigen and subsequent production of maternal immunoglobulin G antibodies that cross the placenta. Maternal IgG binds to a fetal hepatocyte antigen and initiates an innate immune response involving the terminal complement cascade and membrane attach complex. The understanding of the alloimmune origin has led to the use of intravenous immunoglobulin (IVIG) treatment and exchange transfusion, significantly increasing survival. However, approximately 25% of patients may not respond and require salvage liver transplantation. In spite of an increased rate of comorbidities, concern for technical difficulties and limited graft availability, young infants eligible for transplant have been shown to have similar overall patient and graft survival rates compared to older children with other indications for liver transplant.

Purpose

The primary aim of our study is to report a case of NALF with successful liver transplant.

Method

We present the case of a preterm girl with NALF due to GALD refractory to medical management, requiring liver transplantation.

Result(s)

This is a 35-week preterm girl, with scant pre-natal care, birth weight of 1.825 kg and Apgar 9/9. She is the seventh child of non-consanguineous parents, with healthy siblings. On day-of-life (DOL) 1 she presented with acute kidney injury, progressive worsening metabolic acidosis and hyperammonemia and was found to be profoundly coagulopathic (INR 6), with normal liver enzymes and liver failure was diagnosed. Initial investigation ruled out congenital infections, sepsis, neonatal hemophagocytic lymphohistiocytosis and metabolic diseases. Magnetic resonance imaging of the body demonstrated findings in keeping with iron deposition in the thyroid, liver and pancreas, suggestive of GALD. Completed double volume exchange transfusion and IVIG on DOL 9 and repeat IVIG on DOL 13 and 15, with partial improvement in INR. Due to persistent ascites, conjugated hyperbilirubinemia and hyperammonemia she was transferred for urgent liver transplant assessment. Persistent liver dysfunction in the form of hyperammonemia, hypoglycemia and progressive coagulopathy led to transplant listing on DOL 30. ABO incompatible deceased donor liver transplant was completed on DOL 62 (4.075 kg, estimated dry weight 3.5 kg). The procedure was uncomplicated, liver enzymes normalized, coagulopathy and hypoglycemia resolved. She was transferred to the ward on post-operative day (POD) 6. and weaned off sedatives and transitioned to oral feeds within 2 weeks of transplant, with complex abdominal wound closure on POD 29.

Conclusion(s)

Successful liver transplantation is possible in neonates with acute liver failure due to GALD refractory to medical management and weighing 4kg or less.

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Disclosure of Interest

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MICROBIOME & MICROBIAL THERAPY

A258 SEVERE ACUTE HEPATITIS OF UNKNOWN ORIGIN WITH RAPID PROGRESSION TO PAEDIATRIC ACUTE LIVER FAILURE IN A CHILD

Background

Severe acute hepatitis (SAH) of unknown origin among children has been a major public health concern globally in recent times, with >1010 cases reported to WHO, including 28 in Canada as of July2022. The clinical syndrome in all identified cases (median age 3, IQR 2-5 yrs) was acute hepatitis with progression to paediatric acute liver failure (PALF) and need for liver transplantation (LT) in 5.4-13%. Human adenovirus (HAdV), particularly serotypes 40 and 41, remains the most common pathogen detected around the time of presentation in upto 70%. HAdV hepatitis is a rarity in the immunocompetent. The role of adenovirus in SAH remains unclear and investigations continue

Purpose

To report the case of a child meeting the WHO case definition of SAH of unknown origin in whom adenovirus was detected with rapid progression to PALF requiring LT

Method

Case report and literature review

Result(s)

A previously healthy 4year-old girl presented to us with a 1week history of abdominal pain and vomiting followed by onset of jaundice. 1month prior to presentation, she had an episode of conjunctivitis. Examination revealed a well-appearing girl with icterus, hepatosplenomegaly with no stigmata of chronic liver disease and no features of hepatic encephalopathy. Laboratory results on day of presentation revealed transaminases >10 times upper limit of normal (ALT 4686U/L, AST 5986U/L), total bilirubin-233μmol/L (conjugated bilirubin-153μmol/L) and INR-1.6. Work up for viral hepatitis(A-E), metabolic, autoimmune, genetic or mechanical causes of hepatitis was negative (Table 1). HAdV was detected by PCR in blood (9700 copies/mL), stool and nasopharyngeal swab. Treatment with cidofovir (1mg/kg/dose) was started on day8 after presentation.By day11, laboratory parameters had worsened with ALT 1293U/L, AST 2326U/L, total bilirubin 331μmol/L, INR-9.1 and LT was considered. With failure to improve over the next 48hrs, she received a living donor LT on day13 after presentation and had an uneventful post-transplant course. At the time of writing this report, she was 41 days post-transplant, doing well on immunosuppression with tacrolimus and tapering dose of steroids. Histopathological examination of liver showed extensive hepatocyte loss of upto 80%, replaced by ductules, in a background of mild hepatitis (patchy pan-lobular inflammation with minimal portal inflammation) and no significant fibrosis. Electron microscopy (EM) showed patchy hemophagocytosis. No evidence of HAdV on immunohistochemical stains or EM was identified. These findings are directly in line with what others have reported, namely a lack of direct toxic effect of virus on liver tissue

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Conclusion(s)

This case highlights the potential for rapid progression to PALF and need for LT in a child SAH of unknown origin. Early identification and diagnosis of PALF is important and should be followed by transfer to a LT center. As previously described by others, HAdV was detected, but its role in pathogenesis of this clinical syndrome remains elusive

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[Dietary interview: a useful tool for data collection]

Dietary interview is a very useful tool in the process of evaluating the nutritional state of a person and, of course, in the process of dietary counseling, particularly in the case of patients suffering from chronic conditions. The complexity of gathering information at individual or population level requires different models of questionnaires and tools to enhance the identification of the data collected. The current paper is based on the consensus document about dietary interview, made by a working group created during the 1st Meeting of the Spanish Dietitians' and Nutritionists' Association held in Barcelona 2002.