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Kehar M, Ibrahim SH, Ramirez CM, Amin SA, Diamond T, Mohammad S. Utilization and perspectives of weight loss medications in pediatric metabolic dysfunction-associated steatotic liver disease. J Pediatr Gastroenterol Nutr 2024. [PMID: 38698664 DOI: 10.1002/jpn3.12236] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 04/06/2024] [Accepted: 04/21/2024] [Indexed: 05/05/2024]
Abstract
Metabolic dysfunction-associated steatotic liver disease (MASLD) is increasing globally in pediatric populations. Currently, MASLD management primarily relies on lifestyle interventions, which pose challenges in sustaining long-term weight loss. This study investigated the use of weight loss medications in MASLD care through an international survey of 166 pediatric gastroenterologists and hepatologists. The results indicated a notable interest in weight loss medications, with 38% of practitioners considering or using them, particularly glucagon-like peptide-1 receptor agonists. However, the survey also revealed a tendency among clinicians to refer patients to specialists, emphasizing the potential gap between acknowledgment and prescription practices. Challenges include the lack of guidelines and uncertainty regarding side effects. The study highlights a pressing need for education, with over 90% of the respondents expressing an interest. Our study highlights the current management of MASLD, the potential role of pharmacotherapy, and highlights avenues for improved care and education in this dynamic field.
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Affiliation(s)
- Mohit Kehar
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Samar H Ibrahim
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Mayo Clinic, Rochester, Minnesota, USA
| | - Charina M Ramirez
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | | | - Tamir Diamond
- Division of Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, Perelman School of Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Saeed Mohammad
- Division of Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Zhang L, El-Shabrawi M, Baur LA, Byrne CD, Targher G, Kehar M, Porta G, Lee WS, Lefere S, Turan S, Alisi A, Weiss R, Faienza MF, Ashraf A, Sundaram SS, Srivastava A, De Bruyne R, Kang Y, Bacopoulou F, Zhou YH, Darma A, Lupsor-Platon M, Hamaguchi M, Misra A, Méndez-Sánchez N, Ng NBH, Marcus C, Staiano AE, Waheed N, Alqahtani SA, Giannini C, Ocama P, Nguyen MH, Arias-Loste MT, Ahmed MR, Sebastiani G, Poovorawan Y, Al Mahtab M, Pericàs JM, Reverbel da Silveira T, Hegyi P, Azaz A, Isa HM, Lertudomphonwanit C, Farrag MI, Nugud AAA, Du HW, Qi KM, Mouane N, Cheng XR, Al Lawati T, Fagundes EDT, Ghazinyan H, Hadjipanayis A, Fan JG, Gimiga N, Kamal NM, Ștefănescu G, Hong L, Diaconescu S, Li M, George J, Zheng MH. An international multidisciplinary consensus on pediatric metabolic dysfunction-associated fatty liver disease. Med 2024:S2666-6340(24)00129-6. [PMID: 38677287 DOI: 10.1016/j.medj.2024.03.017] [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] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 02/20/2024] [Accepted: 03/26/2024] [Indexed: 04/29/2024]
Abstract
BACKGROUND Non-alcoholic fatty liver disease (NAFLD) is highly prevalent in children and adolescents, particularly those with obesity. NAFLD is considered a hepatic manifestation of the metabolic syndrome due to its close associations with abdominal obesity, insulin resistance, and atherogenic dyslipidemia. Experts have proposed an alternative terminology, metabolic dysfunction-associated fatty liver disease (MAFLD), to better reflect its pathophysiology. This study aimed to develop consensus statements and recommendations for pediatric MAFLD through collaboration among international experts. METHODS A group of 65 experts from 35 countries and six continents, including pediatricians, hepatologists, and endocrinologists, participated in a consensus development process. The process encompassed various aspects of pediatric MAFLD, including epidemiology, mechanisms, screening, and management. FINDINGS In round 1, we received 65 surveys from 35 countries and analyzed these results, which informed us that 73.3% of respondents agreed with 20 draft statements while 23.8% agreed somewhat. The mean percentage of agreement or somewhat agreement increased to 80.85% and 15.75%, respectively, in round 2. The final statements covered a wide range of topics related to epidemiology, pathophysiology, and strategies for screening and managing pediatric MAFLD. CONCLUSIONS The consensus statements and recommendations developed by an international expert panel serve to optimize clinical outcomes and improve the quality of life for children and adolescents with MAFLD. These findings emphasize the need for standardized approaches in diagnosing and treating pediatric MAFLD. FUNDING This work was funded by the National Natural Science Foundation of China (82070588, 82370577), the National Key R&D Program of China (2023YFA1800801), National High Level Hospital Clinical Research Funding (2022-PUMCH-C-014), the Wuxi Taihu Talent Plan (DJTD202106), and the Medical Key Discipline Program of Wuxi Health Commission (ZDXK2021007).
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Affiliation(s)
- Le Zhang
- Department of Paediatrics, Affiliated Children's Hospital of Jiangnan University (Wuxi Children's Hospital), Wuxi, China
| | - Mortada El-Shabrawi
- Department of Pediatrics and Pediatric Hepatology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Louise A Baur
- Children's Hospital Westmead Clinical School, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia; Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - Christopher D Byrne
- Nutrition and Metabolism, Faculty of Medicine, University of Southampton, Southampton, UK; National Institute for Health and Care Research Southampton Biomedical Research Centre, University Hospital Southampton, Southampton, UK
| | - Giovanni Targher
- Department of Medicine, University of Verona, Verona, Italy; Metabolic Diseases Research Unit, IRCCS Sacro Cuore - Don Calabria Hospital, Negrar di Valpolicella, Italy
| | - Mohit Kehar
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Eastern Ontario, Department of Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Gilda Porta
- Pediatric Hepatology, Transplant Unit, Hospital Sírio-Libanês, Hospital Municipal Infantil Menino Jesus, Sau Paulo, Brazil
| | - Way Seah Lee
- Department of Paediatrics, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Sander Lefere
- Hepatology Research Unit, Department Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium; Liver Research Center Ghent, Ghent University, Ghent, Belgium
| | - Serap Turan
- Pediatric Endocrinology and Diabetes, Marmara University School of Medicine, Istanbul, Turkey
| | - Anna Alisi
- Research Unit of Molecular Genetics of Complex Phenotypes, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Ram Weiss
- Department of Pediatrics, Ruth Children's Hospital, Rambam Medical Center and the Bruce Rappaport School of Medicine, Technion, Haifa, Israel
| | - Maria Felicia Faienza
- Pediatric Unit, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari "Aldo Moro", Bari, Italy
| | - Ambika Ashraf
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Shikha S Sundaram
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Pediatric Liver Center, Children's Hospital Colorado, University of Colorado School of Medicine and Anschutz Medical Campus, Aurora, CO, USA
| | - Anshu Srivastava
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Ruth De Bruyne
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Ghent University Hospital, Ghent, Belgium
| | - Yunkoo Kang
- Department of Pediatrics, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Flora Bacopoulou
- Center for Adolescent Medicine and UNESCO Chair in Adolescent Health Care, Aghia Sophia Children's Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece; University Research Institute of Maternal and Child Health & Precision Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Yong-Hai Zhou
- Department of Pediatrics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Andy Darma
- Department of Pediatrics, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | - Monica Lupsor-Platon
- Department of Medical Imaging, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania; "Prof. Dr. O. Fodor" Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | - Masahide Hamaguchi
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
| | - Anoop Misra
- Fortis-C-DOC Centre of Excellence for Diabetes, Metabolic Diseases and Endocrinology, New Delhi, India; National Diabetes, Obesity and Cholesterol Foundation (N-DOC), New Delhi, India; Diabetes Foundation, New Delhi, India
| | - Nahum Méndez-Sánchez
- Liver Research Unit, Medica Sur Clinic and Foundation and Faculty of Medicine, National Autonomous University of Mexico, Mexico City, Mexico
| | - Nicholas Beng Hui Ng
- Department of Paediatrics, Khoo Teck Puat - National University Children's Medical Institute, National University Hospital, Singapore, Singapore; Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Claude Marcus
- Department of Clinical Science, Intervention and Technology, Division of Pediatrics, Karolinska Institutet, Stockholm, Sweden
| | | | - Nadia Waheed
- Department of Pediatrics, Shaheed Zulfiqar Ali Bhutto Medical University, Pakistan Institute of Medical Sciences, Islamabad, Pakistan
| | - Saleh A Alqahtani
- Organ Transplantation Center of Excellence, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia; Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, MD, USA
| | - Cosimo Giannini
- Department of Pediatrics, University of Chieti, Chieti, Italy
| | - Ponsiano Ocama
- Department of Internal Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Mindie H Nguyen
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University Medical Center, Palo Alto, CA, USA; Department of Epidemiology and Population Health, Stanford University, Stanford, CA, USA
| | - Maria Teresa Arias-Loste
- Hospital Universitario Marqués de Valdecilla, Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Instituto de Investigación Marqués de Valdecilla (IDIVAL), Santander, Spain
| | - Mohamed Rabea Ahmed
- Department of Pediatrics, Jahra Hospital, Kuwait and Department of Pediatrics, National Hepatology and Tropical Medicine Research Institute (NHTMRI), Cairo, Egypt
| | - Giada Sebastiani
- Division of Gastroenterology and Hepatology and Division of Infectious Diseases, McGill University Health Centre, Montreal, QC, Canada
| | - Yong Poovorawan
- Centre of Excellence in Clinical Virology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Mamun Al Mahtab
- Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka, Bangladesh
| | - Juan M Pericàs
- Liver Unit, Vall d'Hebron University Hospital, Vall d'Hebron Institute for Research (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain; Centros de Investigación Biomédica en Red, Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | | | - Peter Hegyi
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary; Center for Translational Medicine, Semmelweis University, Budapest, Hungary; Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary
| | - Amer Azaz
- Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Hasan M Isa
- Pediatric Department, Salmaniya Medical Complex and Pediatric Department, Arabian Gulf University, Manama, Bahrain
| | - Chatmanee Lertudomphonwanit
- Division of Gastroenterology, Department of Paediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Mona Issa Farrag
- Department of Pediatrics and Pediatric Hepatology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ahmed Abd Alwahab Nugud
- Department of Pediatrics and Pediatric Hepatology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Hong-Wei Du
- Department of Paediatrics, First Hospital of Jilin University, Changchun, China
| | - Ke-Min Qi
- Laboratory of Nutrition and Development, Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Nezha Mouane
- Department of Pediatric Gastroenterology Hepatology and Nutrition, Academic Children's Hospital Ibn Sina, Mohammed V University, Rabat, Morocco
| | - Xin-Ran Cheng
- Department of Paediatric Genetics, Endocrinology and Metabolism, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | | | - Eleonora D T Fagundes
- Department of Pediatrics, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Hasmik Ghazinyan
- Department of Hepatology, Nikomed Medical Center, Yerevan, Armenia
| | | | - Jian-Gao Fan
- Department of Gastroenterology, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Shanghai Key Lab of Pediatric Gastroenterology and Nutrition, Shanghai, China
| | - Nicoleta Gimiga
- Clinical Department of Pediatric Gastroenterology, "St. Mary" Emergency Children's Hospital, Iași, Romania; Faculty of Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, Iași, Romania
| | - Naglaa M Kamal
- Department of Pediatrics and Pediatric Hepatology, Faculty of Medicine, Cairo University, Cairo, Egypt; Pediatric Hepatology and Gastroenterology, Alhada Armed Forces Hospital, Taif, Saudi Arabia
| | - Gabriela Ștefănescu
- Department of Gastroenterology, "Grigore T. Popa" University of Medicine and Pharmacy, Iași, Romania
| | - Li Hong
- Department of Clinical Nutrition, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Smaranda Diaconescu
- Medical-Surgical Department, Faculty of Medicine, University "Titu Maiorescu", Bucuresti, Romania
| | - Ming Li
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jacob George
- Storr Liver Centre, Westmead Institute for Medical Research, Westmead Hospital, University of Sydney, Sydney, NSW, Australia.
| | - Ming-Hua Zheng
- MAFLD Research Center, Department of Hepatology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China; Institute of Hepatology, Wenzhou Medical University, Wenzhou, China; Key Laboratory of Diagnosis and Treatment for the Development of Chronic Liver Disease in Zhejiang Province, Wenzhou, China.
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Sergi CM, Kehar M, Jimenez-Rivera C. Liver Biopsy Handling of Metabolic-Associated Fatty Liver Disease (MAFLD): the Children's Hospital of Eastern Ontario grossing protocol. Ther Adv Endocrinol Metab 2024; 15:20420188241227766. [PMID: 38322111 PMCID: PMC10846056 DOI: 10.1177/20420188241227766] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 12/19/2023] [Indexed: 02/08/2024] Open
Abstract
Metabolic-(non-alcoholic) associated fatty liver disease (MAFLD/NAFLD) has increasingly become a worldwide epidemic. It has been suggested that renaming NAFLD to MAFLD is critical in identifying patients with advanced fibrosis and poor cardiovascular outcomes. There are concerns that the progression to non-alcoholic steatohepatitis (NASH) may become a constant drive in the future healthcare of children and adolescents. There is a necessity to tackle the emerging risk factors for NASH-associated hepatocellular carcinoma (HCC). In this narrative review, we present the current protocol of liver biopsy separated between pre-analytical, analytical, and post-analytical handling. Genetic association investigations have identified single nucleotide polymorphisms implicated in the progression of MAFLD-HCC, many of which seem to belong to the lipid metabolism pathways. PNPLA3 rs738409 variant, TM6SF2 rs58542926 variant, MBOAT7 rs641738 variant, and GCKR variants seem to be significantly associated with NAFLD disease susceptibility. In disclosing the current comprehensive protocol performed at the Children's Hospital of Eastern Ontario, Ottawa, ON, Canada, we support the most recent Kulkarni-Sarin's pledge to rename NAFLD to MAFLD. Grossing of the liver biopsy is key to identifying histologic, immunophenotypical, and ultrastructure data and properly preserving tissue for molecular genomics data.
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Affiliation(s)
- Consolato M. Sergi
- Division of Anatomic Pathology, Children’s Hospital of Eastern Ontario, University of Ottawa, 401 Smyth Road Ottawa, Ottawa, ON K1H 8L1m, Canada
- Department of Laboratory Medicine and Pathology, Stollery Children’s Hospital, University of Alberta Hospital, Edmonton, AB, Canada
| | - Mohit Kehar
- Division of Gastroenterology, Hepatology and Nutrition, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
| | - Carolina Jimenez-Rivera
- Division of Gastroenterology, Hepatology and Nutrition, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
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Kehar M, Sen Sarma M, Seetharaman J, Jimenez Rivera C, Chakraborty P. Decoding hepatorenal tyrosinemia type 1: Unraveling the impact of early detection, NTBC, and the role of liver transplantation. Can Liver J 2024; 7:54-63. [PMID: 38505790 PMCID: PMC10946188 DOI: 10.3138/canlivj-2023-0018] [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: 08/02/2023] [Accepted: 09/23/2023] [Indexed: 03/21/2024]
Abstract
Hepatorenal tyrosinemia type 1 (HT-1) is a rare autosomal recessive disease that results from a deficiency of fumaryl acetoacetate hydrolase (FAH), a critical enzyme in the catabolic pathway for tyrosine. This leads to the accumulation of toxic metabolites such as fumaryl and maleylacetoacetate, which can damage the liver, kidneys, and nervous system. The discovery of 2-[2-nitro-4-trifluoromethylbenzoyl]-1,3-cyclohexanedione (NTBC or nitisinone) has significantly improved the management of HT-1, particularly when initiated before the onset of symptoms. Therefore, newborn screening for HT-1 is essential for timely diagnosis and prompt treatment. The analysis of succinyl acetone (SA) in dried blood spots of newborns followed by quantification of SA in blood or urine for high-risk neonates has excellent sensitivity and specificity for the diagnosis of HT-1. NTBC combined with dietary therapy, if initiated early, can provide liver transplant (LT) free survival and reduce the risk of hepatocellular carcinoma (HCC). Patients failing medical treatment (eg, due to non-adherence), and who develop acute liver failure (ALF), have HCC or evidence of histologically proven dysplastic liver nodule(s), or experience poor quality of life secondary to severe dietary restrictions are currently indicated for LT. Children with HT-1 require frequent monitoring of liver and renal function to assess disease progression and treatment compliance. They are also at risk of long-term neurocognitive impairment, which highlights the need for neurocognitive assessment and therapy.
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Affiliation(s)
- Mohit Kehar
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children Hospital of Eastern Ontario, Ottawa, Canada
| | - Moinak Sen Sarma
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Jayendra Seetharaman
- Division of Pediatric Gastroenterology and Hepatology, Christian Medical College, Vellore, India
| | - Carolina Jimenez Rivera
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children Hospital of Eastern Ontario, Ottawa, Canada
| | - Pranesh Chakraborty
- Department of Pediatrics, Children's Hospital of Eastern Ontario and University of Ottawa, Ottawa, Ontario, Canada
- Newborn Screening Ontario, Ottawa, Ontario, Canada
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Ramic L, Speckert M, Ramphal R, Ling SC, Temple M, Kehar M. Successful Transjugular Portosystemic Shunt Treatment of Pediatric Sinusoidal Obstruction: Case Report and Review of Literature. JPGN Rep 2023; 4:e355. [PMID: 38034423 PMCID: PMC10684189 DOI: 10.1097/pg9.0000000000000355] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 07/26/2023] [Indexed: 12/02/2023]
Abstract
Background In adults with medically refractory sinusoidal obstruction syndrome (SOS), a transjugular intrahepatic portosystemic shunt (TIPS) has been used successfully to improve portal hypertension and symptoms such as ascites. There is limited data on the use of TIPS for SOS in pediatric patients. Methods The index case was reviewed retrospectively. PubMed and Medline databases were searched to identify other cases. Results A 4-year-old male with high-risk neuroblastoma, developed SOS after tandem autologous stem cell transplant. He was medically managed with defibrotide, diuretics, and peritoneal drainage, but, due to refractoriness, he underwent TIPS day +54 following bone marrow transplant. Hepatic venous pressure gradient improved from 17 to 8 mm Hg following TIPS placement with significant improvement in the patient's clinical status and ascites. However, 15 months later, his shunt remained patent, and he remains clinically well with stable liver enzymes. A literature review identified 13 pediatric cases of TIPS for SOS due to varied causes. TIPS caused a median hepatic venous pressure gradient of 9 mmHg (range, 2-38 mm Hg). The mortality following the procedure was 15%, with 2 cases who died at 2- and 11-days post-TIPS. At the time of the last follow-up (range 8-25 months), 5 patients were alive, and 8 were lost to follow-up. Conclusion We present here a pediatric case of SOS due to stem cell transplant treated successfully with TIPS with a review of the literature. A timely, individualized application of TIPS can be effective in treating children with medication-refractory SOS.
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Affiliation(s)
- Lana Ramic
- From the Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Matthew Speckert
- From the Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Division of Hematology/Oncology, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Raveena Ramphal
- Division of Hematology/Oncology, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Simon C. Ling
- Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Michael Temple
- Division of Diagnostic Imaging, St. Jude Children’s Research Hospital, TN
| | - Mohit Kehar
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
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Brahmania M, Biondi MJ, Joshi S, Lee E, Jung HM, Kehar M. Priority actions for elevating liver health in Canada: A call to action. Can Liver J 2023; 6:283-290. [PMID: 37503516 PMCID: PMC10370728 DOI: 10.3138/canlivj-2022-0041] [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: 11/01/2022] [Accepted: 11/20/2022] [Indexed: 07/29/2023]
Abstract
Chronic liver disease (CLD) has become a silent epidemic in our country and has resulted in significant physical, psychosocial, and financial burden. Although other international liver associations have published frameworks for the principal actions required to improve liver health across health systems, Canada does not have a strategy to address the growing concerns of CLD. Thus, a multidisciplinary group of care providers involved in CLD management in Canada gathered to review the current burden of disease, gaps in management, and key opportunities for improving the identification and management of people at risk of developing progressive CLD.
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Affiliation(s)
- Mayur Brahmania
- Foothills Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Mia J Biondi
- School of Nursing, York University, Toronto, Ontario, Canada
- Viral Hepatitis Care Network (VIRCAN) Study Group, Toronto Centre for Liver Disease, Toronto, Ontario, Canada
| | - Supriya Joshi
- Credit Valley Hospital, Trillium Health Partners, Toronto, Ontario, Canada
| | - Elizabeth Lee
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | | | - Mohit Kehar
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children Hospital of Eastern Ontario, Ottawa, Ontario, Canada
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Kehar M, Griffiths R, Flemming JA. Impact of decompensated cirrhosis in children: A population-based study. Can Liver J 2023; 6:278-282. [PMID: 37503518 PMCID: PMC10370729 DOI: 10.3138/canlivj-2022-0031] [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: 10/26/2022] [Accepted: 11/02/2022] [Indexed: 07/29/2023]
Abstract
Background We describe the proportion of children with compensated cirrhosis who develop decompensation in Ontario, Canada over the past two decades. Methods This is a retrospective population-based cohort study using routinely collected health care data from Ontario, Canada held at ICES during 1997-2017. Diagnosis of cirrhosis was made using validated ICES definition, and decompensation events were defined according to validated coding. Rates of decompensation, type of decompensation, and incidence of liver transplantation after decompensation were analyzed. Databases were linked at the individual level and analyzed at ICES-Queen's. Results A total of 2,755 children with compensated cirrhosis were included and 9% (253) developed decompensation over a median follow-up of 7 years. Children most likely to suffer decompensation were younger (median age 10 versus 4 years, p < 0.001) and female (45% versus 52%, p = 0.03). Ascites (137/253, 54%) was the most frequent complication. 199/2755 (7%) of children with cirrhosis received liver transplantation, of which 64% (128/199) occurred after a decompensation event. Overall, a total of 132 (4.7%) deaths occurred during the study period, with 55 deaths following a decompensating event. Conclusion We present the first study to describe rates of decompensation, type, and rate of liver transplantation after decompensation in pediatric cirrhosis at the population level. To improve the care of children with liver disease, early detection of liver disease, early initiation of specific treatments as well as identification of children who are at risk of becoming decompensated are crucial.
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Affiliation(s)
- Mohit Kehar
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Jennifer A Flemming
- ICES-Queen’s
- Department of Medicine, Queen’s University, Kingston, Ontario, Canada
- Department of Public Health Sciences, Queen’s University, Kingston, Ontario, Canada
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Morkem R, Theal R, Barber D, Flemming J, Queenan J, Kehar M. Screening Patterns of Nonalcoholic Fatty Liver Disease in Children with Obesity in Canadian Primary Care: A Cross-Sectional Study. Can J Gastroenterol Hepatol 2022; 2022:8435581. [PMID: 36594051 PMCID: PMC9805392 DOI: 10.1155/2022/8435581] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 11/04/2022] [Accepted: 11/11/2022] [Indexed: 12/25/2022] Open
Abstract
Background Nonalcoholic fatty liver disease (NAFLD) is the most common pediatric chronic liver disease, and children with a body mass index (BMI) ≥95th percentile are recommended to be screened for NAFLD by liver enzymes. Objectives This study aimed to determine the frequency and predictors of screening for NAFLD among children with obesity in Canada and to evaluate a sample of children with suspected NAFLD. Methods This cross-sectional study used data from the Canadian Primary Care Sentinel Surveillance Network, a repository of electronic medical record data from Canadian primary care practices. Results Of n = 110,827 children aged 9-18 years, 13.9% (n = 9,888) had a BMI ≥95th percentile. Only 8.7% (n = 859) of these patients were screened for NAFLD in the last year, and 23.6% (n = 2336) were ever screened. Using logistic regression, screening in the last year was associated with demographic and clinical characteristics, including previous liver enzyme assessment, prior antidiabetic prescription, and prior anxiolytic prescription. Among children with suspected NAFLD (n = 1,046), 34.7% had a BMI ≥99th percentile and approximately 8% were at increased risk of significant liver disease. Conclusion The study revealed low screening rates for NAFLD in Canadian primary care and highlighted the important role of primary care providers in identifying and managing pediatric NAFLD.
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Affiliation(s)
- Rachael Morkem
- Department of Family Medicine, Queen's University, Kingston, Ontario, Canada
| | - Rebecca Theal
- Department of Family Medicine, Queen's University, Kingston, Ontario, Canada
| | - David Barber
- Department of Family Medicine, Queen's University, Kingston, Ontario, Canada
| | - Jennifer Flemming
- Departments of Medicine and Public Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - John Queenan
- Department of Family Medicine, Queen's University, Kingston, Ontario, Canada
| | - Mohit Kehar
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
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9
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Kehar M, Jimenez-Rivera C. Care Pattern for Fontan-Associated Liver Disease by Academic Pediatric Hepatologists in Canada. JPGN Rep 2022; 3:e207. [PMID: 37168648 PMCID: PMC10158345 DOI: 10.1097/pg9.0000000000000207] [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] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 04/04/2022] [Indexed: 05/13/2023]
Abstract
Fontan-Associated Liver Disease (FALD) is a common extracardiac complication seen in patients following the Fontan procedure. There are no consensus guidelines on screening and management of children with FALD. Objective The current study aims to determine academic pediatric hepatologists' practices and identify variability in management provided to children with FALD in Canada. Methods Using the infrastructure of the Canadian Pediatric Hepatology Research Group, a nationwide survey was distributed electronically to all pediatric hepatologists practicing in university-affiliated hospitals. Results Twelve pediatric hepatologists from 12 of 13 academic centers (92%) responded to the survey. The institutions of only 2 (17%) physicians offer post-Fontan care with a multidisciplinary team, both from different provinces. The screening for other comorbidities, use of noninvasive modality, and timing of liver biopsy for estimation of liver fibrosis and screening for esophageal varices differ from program to program. The frequency of outpatient clinic follow-up varies significantly. Education and counseling concerning liver health are generally used as treatment; only 58% of academic centers have a formal adult care transition plan. Conclusions Significant discrepancies exist in the care provided to children with FALD by hepatologists practicing in academic centers across Canada. Future study is needed to develop a standardized protocol for managing and following children and youth with FALD.
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Affiliation(s)
- Mohit Kehar
- From the Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Children’s Hospital of Eastern Ontario, Department of Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Carolina Jimenez-Rivera
- From the Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Children’s Hospital of Eastern Ontario, Department of Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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10
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Lee-Kim V, Morkem R, Barber D, Flemming JA, Kehar M. Awareness, management, and practice patterns of pediatric NAFLD by primary care physicians. Paediatr Child Health 2022; 27:93-98. [PMID: 35599680 DOI: 10.1093/pch/pxab057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 07/25/2021] [Indexed: 11/15/2022] Open
Abstract
Background Nonalcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease in children. Primary-care physicians (PCPs) play a key role in identifying patients requiring specialist referral. In this study, we aim to determine PCPs' practice patterns for paediatric NAFLD, as knowledge gaps have been reported for adult NAFLD. Methods A survey was sent to 60 PCPs in the Eastern Ontario Network from July 2019 to January 2020. Results Thirty-seven (62%) PCPs responded to the survey. Twenty-one incorrectly considered the prevalence of paediatric NAFLD to be ≤10%. The majority (35/36) cared for less than five paediatric NAFLD patients. Thirty-four (92%) were only 'slightly familiar' or 'not familiar at all' with paediatric NAFLD. Only one PCP routinely screens for NAFLD. Only one PCP was aware of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) clinical guidelines for paediatric NAFLD. Twenty-five (68%) correctly selected lifestyle modifications as a treatment option. Lack of confidence in the knowledge of NAFLD was the most common barrier for managing paediatric cases. Conclusion The majority of PCPs are not screening for paediatric NAFLD and are not familiar with its clinical spectrum, citing a lack of knowledge regarding NAFLD as the greatest barrier. This may cause delays in diagnosis and a presentation with advanced fibrosis at the time of specialist referral. Dissemination and implementation of clinical guidelines have the potential to improve knowledge and screening rates for NAFLD in children at the primary-care level.
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Affiliation(s)
- Victoria Lee-Kim
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Rachael Morkem
- Department of Family Medicine, Queen's University, Kingston, Ontario, Canada
| | - David Barber
- Department of Family Medicine, Queen's University, Kingston, Ontario, Canada
| | - Jennifer A Flemming
- Department of Medicine, Queen's University, Kingston, Ontario, Canada.,Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Mohit Kehar
- Department of Pediatrics, Queen's University, Kingston, Ontario, Canada.,Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children Hospital of Eastern Ontario, Ottawa, Ontario, Canada
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11
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Affiliation(s)
- Mohit Kehar
- Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | | | - Vicky Ng
- Hospital for Sick Children, Toronto, Ontario, Canada
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12
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Nicastro E, Ebel NH, Kehar M, Czubkowski P, Ng VL, Michaels MG, Lobritto SJ, Martinez M, Indolfi G. The Impact of Severe Acute Respiratory Syndrome Coronavirus Type 2 on Children With Liver Diseases: A Joint European Society for Pediatric Gastroenterology, Hepatology and Nutrition and Society of Pediatric Liver Transplantation Position Paper. J Pediatr Gastroenterol Nutr 2022; 74:159-170. [PMID: 34694269 PMCID: PMC8673661 DOI: 10.1097/mpg.0000000000003339] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 10/16/2021] [Indexed: 02/07/2023]
Abstract
ABSTRACT Children are seldom affected by severe forms of severe acute respiratory syndrome coronavirus type 2 (SARS-CoV2) infection; however, the impact of comorbidities in the clinical presentation and outcome of SARS-CoV2 in children is poorly characterized including that of chronic liver disease (CLD) and those taking immunosuppressive medications for autoimmune liver disease or following liver transplantation (LT). Although not the main target organ, a spectrum of liver involvement has been described in children infected with SARS-CoV2 and those presenting with Multisystem Inflammatory Syndrome in Children (MIS-C). The Hepatology Committee of the European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the Society of Pediatric Liver Transplantation (SPLIT) present an evidence-based position paper on liver involvement in children with SARS-CoV2 infection and its impact on those with CLD as well as LT recipients. All children may exhibit acute liver injury from SARS-CoV2 infection, and those with CLD and may experience hepatic decompensation. Preventative and therapeutic measures are discussed.
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Affiliation(s)
- Emanuele Nicastro
- Pediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Noelle H. Ebel
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - Mohit Kehar
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
| | - Piotr Czubkowski
- Department of Gastroenterology, Hepatology, Feeding Disorders and Paediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Vicky L. Ng
- Division of Gastroenterology, Hepatology, and Nutrition, the Hospital for Sick Children, Toronto, ON, Canada
| | - Marian G. Michaels
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Pittsburgh, School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Steven J. Lobritto
- Liver Unit, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Columbia University Irving Medical Center Morgan Stanley Children's Hospital, New York, NY
| | - Mercedes Martinez
- Liver Unit, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Columbia University Irving Medical Center Morgan Stanley Children's Hospital, New York, NY
| | - Giuseppe Indolfi
- Meyer Children's University Hospital, Department NEUROFARBA, University of Florence, Firenze, Italy
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13
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Squires JE, Alonso EM, Ibrahim SH, Kasper V, Kehar M, Martinez M, Squires RH. North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Position Paper on the Diagnosis and Management of Pediatric Acute Liver Failure. J Pediatr Gastroenterol Nutr 2022; 74:138-158. [PMID: 34347674 DOI: 10.1097/mpg.0000000000003268] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [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] [Indexed: 12/31/2022]
Abstract
ABSTRACT Pediatric acute liver failure (PALF) is a rare, rapidly progressive clinical syndrome with significant morbidity and mortality. The phenotype of PALF manifests as abrupt onset liver dysfunction, which can be brought via disparate etiology. Management is reliant upon intensive clinical care and support, often provided by the collaborative efforts of hepatologists, critical care specialists, and liver transplant surgeons. The construction of an age-based diagnostic approach, the identification of a potential underlying cause, and the prompt implementation of appropriate therapy can be lifesaving; however, the dynamic and rapidly progressive nature of PALF also demands that diagnostic inquiries be paired with monitoring strategies for the recognition and treatment of common complications of PALF. Although liver transplantation can provide a potential life-saving therapeutic option, the ability to confidently determine the certainness that liver transplant is needed for an individual child has been hampered by a lack of adequately tested clinical decision support tools and accurate predictive models. Given the accelerated progress in understanding PALF, we will provide clinical guidance to pediatric gastroenterologists and other pediatric providers caring for children with PALF by presenting the most recent advances in diagnosis, management, pathophysiology, and associated outcomes.
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Affiliation(s)
- James E Squires
- Division of Gastroenterology, Hepatology and Nutrition, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Estella M Alonso
- Department Pediatric Hepatology, Ann and Robert H Lurie Children's Hospital, Chicago, Illinois, USA
| | - Samar H Ibrahim
- Department of Pediatrics, Division of Pediatric Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Vania Kasper
- Division of Pediatric Gastroenterology, Nutrition and Liver Diseases, Hasbro Children's Hospital, Providence, RI
| | - Mohit Kehar
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Mercedes Martinez
- Department of Pediatrics, Vagelos College of Physician and Surgeons, Columbia University, New York, NY
| | - Robert H Squires
- Division of Gastroenterology, Hepatology and Nutrition, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
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14
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Kehar M, Ebel NH, Ng VL, Baquero JER, Leung DH, Slowik V, Ovchinsky N, Shah AA, Arnon R, Miloh T, Gupta N, Mohammad S, Kogan-Liberman D, Squires JE, Sanchez MC, Hildreth A, Book L, Chu C, Alrabadi L, Azzam R, Chepuri B, Elisofon S, Falik R, Gallagher L, Kader H, Mogul D, Mujawar Q, Namjoshi SS, Valentino PL, Vitola B, Waheed N, Zheng MH, Lobritto S, Martinez M. Severe Acute Respiratory Syndrome Coronavirus-2 Infection in Children With Liver Transplant and Native Liver Disease: An International Observational Registry Study. J Pediatr Gastroenterol Nutr 2021; 72:807-814. [PMID: 33605666 PMCID: PMC8183254 DOI: 10.1097/mpg.0000000000003077] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 02/06/2021] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Increased mortality risk because of severe acute respiratory syndrome coronavirus-2 (SARS-CoV2) infection in adults with native liver disease (LD) and liver transplant (LT) is associated with advanced age and comorbid conditions. We aim to report outcomes for children with LD and LT enrolled in the NASPGHAN/SPLIT SARS-CoV2 registry. METHODS In this multicenter observational cohort study, we collected data from 91 patients <21 years (LD 44, LT 47) with laboratory-confirmed SARS-CoV2 infection between April 21 and September 17, 2020. RESULTS Patients with LD were more likely to require admission (70% vs 43% LT, P = 0.007) and pediatric intensive care unit (PICU) management (32% vs 4% LT, P = 0.001). Seven LD patients required mechanical ventilation (MV) and 2 patients died; no patients in the LT cohort died or required MV. Four LD patients presented in pediatric acute liver failure (PALF), 2 with concurrent multisystem inflammatory syndrome in children (MIS-C); all recovered without LT. Two LD patients had MIS-C alone and 1 patient died. Bivariable logistic-regression analysis found that patients with nonalcoholic fatty LD (NAFLD) (odds ratio [OR] 5.6, P = 0.02) and LD (OR 6.1, P = 0.01, vs LT) had higher odds of severe disease (PICU, vasopressor support, MV, renal replacement therapy or death). CONCLUSIONS Although not directly comparable, LT recipients had lower odds of severe SARS-CoV2 infection (vs LD), despite immunosuppression burden. NAFLD patients reported to the registry had higher odds of severe SARS-CoV2 disease. Future controlled studies are needed to evaluate effective treatments and further stratify LD and LT patients with SARS-CoV2 infection.
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Affiliation(s)
- Mohit Kehar
- Queen's University, Kingston
- Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Stanford University, Stanford, CA
| | | | - Vicky L. Ng
- Hospital for Sick Children, Toronto, Ontario, Canada
| | | | | | | | | | - Amit A. Shah
- Children's Hospital of Philadelphia, Philadelphia, PA
| | | | | | - Nitika Gupta
- Emory University School of Medicine, Atlanta, GA
| | | | | | | | | | | | - Linda Book
- Primary Children's Hospital, Salt Lake City, UT
| | | | | | | | | | | | - Rachel Falik
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Lisa Gallagher
- University of California, San Francisco, San Francisco, CA
| | - Howard Kader
- University of Maryland School of Medicine, Baltimore, MD
| | | | | | | | | | | | - Nadia Waheed
- Children's Hospital and the Institute of Child Health, Lahore, Pakistan
| | - Ming-Hua Zheng
- The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
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15
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Kehar M, Grunebaum E, Jimenez-Rivera C, Mozer-Glassberg Y, Jamal A, Ng VL, Avitzur Y. Conversion from tacrolimus to sirolimus as a treatment modality in de novo allergies and immune-mediated disorders in pediatric liver transplant recipients. Pediatr Transplant 2020; 24:e13737. [PMID: 32428390 DOI: 10.1111/petr.13737] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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: 08/19/2019] [Revised: 01/31/2020] [Accepted: 04/20/2020] [Indexed: 01/19/2023]
Abstract
De novo PTAID may develop in pediatric solid organ transplant recipients, have a diverse spectrum, and are occasionally treatment resistant. Previous reports showed resolution of immune cytopenias in solid organ transplant recipients following replacement of the calcineurin inhibitor tacrolimus with the mTOR inhibitor sirolimus. Herein we describe a retrospective review (2000-2017) of subjects who developed PTAID in whom immunosuppression was changed to sirolimus. Eight recipients (6 males) of either liver (n = 7) or multivisceral transplant (n = 1) suffered from severe, treatment-resistant PTAID and were switched from tacrolimus to sirolimus. The median age at transplant was 1 year (range 0.5-2.4 years). Six (75%) recipients developed de novo allergy and 2 immune-mediated diseases. The median age at presentation of PTAID was 2.7 (1.4-9) years at a median of 1.3 (0.25-8) years after transplantation. The median time from PTAID presentation to conversion to sirolimus was 1.8 (0.45-10) years. Complete resolution of symptoms was seen in 4 (50%) patients after a median of 12 (range 4-24) months including 2 patients with immune-mediated disease, 1 eczema, and 1 with eosinophilic colitis. One patient with multiple food allergies had a partial response and 3 (38%) had no response. None of the 8 recipients developed sirolimus-attributed adverse events or acute rejection during a median follow-up of 5 (0.6-8) years after the conversion. Immunosuppression conversion from tacrolimus to sirolimus can be an effective therapy in patients suffering severe or treatment-resistant PTAID, suggesting a potential role for tacrolimus in the pathogenesis of PTAID.
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Affiliation(s)
- Mohit Kehar
- Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
- Department of Pediatrics, Queens University, Kingston, ON, Canada
| | - Eyal Grunebaum
- Division of Immunology and Allergy, Food Allergy and Anaphylaxis Program, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Carolina Jimenez-Rivera
- Division of Gastroenterology Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Yael Mozer-Glassberg
- Institute of Gastroenterology, Nutrition, and Liver Diseases, Schneider Children's Medical Center of Israel, Petah-Tikva, Israel
| | - Alisha Jamal
- Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Vicky Lee Ng
- Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Yaron Avitzur
- Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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16
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Soudek L, Siddiqui I, Guerin A, Sondheimer N, Inbar-Feigenberg M, Abuquteish D, Walia JS, Kamath BM, Kehar M. Liver transplantation for Gaucher disease presenting as neonatal cholestasis: Case report and literature review. Pediatr Transplant 2020; 24:e13718. [PMID: 32324335 DOI: 10.1111/petr.13718] [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: 09/10/2019] [Revised: 03/21/2020] [Accepted: 03/30/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND We present a rare case of neonatal cholestasis in a female infant with Gaucher Disease (GD), who received liver transplantation. We review the relevant literature on similar disease presentations. METHODS A chart review of the index case was performed. PubMed and Medline databases were searched to identify other cases. RESULTS A 4-day-old female was referred with conjugated hyperbilirubinemia. Physical examination revealed icterus with hepatosplenomegaly and normal neurologic examination. The diagnosis of GD was confirmed through liver biopsy, low glucocerebrosidase enzyme activity, and two pathogenic mutations in GBA gene. Despite early initiation of ERT, the patient had worsening of her liver failure and underwent a left lateral segment liver transplant from a living donor at 7 months of age. She experienced improvement of her liver enzymes and coagulation, but passed away at 8 months due to the late onset of neurologic involvement. Nine other cases of GD presenting with neonatal cholestasis have been reported. Forty-four percent (4/9) of cases received ERT and none were considered for transplant. Overall, the literature suggests a poor prognosis with death reported in 77% (7/9) cases. CONCLUSIONS Neonatal presentation of GD represents a poor prognosis despite early initiation of treatment. Diagnosis remains a challenge as the presentation is rare and multiple tests such as BM biopsy, liver biopsy with both light and electron microscopy, enzymology, and genetic testing may need to be completed to reach a diagnosis. Neurological sequelae may manifest later making the decision to proceed with liver transplantation a difficult one.
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Affiliation(s)
- Lucy Soudek
- Department of Pediatrics, Kingston Health Sciences Center, Queen's University, Kingston, ON, Canada
| | - Iram Siddiqui
- Department of Pathology, Hospital for Sick Children, Toronto, ON, Canada
| | - Andrea Guerin
- Department of Pediatrics, Kingston Health Sciences Center, Queen's University, Kingston, ON, Canada
| | - Neal Sondheimer
- Division of Clinical and Biochemical Genetics, Hospital for Sick Children, Toronto, ON, Canada
| | - Michal Inbar-Feigenberg
- Division of Clinical and Biochemical Genetics, Hospital for Sick Children, Toronto, ON, Canada
| | - Dua Abuquteish
- Department of Pathology, Hospital for Sick Children, Toronto, ON, Canada
| | - Jagdeep S Walia
- Department of Pediatrics, Kingston Health Sciences Center, Queen's University, Kingston, ON, Canada
| | - Binita M Kamath
- Division of Gastroenterology, Hepatology, and Nutrition, Hospital for Sick Children, Toronto, ON, Canada
| | - Mohit Kehar
- Department of Pediatrics, Kingston Health Sciences Center, Queen's University, Kingston, ON, Canada
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17
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Goldaracena N, Echeverri J, Kehar M, DeAngelis M, Jones N, Ling S, Kamath BM, Avitzur Y, Ng VL, Cattral MS, Grant DR, Ghanekar A. Pediatric living donor liver transplantation with large-for-size left lateral segment grafts. Am J Transplant 2020; 20:504-512. [PMID: 31550068 DOI: 10.1111/ajt.15609] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [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: 04/03/2019] [Revised: 08/26/2019] [Accepted: 09/03/2019] [Indexed: 02/07/2023]
Abstract
Usage of "large-for-size" left lateral segment (LLS) liver grafts in children with high graft to recipient weight ratio (GRWR) is controversial due to concerns about increased recipient complications. During the study period, 77 pediatric living donor liver transplantations (LDLTs) with LLS grafts were performed. We compared recipients with GRWR ≥2.5% (GR-High = 50) vs GRWR <2.5% (GR-Low = 27). Median age was higher in the GR-Low group (40 vs 8 months, P> .0001). Graft (GR-High: 98%, 98%, 98% vs GR-Low: 96%, 93%, 93%) and patient (GR-High: 98%, 98%, 98% vs GR-Low: 100%, 96%, 96%) survival at 1, 3, and 5 years was similar between groups (P = NS). Overall complications were also similar (34% vs 30%; P = .8). Hepatic artery and portal vein thrombosis following transplantation was not different (P = NS). Delayed abdominal fascia closure was more common in GR-High patients (17 vs 1; P = .002). Subgroup analysis comparing recipients with GRWR ≥4% (GR-XL = 20) to GRWR <2.5% (GRWR-Low = 27) revealed that delayed abdominal fascia closure was more common in the GR-XL group, but postoperative complications and graft and patient survival were similar. We conclude that pediatric LDLT with large-for-size LLS grafts is associated with excellent clinical outcomes. There is an increased need for delayed abdominal closure with no compromise of long-term outcomes. The use of high GRWR expands the donor pool and improves timely access to the benefits of transplantation without extra risks.
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Affiliation(s)
- Nicolas Goldaracena
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of General Surgery, University Health Network, Toronto, Ontario, Canada.,Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada.,Division of Transplant Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Juan Echeverri
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of General Surgery, University Health Network, Toronto, Ontario, Canada.,Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Mohit Kehar
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.,Division of Gastroenterology, Hepatology, and Nutrition, Hospital for Sick Children, Toronto, Ontario, Canada.,Liver Transplant Program, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Maria DeAngelis
- Liver Transplant Program, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Nicola Jones
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.,Division of Gastroenterology, Hepatology, and Nutrition, Hospital for Sick Children, Toronto, Ontario, Canada.,Liver Transplant Program, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Simon Ling
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.,Division of Gastroenterology, Hepatology, and Nutrition, Hospital for Sick Children, Toronto, Ontario, Canada.,Liver Transplant Program, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Binita M Kamath
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.,Division of Gastroenterology, Hepatology, and Nutrition, Hospital for Sick Children, Toronto, Ontario, Canada.,Liver Transplant Program, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Yaron Avitzur
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.,Division of Gastroenterology, Hepatology, and Nutrition, Hospital for Sick Children, Toronto, Ontario, Canada.,Liver Transplant Program, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Vicky L Ng
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.,Division of Gastroenterology, Hepatology, and Nutrition, Hospital for Sick Children, Toronto, Ontario, Canada.,Liver Transplant Program, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Mark S Cattral
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of General Surgery, University Health Network, Toronto, Ontario, Canada.,Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada.,Liver Transplant Program, Hospital for Sick Children, Toronto, Ontario, Canada.,Division of General Surgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - David R Grant
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of General Surgery, University Health Network, Toronto, Ontario, Canada.,Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada.,Liver Transplant Program, Hospital for Sick Children, Toronto, Ontario, Canada.,Division of General Surgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Anand Ghanekar
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of General Surgery, University Health Network, Toronto, Ontario, Canada.,Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada.,Liver Transplant Program, Hospital for Sick Children, Toronto, Ontario, Canada.,Division of General Surgery, Hospital for Sick Children, Toronto, Ontario, Canada
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Kehar M, Brandao L, Bowdin S, Cutz E, Ling SC, Ng V. A204 FIBRINOGEN STORAGE DISEASE:A CASE SERIES AND LITERATURE REVIEW. J Can Assoc Gastroenterol 2018. [DOI: 10.1093/jcag/gwy008.205] [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] [Indexed: 11/15/2022] Open
Affiliation(s)
- M Kehar
- Pediatric gastroenterology,hepatology and nutrition, Hospital for sick children, Toronto, ON, Canada
| | - L Brandao
- The Hospital for Sick Children, Toronto, ON, Canada
| | - S Bowdin
- The Hospital for Sick Children, Toronto, ON, Canada
| | - E Cutz
- The Hospital for Sick Children, Toronto, ON, Canada
| | - S C Ling
- The Hospital for Sick Children, Toronto, ON, Canada
| | - V Ng
- Division of Pediatric GI/Hepatology/Nutrition, The Hospital for Sick Children, Toronto, ON, Canada
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Kehar M, Bijarnia S, Ellard S, Houghton J, Saxena R, Verma IC, Wadhwa N. Erratum to: Fanconi-Bickel Syndrome - Mutation in SLC2A2 Gene. Indian J Pediatr 2016; 83:1362. [PMID: 27477478 PMCID: PMC6763504 DOI: 10.1007/s12098-016-2197-9] [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] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Mohit Kehar
- Division of Pediatric Gastroenterology and Hepatology, Sir Ganga Ram Hospital, Rajendra Nagar, New Delhi, India
| | - Sunita Bijarnia
- Center of Medical Genetics, Sir Ganga Ram Hospital, Rajendra Nagar, New Delhi, 110060, India.
| | - Sian Ellard
- Department of Molecular Genetics, Foundation Trust, Royal Devon and Exeter NHS, Exeter, EX2 5AD, UK.,Institute of Biomedical and Clinical Science, Medical School, University of Exeter, Exeter, EX2 5DW, UK
| | - Jayne Houghton
- Department of Molecular Genetics, Foundation Trust, Royal Devon and Exeter NHS, Exeter, EX2 5AD, UK
| | - Renu Saxena
- Center of Medical Genetics, Sir Ganga Ram Hospital, Rajendra Nagar, New Delhi, 110060, India
| | - I C Verma
- Center of Medical Genetics, Sir Ganga Ram Hospital, Rajendra Nagar, New Delhi, 110060, India
| | - Nishant Wadhwa
- Division of Pediatric Gastroenterology and Hepatology, Sir Ganga Ram Hospital, Rajendra Nagar, New Delhi, India
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Kehar M, Wadhwa N. Chylous ascitis post primary living donor liver transplantation managed by dietary modification. ACTA ACUST UNITED AC 2016; 36:268-9. [PMID: 27509708 DOI: 10.7869/tg.304] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Jain A, Sathenahalli VB, Sarkar S, Sarkar JK, Kehar M, Sharma M, Ismail J, Rathi S, Gupta R, Mori F, Barni S. Correspondence. Indian Pediatr 2015; 52:161. [DOI: 10.1007/s13312-015-0595-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Kehar M, Sharma M. Esophageal stricture following retained foreign body in a child. Indian Pediatr 2015; 52:162-163. [PMID: 25691195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- Mohit Kehar
- Division of Pediatric Gastroenterology and Hepatology, Institute of Child Health, Sir Ganga Ram Hospital, Delhi; and #Jaswant Rai hospital, Meerut, UP.
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Sathiyasekaran M, Bavanandam S, Sankaranarayanan S, Mohan N, Geetha M, Wadhwa N, Kehar M, Biradar V. A questionnaire survey of pediatric inflammatory bowel disease in India. Indian J Gastroenterol 2014; 33:543-9. [PMID: 25588920 DOI: 10.1007/s12664-014-0507-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [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: 05/15/2014] [Accepted: 09/15/2014] [Indexed: 02/04/2023]
Abstract
BACKGROUND Inflammatory bowel disease (IBD) is not uncommon in children and is an important cause of morbidity. Since information on IBD in Indian children is sparse, the study aimed at highlighting the salient features in them. MATERIALS AND METHODS A questionnaire survey was done among 221 children and adolescents with IBD [ulcerative colitis (UC) 93 (42.1 %); Crohn's disease (CD) 122 (55.2 %); unclassified (IBD-U) 6 (2.7 %)] across seven centers in India. The cut-off age was 18 years and below. RESULTS The mean age of presentation for UC and CD was 10.2 ± 4.4 and 11.0 ± 4.5 years, respectively, with no gender difference. Diarrhea (69.9 %, p = 0.001) and blood in the stools (90.3 %, p = 0.0001) were common in UC, whereas abdominal pain (73.8 %, p = 0.01), fever (39.3 %, p = 0.0001), anemia (64.7 %, p = 0.001), and growth failure (76.2 %, p = 0.0001) were common in CD. Extraintestinal manifestations (EIM) were a feature in 23.6 % and 36.1 % of UC and CD, respectively. Pancolitis (E3) was predominant in UC (70.9 %) and 88 % required steroids. Ileocolonic CD (L3) was common in 72.9 %; 76.2 % required azathioprine for maintenance. Of the children with UC, 11.8 % had complications like massive hemorrhage and toxic megacolon, while 27 % of CD had fistulae, perianal abscess, stricture, and perforation. Biologicals were used in 0.8 % of severe UC and in 12.2 % of CD. In UC, 4.3 % required surgical intervention. CONCLUSION Pediatric inflammatory bowel disease (P-IBD) in India shares similarities with adult-onset IBD. Distinctive features were growth failure and more severe forms of the disease necessitating immunomodulators.
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Affiliation(s)
- Malathi Sathiyasekaran
- Kanchi Kamakoti Childs Trust Hospital, 12 A, Nageshwara Road, Nungambakkam, Chennai, 600 034, India,
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Kehar M, Wadhwa N, Upadhyay S. Percutaneous Endoscopic Gastrostomy in Children: Experience from Single Center of a Developing Country. J Nepal Paedtr Soc 2014. [DOI: 10.3126/jnps.v34i2.10960] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Introduction: Nutrition is of paramount importance for adequate growth and development of a child. Various routes of providing enteral nutrition to a paediatric patient are by nasogastric, nasojejeunal and gastrostomy which can be placed surgically or endoscopically. The objectives of this study were to review cases with percutaneous endoscopic gastrostomy (PEG) procedure and patient characteristics, indications, complications and outcome of PEG tube insertion in children at our center.Materials and Methods: This was a prospective study carried out in Sir Ganga Ram Hospital in New Delhi, India for a period of two years from August 2010 to August 2012. It included patients in whom PEG tube were placed during the study period and have had at least one year of post procedure follow up. Demograhic details, duration of procedure, complications, initial weight and height and then at 3 month, 6 months and 12 months of PEG tube placement were also recorded. Data between groups was compared using ANOVA and within groups across follow-ups was done using paired t-test.Results: Fourty six PEG insertions were performed during the study period, 26 twenty six conversions to BRT or Mickey button and ten PEG removals. The main indications for PEG insertion were Cerebral palsy with feeding difficulty (47.8 %). Erythema at the PEG insertion site was the most common complication (21%). There was significant improvement in the weight and height in all age group of patients at 3, 6 and 12 months post procedure with a p value <0.5. The average weight gain after 3, 6 and 12 months was 1.3 kg, 2.8 kg and 4.2 kg and the average height gain after 3, 6 and 12 months was 1.6 cm, 2.5 cm and 4.13 cm respectively.Conclusions: PEG is effective means for optimizing the nutritional goals of patients who are nutritionally debilitated with minimal complications. DOI: http://dx.doi.org/10.3126/jnps.v34i2.10960J Nepal Paediatr Soc 2014;34(2):125-131
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