Combined Liver-Kidney Transplantation in Children: Single-Center Experiences and Long-Term Results

Combined liver-kidney transplantation (CLKT) is a rare procedure in pediatric patients in which liver and kidney from 1 donor are transplanted to a recipient during a single operation. The aim of our study was to analyze indications and results of CLKT in children.

MATERIALS AND METHODS

Between 1990 and 2017 we performed 722 liver transplantations in children; we performed 920 kidney transplantations in children since 1984. Among them, 25 received CLKT. Primary diagnosis was fibro-polycystic liver and kidney disease in 17 patients, primary hyperoxaluria type 1 in 6 patients, and atypical hemolytic uremic syndrome-related renal failure in 2 children. Age of patients at CLKT was 3 to 23 years (median 16 years) and body mass was 11 to 55 kg (median 35.5kg). All patients received whole liver graft. Kidney graft was transplanted after liver reperfusion before biliary anastomosis. Cold ischemia time was 5.5 to 13.3 hours (median 9.4 hours) for liver transplants and 7.3 to 15 hours (median 10.4 hours) for kidney transplants. In 8 patients X-match was positive. We analyzed posttransplant (Tx) course and late results in our group of pediatric recipients of combined grafts.

RESULTS

Tx follow-up ranged from 1.5 to 17 years (median 4.5 years). Two patients died: 1 patient with oxalosis lost renal graft and died 2.6 years after Tx due to complications of long-term dialysis, and 1 died due to massive bleeding in early postoperative period. Twelve patients were transferred under the care of adult transplantation centers. Six patients were dialyzed after CLKT due to acute tubular necrosis, and time of kidney function recovery was 10 to 27 days in these patients. In 1 patient with aHUS, renal function did not recover. In children with oxalosis, hemodialysis was performed for 1 month after Tx as a standard, with the aim to remove accumulated oxalate. Primary immunosuppression consisted of daclizumab or basiliximab, tacrolimus, mycophenolate mofetil, and steroids. Acute rejection occurred in 4 liver and 3 kidney grafts. One patient required liver retransplantation due to hepatitis C virus recurrence and 2 patients required kidney retransplantation. Two patients required dialysis.

CONCLUSIONS

CLKT in children results in low rate of rejection and high rate of patient and graft survival.

Profiles of all 550 procurements and transplantations of kidneys from living donors in Poland, 1967-2012

INTRODUCTION

Nationwide live organ donor registry is mandatory to ensure the quality and safety of kidney procurement from living donors and for donor protection. In Poland, this concept is achieved with the use of an Internet tool (www.rejestry.net); donation centers are obligated to collect donors' data (demographic characteristics, including pre-, peri-, and post-donation and long-term follow-up). The registry currently handles data from 2008 but is incomplete in the collection of historical procurements. The goal of the research was to collect in one database all information regarding cases of kidney procurements and transplantations from living donors in Poland starting from the first such transplant in 1967.

MATERIALS AND METHODS

Data were gathered from several existing but incomplete records stored by transplant centers.

RESULTS

A total of 550 kidney procurements and transplantations from living donors were made in the years 1967 to 2012. We collected 100% of information on the date and donation centers and 100% of information regarding the recipients but only 65% of information regarding the donor and 80% regarding donor-recipient relations. According to the data, women accounted for 60% of living donors and men for 40% of living donors. The mean age of a donor was 45 years, and the mean age of a recipient was 28 years. Among related donors, parents constituted the majority (59%), siblings accounted for 21%, and spouses accounted for 12%.

CONCLUSIONS

Although the collected data are incomplete, our research provided the Polish live-donor registry a solid starting point (eg, all dates, center procurements, records of transplantations) to enter remaining data and to build a serviceable tool for full assessment of all live-donor kidney donations in the country.

Liver transplantation in children with hepatocellular carcinoma. Do Milan criteria apply to pediatric patients?

HCC constitutes 25-30% of primary malignant liver tumors in children. Conventional surgical excision is not possible in more than 50% of patients. LTx has recently become an important therapeutic option for adults and children with primary liver tumors. The aim of this study was a retrospective analysis of the clinical and pathological data of children with HCC treated with LTx in relation to Milan criteria assessed at diagnosis and then immediately before transplantation, in comparison with a group of patients treated conventionally. Between 1990 and 2007 we have treated 21 children diagnosed with HCC. Patients were divided into two groups: group I, 10 children treated conventionally and group II, 11 children treated with LTx regardless of previous therapy. The outcome of our patients treated conventionally with resection and chemotherapy is very poor--the disease-free survival rate is 30%. In contrast, despite that only 3 children having fulfilled adult Milan criteria, early clinical results of LTx are much superior. Total hepatectomy followed by LTx is the main treatment option for the majority of children with HCC. Decisions on the type of surgical treatment is made individually, but very early in the course of treatment.

Prevention of de Novo Hepatitis B Virus Infection by Vaccination and High Hepatitis B Surface Antibodies Level in Children Receiving Hepatitis B Virus Core Antibody-Positive Living Related Donor Liver: Case Reports

Transmission of hepatitis B virus (HBV) infection from donors negative for hepatitis B surface antigen (HBsAg) but positive for antibody to hepatitis B core antigen (anti-HBc) have been reported. The aim of our study was to evaluate the outcomes of recipients who received liver grafts from living related donors with serological evidence of previous exposure to hepatitis B virus (HBsAg-negative/anti-HBc-positive) after recipient vaccination against HBV before and after liver transplantation.

Organ donation in Poland 2006

Organ transplantation program has been slowly developing over last 30 years. The number of DD (deceased donors) stabilized on the level of approximately 13/million of population. Multiorgan donation has been 45%, due to some problems with donor management. Polish Transplant Coordinating Center POLTRANSPLANT which is responsible for organization of procurement, organ allocation and providing several registries (registry of objections, registry of transplantation, waiting lists of potential organ recipients etc). National data on organ donation and transplantation are each year submitted to the Ministry of Health and the National Transplantation Council which is the Advisory Committee to the Minister.

Vascular Complications After Pediatric Liver Transplantation From the Living Donors

Early arterial or portal vein thrombosis is a complications that can lead to graft loss and patient death or need of immediate retransplantation. The aim of the study was to assess the incidence, causes, treatment, and outcome of vascular thrombosis after living related donor liver transplantation (LRdLTx). Between 1999 and 2004 71 LRdLTx were performed in children aged from 6 months to 10 years. Vascular thrombosis was found in 12 recipients. Hepatic artery thrombosis (HAT) occurred in 4 (5.6%), portal vein thrombosis (PVT) in 8 (11.2%) cases. HAT occurred 5 to 8 days, PVT 1 to 22 days after LTx. Diagnosis of vascular thrombosis was confirmed by routine Doppler ultrasound examination. Thrombectomy was successful in one patient with HAT and in three patients with PVT. Venous conduit was performed in one patient with PVT after second thrombosis. Two children developed biliary strictures as a late complication of HAT and required additional surgical interventions. Two children with PVT developed portal hypertension with esophageal bleeding, which required surgical intervention; one another underwent endoscopic variceal ligation for grade III varices. Follow-up ranged from 7 to 60 months. One patient died as a result of HAT after retransplantation due to multiple intrahepatic abscesses 2 months after first transplant. Any risk factors of vascular thrombosis that can be controlled should be avoided after transplantation. Routine posttransplant Doppler examination should be performed at least twice a day within 7 to 14 posttransplant days. Immediate thrombectomy should be always carried out to avoid late complications and even mortality.

Analysis of Neurological Complications in Children Transplanted Due to Fulminant Liver Failure

Treatment of patients with fulminant liver failure is a challenge of contemporary medicine. Liver transplantation, in this group, is presently the only reasonable alternative, but in many patients the disastrous condition of the patient results in serious life-threatening complications, including neurological sequelae, which may influence the quality of life after transplantation, and in some cases even cause death. From 1990 to 2004, we performed 241 liver transplantations in children, including 20 transplanted due to fulminant liver failure (8.2%). Serious neurological complications followed liver transplantation in five cases (20%), three of which were fatal. The analysis revealed that the duration of pretransplant coma (grade III or IV) strongly correlated with the incidence of neurological complications (P < .05). Also a suboptimal quality of the donor liver and poor early graft function may contribute to these posttransplant complications.

Anatomical alteration of the vascular tree observed during living related liver transplantation

INTRODUCTION

The number of available cadaveric donor organs has reached a plateau. One current solution has been to increase number of living related liver transplantations.

MATERIAL AND METHODS

Since October 1999 in the Department of General, Transplant and Liver Surgery, Medical University of Warsaw, 40 living related liver transplantation have been carried out.

RESULTS

In 31 (77.5%) cases, a normal arterial supply was observed: the common hepatic artery arose from a celiac trunk. In two cases (5.0%), there was a partial arterial blood supply by the right accessory hepatic artery originating from the superior mesenteric artery. In two cases (5.0%), a right hepatic artery arose completely from the superior mesenteric artery (replaced artery). In one case (2.5%), a common hepatic artery originated from the superior mesenteric artery. In two cases (5.0%), an accessory left segmental artery originated from the left gastric artery. In two cases (5.0%), the function of an absent left hepatic artery was assumed by a replaced left hepatic artery originating from the left gastric artery. In two (5.0%) cases, there were two separate ducts draining the right hemiliver. There were two (5.0%) cases of an accessory duct draining segment IV, originating within the confluence of the right and left hepatic ducts. In one (2.5%) case, the common hepatic duct showed a trifurcation.

CONCLUSION

During harvesting from a living donor knowledge of anatomical variants must be used to optomize the liver graft.

Harvesting liver fragments from living-related donors: a single-center experience

The aim of the study was to estimate the risk of harvesting a liver fragment from a living-related adult donor. Liver fragments were harvested from 44 donors. Liver segments II and III were harvested from 36 donors. Liver segments II, III, IV were harvested from 6 donors, 2 donors gave segments V, VI, VII, and VIII. After preliminary donor selection volumetric assessment of liver segments by computed tomography and arteriography was performed to visualize the cenac trunk and superior mesenteric artery. None of the donors died. No complications were observed during the operation. Only one case, a bile collection, was observed after surgery. We treated this patient with a satisfactory result by sonography-guided drainage. We observed temporary elevation of bilirubin and transaminase levels and a decrease in prothrombin index value. Blood transfusion was not necessary during any of the procedures. Mean hospitalization time after the surgery was 9.4 days. Mean graft weight/recipient weight ratio was 2.54%. The risk of the harvesting liver fragment from a living-related adult donor seems to be minimal.

Bile duct variations in partial liver transplantations from living-related donors

The aim of this paper was to present anatomic variations of bile ducts and their effect on the perioperative course of living-related donors in partial liver transplantations in children. Liver fragments for partial transplantation were harvested from 41 related donors. Segments II and III were harvested from 35 and segments II, III, and IV from 6 donors. During the procedure, cholangiography through cystic duct was performed revealing a normal anatomy of the bile ducts in 33 (80.5%) cases. The rest of the donors showed anatomic variations. There was only one case of complications related to the bile duct. The intraoperative diagnosis of anatomic variations allowed for safe partial liver harvesting.

MARS procedure as a bridge to combined liver-kidney transplantation in severe chromium-copper acute intoxication: a paediatric case report

We describe a case of multi-organ failure (liver-kidney insufficiency and brain oedema) caused by accidental, acute intoxication with a chromium and copper-containing substance, as an example of the introduction of the new extracorporeal procedure MARS (molecular adsorbents recirculating system) in a girl 3.5 years old.

Liver regeneration in living-related donors after harvesting of liver segments II and III or II, III and IV

BACKGROUND

CT-assisted volumetry permits an estimation of the volume of the graft in liver transplantation, as well as monitoring the donor's liver regeneration. The aim of the study was to observe the restitution of liver tissue in donors after harvesting of the liver fragment for living-related liver transplantation (LRLT).

METHODS

The size of the whole liver and of segments II, III and IV was assessed by preoperative CT volumetry in 29 living-related liver donors. Segments II and III were harvested in 22 patients, segments II, III and IV in 6 patients. The remnant liver was assessed by CT volumetry on the 7th and 30th postoperative days.

RESULTS

The correlation between the calculated volume of the graft and its weight was linear (r=0.56, p<0.04). Postoperative CT volumetry of the liver of living-related donors showed a different pattern of volume restoration (regeneration index) at both 7 and 30 days between donors who sacrificed segments II and III and those who sacrificed segments II, III and IV. The mean regeneration indexes were significantly higher in donors of segments II, III and IV as compared with donors of segments II and III (7 days, p<0.02; 30 days, p<0.05).

DISCUSSION

It is possible that the donor's liver displays a different pattern of growth due to the alteration in blood supply to segment IV.

Immunological abnormalities in children with biliary atresia

Since orthotopic liver transplantation is the treatment of choice for bilary atresia, the role of nutritional support preceding this procedure is significant. The aim of this study was to assess the selected parameters of both humoral and cellular immunity before and after nutritional support. Eight children aged 1.08-7 years. with biliary atresia, qualified to LTx, received high-calorie standard diet supplemented with MCT oil. The distribution of functionally different lymphocyte subpopulations in the peripheral blood was evaluated using double color flow cytometry (EPICS-MCL, Coulter). The concentrations of total serum immunoglobulins were measured by nephelometry (Beckman Array 360) and concentrations of IgG subclasses by ELISA. Abnormalities in the expression of lymphocyte surface markers as well as in immunoglobulin synthesis were as follows: 1) decrease in the percentage of total CD3+ (4/8), CD4+ (5/8), CD8+ (3/8) cells and markedly elevated percentage of CD19+ B cells (4/8); 2) reduction of the proportion of 'naive' CD4+ and CD8+ lymphocytes but normal percentage of 'memory' CD4+ and CD8+ cell subsets; 3) hypergammaglobulinemia with especially high levels of IgG (16.0-3.05 g/l) and IgA (2.6-6.66 g/l) was found in 6 out of 8 children. Treatment with hypercaloric diet did not improve the immunological parameters. We conclude that lymphopenia and possibly also hypergammaglobulinemia observed in BA children resulted mainly from the deficiency of the so-called 'naive', suppressor-inducer CD4+ T cell subset (CD4+/CD45RA+) that is known to maintain the proper level of immunoglobulin synthesis by inhibition of B cell differentiation into plasma cells.

Treatment of progressive familial intrahepatic cholestasis: liver transplantation or partial external biliary diversion

Progressive intrahepatic familial cholestasis (PFIC), previously called Byler's disease, is a syndrome in which children develop severe cholestasis progressing to biliary cirrhosis and chronic liver failure, usually during the first decade of life. Clinical features include jaundice, hepatomegaly, splenomegaly, growth retardation and severe pruritus. Laboratory tests demonstrate elevated bilirubin and bile acids, without an increase in serum gamma-glutamyl-transpeptidase or cholesterol. This study was performed to evaluate our experience with medical therapy as well as two types of surgical treatment used in children with PFIC, particularly partial external biliary diversion (PEBD) as an alternative method of therapy to liver transplantation (OLTx). Between 1979 and 1998 we have treated 46 children with PFIC (27 boys and 19 girls), aged 10 months to 19 yr (at the time of this study). Medical treatment with ursodeoxycholic (UDCA) was used in 39 patients for the period between 6 and 82 months. PEBD (cholecysto-jejuno-cutaneostomy) was performed in 16 patients, OLTx in eight children (including one after unsuccessful PEBD). Retrospective analysis of the clinical course and selected laboratory tests (bilirubin, ASPAT, ALAT, bile acids), and histopathological examinations were performed. Results of treatment were assessed by means of influence of the type of treatment on clinical symptoms, laboratory tests, progress of liver cirrhosis and hepatic failure, as well as physical development and survival. Medical therapy was effective in the long term in four (10%) of the patients resulting in clinical and biochemical normalization. Both surgical methods of therapy of PFIC, PEBD and OLTx, resulted in an 80% success rate and therefore should be used as complementary therapies. In patients before established liver cirrhosis, PEBD should be the first choice of treatment. Patients presenting with cirrhosis or after ineffective PEBD should qualify for OLTx. With this strategy most children with PIFC can be cured.

Diagnosis and monitoring of cytomegalovirus infection after liver transplantation in children

Cytomegalovirus infection (CMV) complicated the posttransplant course in 9 of 24 children after liver transplantation. We found specific antibodies (IgG and IgM) to be of very low value in diagnosis and monitoring of CMV infection after liver transplantation. Detection of CMV-DNA by PCR method in the blood or urine was very useful for diagnosis, but less for monitoring of the course of disease and its treatment. Measurements of early immediate CMV antigen (IEA), in peripheral blood leucocytes allowed for very early diagnosis of CMV infection and correlated well with the course of disease and response to treatment of the patient.

Primary vascular thrombosis after renal transplantation in children

The aim of the study was to assess the incidence, causes, diagnostic and treatment modalities, and outcome of vascular thrombosis after kidney transplantation in children. Between 1984 and 1995 we performed 176 kidney transplants in pediatric recipients aged 1 to 18 years. Vascular thrombosis followed 7 transplants, 4 were renal vein and 3 arterial thromboses. Venous thromboses occurred 2 to 12 days after transplantation. All of the patients with a renal vein thrombosis lost their grafts. Arterial thrombosis developed in 2 cases of double renal arteries which were separately anastomosed into the recipient vessels. One graft was lost, but the other was saved by thrombolytic therapy (streptokinase). One child experienced intrarenal segmental artery thrombosis during acute vascular rejection, which resolved following combined anti-rejection and thrombolytic (intra-arterial streptokinase) treatment with full recovery of graft function. In all, vascular thrombosis complicated 7 out of 176 transplants (4.0%), and was the cause of 5 graft losses (2.8%). The incidence of vascular thrombosis was not increased in grafts with vascular anomalies (3/34 v. 4/142; p>0.05, chi sq.). We conclude that acute tubular necrosis, rejection and unstable volemia may predispose to vascular thrombosis. In selected cases, early diagnosis of vascular thrombosis may enable graft salvage by surgical or thrombolytic treatment.

Esophageal manometric studies in children with achalasia before and after operative treatment

This study manometrically assessed and compared esophageal function in 16 children with achalasia before and after surgical treatment (anterior esophagomyotomy with antireflux partial fundoplication). Manometric examinations were done in 10 children preoperatively and in 12, 3 months to 8 years postoperatively. Both pre- and postoperative examinations were done in 6 patients. The following parameters were measured: lower esophageal sphincter (LES) pressure and length, spontaneous motility of the esophageal body, and motility provoked by swallowing of fluids. Preoperative examinations confirmed disturbances typical for achalasia: increased LES pressure (mean 39.4 mmHg), lack of relaxation upon swallowing, and various types of anomalous esophageal motility (lack of propulsive waves, segmental waves, breaks in propagation of contractions, tonic contractions, etc.). Postoperative examinations showed normalization of LES pressure; however, relaxation did not appear in any patient. Esophageal motility improved after surgery in most patients and was already noticeable 3-6 months postoperatively, but motility never returned to normal. Clinically, all but 1 patient with reflux esophagitis were doing well despite persistent motility disturbances. Our study confirms that achalasia is a complex motor disorder of the entire esophagus. The improvement of esophageal contractility after esophagomyotomy suggests both primary and significant secondary damage to motility of the esophageal body in most patients. It appears that secondary disturbances are reversible to some extent in children after surgical treatment.

[Successful autotransplantation of a solitary kidney in a 2-year old girl with malignant hypertension caused by critical renal artery stenosis]

A 22-month-old girl with malignant hypertension caused by critical stenosis of the right renal artery resistant to all of pharmacological treatment is described. Left renal function was lost in the course of the hypertensive crisis. The child was successfully treated by autotransplantation of the right kidney.

The surgical approach to hyperinsulinism and hypoglycemia in children

Authors present 19 children aged from 2 weeks to 16 y with severe hypoglycemia. In 3 oldest children a single nesidioma was found. In other 16 children mainly infants nesidioblastosis has been recognised, and in those cases the subtotal pancreatectomy was performed. In 4 infants the additional resection of the pancreas was done because after the primary procedure hypoglycemia persisted. All patients survived and were euglycemic. Severe hypoglycemia leads to brain damage and therefore should be treated as an urgent state.

[Gastroesophageal reflux and diseases of the respiratory system in children; etiopathogenesis, diagnosis and treatment]

16 children with various pulmonary symptoms were presented. Gastrooesophageal reflux was diagnosed as a cause of that. The causal correlation between gastrooesophageal reflux and respiratory symptoms was established on the ground of 24-hour monitoring of oesophageal pH, radioisotopic examination of the stomach and oesophagus, evaluation of the bronchial reactivity to the acidification of the oesophagus and of the allergic tests. Eventually surgical treatment was performed in all children which resulted in the complete remission of the symptoms or marked subjective improvement. It has been shown that gastrooesophageal reflux is an important cause of acute or chronic lung disease. The close collaboration should be established between pediatricians and pediatric surgeons in the treatment of gastrooesophageal reflux.