Pediatric Donor Liver Research Articles

A Curious Case of Methemoglobinemia Complicating a Pediatric Live Donor Liver Transplantation Surgery

Pediatric live donor liver transplantation (LDLT) surgery is by itself a complicated surgery. Added to the difficulty in the operative technique are the complex preoperative work-up, optimization, and postoperative treatment. Intraoperative events and immediate postoperative recovery are important in graft function and the patient's overall recovery. Intraoperative greenish-blue urine and hypoxia are seldom seen during this period in the case of LDLT. Knowing the differential diagnosis and treatment are of predominant importance. A case of decompensated chronic liver disease due to Wilson's disease underwent routine LDLT. Here we describe an uncommon complication, methemoglobinemia, which complicated this patient's recovery. The case is presented for the condition's rarity and the confusing clinical picture it produced. Observations of greenish-blue urine, ascites, serum, gastric aspirate, bile, maroon or brown-colored blood, and hypoxia with normal PaO2 were made in this case. Timely diagnosis of suspected drug-induced methemoglobinemia and treatment, which led to the uneventful recovery of the patient, are explained. Even though methemoglobinemia does not have a direct graft effect, it can affect the graft oxygen perfusion and the overall oxygenation of the postoperative patient, causing adverse impacts if not detected and treated promptly. No such association of methemoglobinemia with Wilson's disease or during transplantation has been reported in the literature so far.

Outcome of pediatric-to-adult liver transplantation:a single-center study in China

Objective: To explore the outcome of the pediatric-to-adult liver transplantation, including postoperative complications and relevant factors which affecting graft survival. Methods: Data of 55 patients undergoing pediatric-to-adult liver transplantation at the First Affiliated Hospital of Zhejiang University between January 2015 and August 2021 were retrospectively analyzed. The donors consisted of 34 males and 21 females, and the age was (11.8±4.7) years (range: 1 to 17 years). Among the cases,17 cases (30.9%) were donation of brain death,32 cases (58.2%) were donation of cardiac death, and 6 cases (10.9%) were donation after brain death plus cardiac death. The recipients consisted of 32 males and 23 females, and the age was (51.6±10.1) years (range: 27 to 70 years). Among the recipients,10 cases (18.2%) were ABO-incompatible liver transplantation.The influencing factors of early graft survival were analyzed by Student t test,Mann-Whitney U test or χ2 test,respectively.Survival curve was drawn by Kaplan-Meier method.Logistic multivariate analysis was used to analyze the independent relevant factors of early postoperative graft loss. Results: Up to October 31,2021,the follow-up time (M(IQR)) was 36.0(43.1)months(range:5.9 to 81.7 months).There were 13 cases with graft loss (two of them underwent re-transplantation due to acute liver failure).The monofactor analysis indicated that cold ischemia time and donor-recipient blood group matching were the relevant factors affecting the early graft survival rate(both P<0.05).Logistic multivariate analysis showed that cold ischemia time and history of recipient gastrointestinal bleeding were independent relevant factors(both P<0.05).Postoperative hepatic artery thrombosis occurred in 3 cases(5.5%), portal vein thrombosis diagnosed in 4 cases(7.3%), portal vein stenosis occurred in 2 cases(3.6%),biliary complications diagnosed in 7 cases(12.7%), and small liver syndrome was found in 8 cases(14.5%). Conclusions: Adult liver transplantation with pediatric donor liver is an effective method to treat end-stage liver disease.Cold ischemia time and history of recipient gastrointestinal bleeding were independent relevant factors for the early graft survival.

Implementing a Height-Based Rule for the Allocation of Pediatric Donor Livers to Adults: A Liver Simulated Allocation Model Study.

Liver TransplantationVolume 27, Issue 7 p. 1058-1060 Brief Report Implementing a Height-Based Rule for the Allocation of Pediatric Donor Livers to Adults: A Liver Simulated Allocation Model Study Jin Ge M.D., M.B.A., Corresponding Author Jin Ge M.D., M.B.A. jin.ge@ucsf.edu orcid.org/0000-0003-1574-1525 Division of Gastroenterology and Hepatology, Department of Medicine, University of California–San Francisco, San Francisco, CA These authors contributed equally to this work. Address reprint requests to Jin Ge, M.D., M.B.A., Division of Gastroenterology and Hepatology, Department of Medicine, University of California–San Francisco, 513 Parnassus Avenue, S-357, San Francisco, CA 94143. Telephone: 415-476-1529; FAX: 415-476-0659; E-mail: jin.ge@ucsf.eduSearch for more papers by this authorNicholas Wood Ph.D., Nicholas Wood Ph.D. Department of Mathematics, United States Naval Academy, Annapolis, MD These authors contributed equally to this work.Search for more papers by this authorDorry Segev M.D., Ph.D., Dorry Segev M.D., Ph.D. Department of Surgery, Johns Hopkins Hospital, Baltimore, MDSearch for more papers by this authorJennifer C. Lai M.D., M.B.A., Jennifer C. Lai M.D., M.B.A. orcid.org/0000-0003-2092-6380 Division of Gastroenterology and Hepatology, Department of Medicine, University of California–San Francisco, San Francisco, CASearch for more papers by this authorSommer Gentry Ph.D., Sommer Gentry Ph.D. orcid.org/0000-0003-4530-8917 Department of Mathematics, United States Naval Academy, Annapolis, MD Department of Surgery, Johns Hopkins Hospital, Baltimore, MDSearch for more papers by this author Jin Ge M.D., M.B.A., Corresponding Author Jin Ge M.D., M.B.A. jin.ge@ucsf.edu orcid.org/0000-0003-1574-1525 Division of Gastroenterology and Hepatology, Department of Medicine, University of California–San Francisco, San Francisco, CA These authors contributed equally to this work. Address reprint requests to Jin Ge, M.D., M.B.A., Division of Gastroenterology and Hepatology, Department of Medicine, University of California–San Francisco, 513 Parnassus Avenue, S-357, San Francisco, CA 94143. Telephone: 415-476-1529; FAX: 415-476-0659; E-mail: jin.ge@ucsf.eduSearch for more papers by this authorNicholas Wood Ph.D., Nicholas Wood Ph.D. Department of Mathematics, United States Naval Academy, Annapolis, MD These authors contributed equally to this work.Search for more papers by this authorDorry Segev M.D., Ph.D., Dorry Segev M.D., Ph.D. Department of Surgery, Johns Hopkins Hospital, Baltimore, MDSearch for more papers by this authorJennifer C. Lai M.D., M.B.A., Jennifer C. Lai M.D., M.B.A. orcid.org/0000-0003-2092-6380 Division of Gastroenterology and Hepatology, Department of Medicine, University of California–San Francisco, San Francisco, CASearch for more papers by this authorSommer Gentry Ph.D., Sommer Gentry Ph.D. orcid.org/0000-0003-4530-8917 Department of Mathematics, United States Naval Academy, Annapolis, MD Department of Surgery, Johns Hopkins Hospital, Baltimore, MDSearch for more papers by this author First published: 18 January 2021 https://doi.org/10.1002/lt.25986 This analysis was funded by R01DK111233 (National Institute of Diabetes and Digestive and Kidney Diseases to Sommer Gentry), R01AG059183/K23AG048337 (National Institute on Aging to Jennifer C. Lai), and 5T32DK060414-17 (National Institute of Diabetes and Digestive and Kidney Diseases to Jin Ge). The funding agencies played no role in the analysis of the data or the preparation of this brief correspondence. Jennifer C. Lai consults for Axcella Health Inc. and BioMarin and advises for Ambys Medicines, Inc. Jin Ge participated in study concept and design, analysis and interpretation of data, article drafting, critical revision of the article for important intellectual content, and statistical analysis. Nicholas Wood participated in study concept and design, acquisition of data, analysis and interpretation of data, and critical revision of the article for important intellectual content. Dorry Segev participated in the analysis and interpretation of data and critical revision of the article for important intellectual content. Jennifer C. Lai participated in study concept and design, analysis and interpretation of data, critical revision of the article for important intellectual content, study supervision, and by obtaining funding. Sommer Gentry participated in study concept and design, acquisition of data, analysis and interpretation of data, critical revision of the article for important intellectual content, and study supervision. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume27, Issue7July 2021Pages 1058-1060 RelatedInformation

Whole liver deceased donor liver transplantation for pediatric recipients: single-center experience for 20 years.

BackgroundWe investigated the incidence and outcomes of pediatric deceased donor liver transplantation (DDLT) using whole liver grafts in a high-volume liver transplantation (LT) center.MethodsThe study was a retrospective single-center analysis of whole LT in pediatric recipients. The study period was set as 20 years between January 2000 and December 2019. We defined pediatric recipients and donors to be aged ≤18 years.ResultsDuring the study period, there were 98 cases of pediatric DDLT, and 34 patients (34.7%) received whole liver grafts. The age range of the deceased donors was 3 months to 56 years and that of pediatric recipients was 7 months to 17 years. Common primary diseases for LT were biliary atresia in 13, acute liver failure in four, Wilson disease in four, congenital portal vein agenesis in three, and genetic metabolic diseases in three. Pediatric-to-pediatric and adult-to-pediatric whole LTs were 22 (64.7%) and 12 (35.3%), respectively. A good correlation was noted between the donor and the recipient’s body weight, and the recipient’s body weight and allograft’s weight. Graft and overall patient survival rates were 91.2% and 91.2% at 1 year, 88.0% and 88.0% at 3 years, and 88.0% and 88.0% at 5 years, respectively.ConclusionsThe results of this study revealed that Korean Network for Organ Sharing (KONOS) regulations with donor-recipient body weight matching exhibited good performance. Considering the reciprocal trades of liver organs among pediatric and adult donors and recipients, it is necessary to establish a policy for pediatric donor liver grafts to pediatric recipients on a priority basis.

Whole liver deceased donor liver transplantation for pediatric recipients: single-center experience for 20 years

Background: We investigated the incidence and outcomes of pediatric deceased donor liver transplantation (DDLT) using whole liver grafts in a high-volume liver transplantation (LT) center. Methods: The study was a retrospective single-center analysis of whole LT in pediatric recipients. The study period was set as 20 years between January 2000 and December 2019. We defined pediatric recipients and donors to be aged ≤18 years. Results: During the study period, there were 98 cases of pediatric DDLT, and 34 pa tients (34.7%) received whole liver grafts. The age range of the deceased donors was 3 months to 56 years and that of pediatric recipients was 7 months to 17 years. Common primary diseases for LT were biliary atresia in 13, acute liver failure in four, Wilson dis ease in four, congenital portal vein agenesis in three, and genetic metabolic diseases in three. Pediatric-to-pediatric and adult-to-pediatric whole LTs were 22 (64.7%) and 12 (35.3%), respectively. A good correlation was noted between the donor and the re cipient’s body weight, and the recipient’s body weight and allograft’s weight. Graft and overall patient survival rates were 91.2% and 91.2% at 1 year, 88.0% and 88.0% at 3 years, and 88.0% and 88.0% at 5 years, respectively. Conclusions: The results of this study revealed that Korean Network for Organ Sharing (KONOS) regulations with donor-recipient body weight matching exhibited good perfor mance. Considering the reciprocal trades of liver organs among pediatric and adult do nors and recipients, it is necessary to establish a policy for pediatric donor liver grafts to pediatric recipients on a priority basis.

Korea-nationwide incidence of pediatric deceased donors and single-institutional status of liver transplantation using pediatric donor liver grafts

Korea-nationwide incidence of pediatric deceased donors and single-institutional status of liver transplantation using pediatric donor liver grafts

Korea-nationwide incidence of pediatric deceased donors and single-institutional status of liver transplantation using pediatric donor liver grafts.

BackgroundThe present study intended to investigate the allocation status of pediatric deceased donor liver allografts. We analyzed the incidence of pediatric deceased donors in the Korean Network for Organ Sharing (KONOS) database and single-institutional status of liver transplantation (LT) using pediatric donors.MethodsWe assessed the nationwide incidence of pediatric donors aged ≤15 years and conducted single-center analysis of LT using pediatric donors.ResultsBetween 2010 and 2019, pediatric donors aged ≤15 years accounted for 171 out of 4,395 donors (3.9%) in the KONOS database and 31 out of 640 liver donors (4.8%) in Asan Medical Center (AMC) database. In AMC, 11 (35.5%) and 20 (64.5%) grafts were allocated to pediatric recipients aged ≤15 years and adult recipients aged ≥19 years, respectively. All nine livers from donors aged ≤5 years were implanted in pediatric recipients aged ≤5 years. From 21 donors aged ≥9 years, 16 whole liver grafts and four split extended right liver grafts were implanted in 20 adult recipients and two split left lateral section grafts were implanted in two pediatric recipients. Four split liver grafts were implanted in other institutions. The overall patient survival rates at 1, 3, and 5 years were 90.9%, 80.8%, and 80.8%, respectively in pediatric-to-pediatric LT group and 69.6%, 58.4%, and 58.4%, respectively in pediatric-to-adult LT group (P=0.21).ConclusionsMore than half of the pediatric donor livers were allocated to adult patients. Recipient criteria for allocation of liver allografts from pediatric donors need revision for children on pediatric LT waitlist.

Adult liver transplantation using pediatric donor livers after cardiac or brain death: A report of three cases.

The present study reports on the experience at Jiangxi Provincial People's Hospital (Nanchang, China) with liver transplantation in adults using pediatric donor livers, including indications, technique and results. A total of three cases of liver transplantation performed between April 2008 and May 2016 were retrospectively reviewed. Liver procurement and trimming, recipient selection, surgical tips, prevention and treatment of small-for-size syndrome, selection of immunosuppressive regimens, prevention and treatment of vascular complications and anticoagulant therapy were discussed. The three pediatric donors were 8, 8 and 10 years old. The three recipients were confirmed to have primary liver cancer. In recipient 1 (female; age, 39 years), jaundice persisted in the recipient after the liver transplantation. A reduced dose of FK506 was then given to gradually decrease the total bilirubin level to the normal range. Recipient 1 recovered and was discharged from hospital; however, the patient died of liver cancer recurrence and bone metastasis 6 years post-transplantation. In recipient 2 (male; age, 56 years), the recipient experienced sudden abdominal distension on postoperative day 7. The patient's clotting time was prolonged and the transaminase level was sharply increased, peaking on day 9. The patient was suspected of having small-for-size syndrome and was treated symptomatically. The patient experienced a significant improvement in symptoms on postoperative day 13 and regular postoperative follow-ups were performed until now and the patient is now in remission. In recipient 3 (male; age, 48 years), the recipient recovered well and the liver function returned to normal on postoperative day 3. The patient was discharged from hospital and has been in remission thus far. Adult liver transplantations from pediatric donors are feasible treatments. Systematic donor and recipient assessments, sound surgical skills and optimal postoperative treatments are essential for success in the transplantation of livers from pediatric donors into adult recipients. Considering the condition of the donor liver, the selection of recipients and appropriate surgical methods are particularly important in these cases.

Analysis of Outcomes in Living Donor Liver Transplants Involving Reconstructive Microsurgeons

Living donor transplantation is becoming increasingly popular as a modality for patients necessitating liver transplantation. Hepatic artery thrombosis (HAT) remains the most feared acute postoperative complication associated with living-donor liver transplantation. Preoperative planning, including scheduling reconstructive microsurgeons to perform the hepatic artery anastomosis using a surgical microscope or loupes, can decrease HAT rates. A retrospective review of two reconstructive microsurgeons at a single institution was performed to analyze postoperative outcomes of adult and pediatric live donor liver transplants where reconstructive microsurgeons performed the hepatic artery anastomosis. One surgeon utilized the surgical microscope, while the other surgeon opted to use surgical loupes for the anastomosis. A total of 38 patients (30 adult and eight pediatric) met inclusion criteria for this study, and average patient age in the adult and pediatric population studied was 48.5 and 3.6 years, respectively. Etiologies of adult patients' liver failure were most commonly cholestatic (43%), followed by alcohol (23%), hepatitis C virus-related cirrhosis (17%), and nonalcoholic steatohepatitis (7%), while etiologies of pediatric liver failure were most commonly cholestatic (62.5%). None of the patients (0%) experienced acute postoperative HAT. On average, 22 and 25 months of postoperative follow-up was obtained for the adult and pediatric cohorts, respectively, and only one adult patient was found to have any liver-related complication. A collaborative relationship between reconstructive microsurgeons and transplant surgeons mitigates the risk of HAT and improves patient outcomes in living donor liver transplantation.

The Impact of Increased Allocation Priority for Children Awaiting Liver Transplant: A Liver Simulated Allocation Model (LSAM) Analysis.

The aim of the study was to investigate the impact of prioritizing infants, children, adolescents, and the sickest adults (Status 1) for deceased donor livers. We compared outcomes under two "SharePeds" allocation schema, which prioritize children and Status 1 adults for national sharing and enhanced access to pediatric donors or all donors younger than 35 years, to outcomes under the allocation plan approved by the Organ Procurement and Transplant Network in December 2017 (Organ Procurement and Transplantation Network [OPTN] 12-2017). The 2017 Liver Simulated Allocation Model and Scientific Registry of Transplant Recipients data on all US liver transplant candidates and liver offers 7/2013 to 6/2016 were used to predict waitlist deaths, transplants, and post-transplant deaths under the OPTN 12-2017 and SharePeds schema. Prioritizing national sharing of pediatric donor livers with children (SharePeds 1) would decrease waitlist deaths for infants (<2 years, P = 0.0003) and children (2-11 years, P = 0.001), with no significant change for adults (P = 0.13). Prioritizing national sharing of all younger than 35-year-old deceased donor livers with children and Status 1A adults (SharePeds 2) would decrease waitlist deaths for infants, children, and all Status 1A/B patients (P < 0.0001 for each). SharePeds 1 and 2 would increase the number of liver transplants done in infants, children, and adolescents compared to the OPTN-2017 schema (P < 0.00005 for all age groups). Both SharePeds schema would increase the percentage of pediatric livers transplanted into pediatric recipients. Waitlist deaths could be significantly decreased, and liver transplants increased, for children and the sickest adults, by prioritizing children for pediatric livers and with broader national sharing of deceased donor livers.

Deceased Pediatric Donor Livers: How Current Policy Drives Allocation and Transplantation.

Each year, approximately 60 children, representing 12% of waitlist candidates, die awaiting liver transplantation. The current allocation algorithm for pediatric donor livers prioritizes local/regional adults over national children. We attempted to better understand the impact of the present algorithm on pediatric candidates. We analyzed pediatric donor liver offers from 2010 to 2014. Donors and recipients were classified based on age. We mapped allocation and acceptance patterns and used subgroup analyses to explore the significance of donor service areas (DSAs) with low pediatric transplant volumes. We used Cox proportional hazard regressions to evaluate posttransplantation outcomes: 3,318 pediatric donor livers were transplanted into 3,482 recipients, and 45% (1,569) were adults. Of the 1,569 adults, 25% (390) received a pediatric organ that was never offered to children; 52% (204) of these 390 pediatric organs originated in the 37 DSAs, with ≤25 pediatric liver transplantations; 278 children died or were delisted due to illness during the same time, with higher mortality rates in the 37 DSAs (10% versus 6%, P < 0.01). Compared to adults, pediatric recipients aged <12 years had lower risks of posttransplant mortality (hazard ratio, 0.62; 95% confidence interval, 0.46-0.81; P < 0.01). Conclusions: We found that 45% of pediatric donor livers were transplanted into adults: 390 adults were transplanted with pediatric organs never offered to children, while 278 children died or were delisted due to illness, which was more apparent in DSAs with low pediatric transplant volumes; we advocate for a change to allocation policies to allow pediatric organs to be offered to national children with status 1B or Model for End-Stage Liver Disease/Pediatric End-Stage Liver Disease >15 before being offered to local/regional + circle non-status 1A adults.

Receipt of a pediatric liver offer as the first offer reduces waitlist mortality for adult women.

Our study examines allograft selection by donor age, recipient sex, and in effect size as a means to address disparities in waitlist mortality. We found that women who received a pediatric donor liver as the first offer had a lower risk of waitlist mortality compared with those who receive adult offers. Our data provides a simple approach to mitigating the increased waitlist mortality experienced by women by incorporating donor and recipient size as variables into organ allocation. (Hepatology 2018).

Outcomes of Pediatric Liver Transplantation: Deceased Donor Liver Transplantation vs Living Donor Liver Transplantation

BackgroundThe use of pediatric donor liver for pediatric liver transplantation (LT) remains controversial and few studies have focused on pediatric deceased donors. To address this issue, we decided to perform a retrospective research, trying to compare the clinical effects between deceased donor LTs (DDLTs) and living donor LTs (LDLTs). MethodsA retrospective review of pediatric LTs using grafts from deceased donors and living donors from June 2013 to August 2016 was performed. The children were divided into a DDLT group and a LDLT group based on their donor styles. The incidence of early vascular complications (VC), biliary complications, and graft and patient survival rates were observed between the 2 groups. ResultsThere were 217 cases of pediatric LTs performed in our hospital from June 2013 to August 2016 (83 DDLTs and 134 LDLTs). The 1-year cumulative survival rates of grafts and recipients were 89.16% and 91.57% in DDLTs, and 95.47% and 95.52% in LDLTs, respectively (P > .05). The incidence of early VC was lower in LDLTs than that in DDLTs (3.7% vs 19.3%, P < .001). The incidence of HAT in children aged less than 1 year was significantly higher in the DDLT group (P < .001) and can be up to 31.82%. The incidence of biliary complications was similar in the 2 groups (8.4% vs 13.5%, P = .285). ConclusionsPediatric DDLTs have similar graft and patient survival rates with LDLT. The incidence of early VC was higher in DDLTs, and children aged less than 1 year are at a higher risk of developing HAT.

Application of Pediatric Donor Livers After Circulatory Death in Adult Liver Transplantation: A Single-Center Experience.

This study aimed to investigate the outcomes of adult liver transplant procedures using grafts from pediatric donors after circulatory death. We retrospectively analyzed the data of 19 pediatric-to-adult liver transplant procedures from July 2013 to May 2016 in our hospital. Nineteen adult liver transplant procedures were performed using livers from pediatric donors after circulatory death. We performed 18 orthotopic and 1 piggyback liver transplant procedure. The median graft-to-recipient weight ratio was 1.26% (range, 0.86% to 2.46%). The median warm and cold ischemia times were 11 minutes (range, 8-20 min) and 638 minutes (range, 200-843 min), respectively. Complications after the operation included postoperative pulmonary infection (8 patients), fungal infection (1 patient), cytomegalovirus infection (1 patient), hepatic artery thrombosis and biliary stricture (1 patient), portal vein stenosis (1 patient), and graft failure (2 patients). For patients with graft failure, 1 patient received retransplant and 1 died. The patients were followed for 22.44 months (range, 9.63-44.07 mo) after transplant and showed normal liver function and good health. The 3-year survival rates of grafts and patients were 89.47% and 94.74%, respectively. Appropriate evaluation of donors and recipients and accurate intraoperative and postoperative treatment can ensure successful application of livers from pediatric donors after circulatory death in adult recipients.

Pure Laparoscopic Left Lateral Sectionectomy in Living Donors

In this study, we report the results obtained from 70 living donors in France. Left lateral sectionectomy for pediatric live donor liver transplantation is a well-standardized surgical procedure. Our team introduced the laparoscopic approach to live donation in 2002, and the reproducibility and safety of this method was discussed in 2006. Between March 2001 and October 2012, a total of 70 donors underwent a liver procurement. Sixty-seven donors (95.7%) underwent a left lateral sectionectomy, and 3 underwent a left hepatectomy without middle hepatic vein procurement. All data were prospectively recorded in a database. Of the 70 donors, 66 (94%) liver grafts were procured by laparoscopy, whereas 4 (6%) patients required conversion into an open technique. Seventeen donors experienced complications, leading to an overall complication rate of 24.2%. Eleven donors (16%) had grade 1 complications, according to the Clavien system. Five donors (7.1%) presented grade 2 complications, and 1 donor (1.4%) had a grade 3 complication. No death occurred. Overall, patient and graft survival rates for pediatric recipients were 95% and 92% at 1 year, 95% and 88% at 3 years, and 95% and 84% at 5 years, respectively. The laparoscopic retrieval of the left lateral section for live donor liver transplantation is safe and reproducible and has transitioned from an innovative surgery to a development phase in France.

Results of Pediatric Live Donor Liver Transplantation Compared To Pediatric Deceased Donor Liver Transplantation According To PELD/MELD Score.

Results of Pediatric Live Donor Liver Transplantation Compared To Pediatric Deceased Donor Liver Transplantation According To PELD/MELD Score.

Humoral immunity is involved in the development of pericentral fibrosis after pediatric live donor liver transplantation

Although LT can be successful for treating end-stage liver disease in children, some patients develop fibrosis around the central vein area (PCF). This raises the possibility that PCF could lead to later cirrhosis and graft failure. Here, we report a retrospective immunohistochemical study of 28 patients who received a live donor liver transplant. We assessed the incidence and etiology of PCF using CD3, CD20, HLA-DR, and C4d-specific antibodies. Histological evidence of PCF was found in 13 cases (46.4%), of which 11 (84.6%) had experienced ACR and/or CP events post-transplant. Immunohistochemical evaluation revealed significantly stronger staining with these antibodies in the central vein area in PCF, especially for CD20 and C4d. This implies humoral immunopathology and suggests involvement of humoral immunity in the development of PCF. These results further imply that suppression of cellular immunity alone is insufficient to prevent PCF. We therefore suggest that suppression of both humoral and cellular immunity in combination would be required for prevention of PCF.

Portal Vein Complications after Pediatric Liver Transplantation

Relatively few pediatric donors are available in relation to the number of children waiting for a liver transplant. This limited number of pediatric donor livers leads to the use of adult livers, usually requiring more complex portal vein (PV) anastomoses. These anastomoses are complicated by differences in PV caliber between donors and recipients, as well as by limitations of PV length, which may be inadequate to reach the recipient spleno-mesenteric junction. Three types of post-transplant complications result from these complexities: 1) anomalies of the portal flow; 2) stenosis of the PV anastomosis; and 3) PV thrombosis. Abnormal portal flow may rarely need a specific intervention, but persistent stenosis or appearance of signs of portal hypertension need to be corrected. Balloon dilatation and placement of a stent are usually successful to repair stenosis. Portal vein thromboses are in general diagnosed in the immediate post-operative period and frequently lead to re-transplantation; however, thrombolytic therapy should be attempted in children without major signs of liver necrosis. When intra-hepatic portal vein(s) are permeable, despite extrahepatic PV thrombosis, a Meso-Rex shunt may be the indicated therapy.

Toward a Standardized System for Reporting Surgical Outcome of Pediatric and Adolescent Live Donor Renal Allotransplantation

There is a lack of a standardized reporting methodology for surgical complications of pediatric renal transplantation. We applied Martin criteria and the modified Clavien-Dindo classification in pediatric renal transplantation. We retrospectively reviewed the charts of 447 patients 20 years or younger who underwent renal transplantation between March 1976 and January 2011. Martin criteria were fulfilled and complications were graded according to the modified Clavien-Dindo classification. For early complications grades I and II were considered low grade and III to V high grade. A similar grading system was adopted for late complications. A total of 84 early complications (18.5%) occurred in 77 transplant recipients (17%). Of grade I complications 37 (8.1%) were asymptomatic lymphoceles. Grade II complications were observed in 2 patients (0.4%). Grade IIIa complications included aspiration of hematoma (1 case), percutaneous nephrostomy fixed for ureteral obstruction (3), percutaneous tube drain for symptomatic lymphoceles (7) and antegrade ureteral stenting for ureteral leakage (6). Grade IIIb complications included exploration for wound dehiscence (1 case), revision of ureterovesical anastomosis (8), marsupialization of lymphoceles (4), hemorrhage (3) and vascular thrombotic accidents (6). Graft nephrectomy (grade IVa) complications occurred in 2 transplant recipients. Among 4 mortalities (grade V) only 1 patient died due to surgical complications. On multivariate analysis delayed graft function was the only predicator of high grade surgical complications (p = 0.005). High grade surgical complications affected recipient but not graft survival. Using a standardized, high quality reporting methodology is feasible in pediatric renal transplantation. However, consensus should be sought regarding medical complications and a grading system should be developed for reporting of late complications.

Biliary reconstruction in pediatric live donor liver transplantation: duct-to-duct or Roux-en-Y hepaticojejunostomy

Background Duct-to-duct biliary reconstruction (DD) is currently a standard procedure in adult live donor liver transplantation (LDLT). Its pediatric feasibility, however, has rarely been reported. The goal of this study is to assess the incidence and treatment of biliary complication after pediatric LDLT with DD or Roux-en-Y hepaticojejunostomy (RY). Method Sixty children received LDLT between November 2005 and June 2008, and their database was reviewed. Results Biliary reconstruction was achieved with DD in 14 patients and with RY in 46 patients with mean follow-up period of 26.0 and 22.3 months, respectively. The incidence of biliary leakage in the DD and RY groups was 7.1% and 8.7%, respectively, and that of stricture was 28.6% and 10.9%, respectively; but the differences were not statistically significant. Biliary stricture in the DD group tended to require revision surgery with RY and longer treatment with percutaneous transhepatic cholangiodrainage compared with that in the RY group. Conclusion Theoretical advantages of DD over RY were not confirmed in this study. Duct-to-duct biliary reconstruction tended to encounter more biliary complications, especially stricture, with more difficulty in treating it than RY. Roux-en-Y hepaticojejunostomy seems preferable to DD in the setting of pediatric LDLT, but DD must be considered when making new Roux-en-Y limb seems impossible or troublesome owing to abdominal dense adhesion or short bowel syndrome.