Liver Transplantation in Children: Update 2010

Children from minoritized/socioeconomically deprived backgrounds suffer disproportionately high rates of uninsurance and graft failure/death after liver transplant. Medicaid expansion was developed to expand access to public insurance. Our objective was to characterize the impact of Medicaid expansion policies on long-term graft/patient survival after pediatric liver transplantation. All pediatric patients (<19 years) who received a liver transplant between January 1, 2005, and December 31, 2020 in the US were identified in the Scientific Registry of Transplant Recipients (N = 8489). Medicaid expansion was modeled as a time-varying exposure based on transplant and expansion dates. We used Cox proportional hazards models to evaluate the impact of Medicaid expansion on a composite outcome of graft failure/death over 10 years. As a sensitivity analysis, we conducted an intention-to-treat analysis from time of waitlisting to death (N = 1 1901). In multivariable analysis, Medicaid expansion was associated with a 30% decreased hazard of graft failure/death (hazard ratio, 0.70; 95% confidence interval, 0.62, 0.79; P < .001) after adjusting for Black race, public insurance, neighborhood deprivation, and living in a primary care shortage area. In intention-to-treat analyses, Medicaid expansion was associated with a 72% decreased hazard of patient death (hazard ratio, 0.28; 95% confidence interval, 0.23-0.35; P < .001). Policies that enable broader health insurance access may help improve outcomes and reduce disparities for children undergoing liver transplantation.

Congenital malformations like duodenal and other gut atresia, biliary atresia, bowel resections, imperforate anus, and necrotizing enterocolitis are the primary procedures performed in neonatal abdominal surgery. Although abdominal wall defects also require immediate surgical attention, bleeding complications are rare. Infants, toddlers, and young children require abdominal surgery mainly for the treatment of solid tumors or abdominal organ transplantation. In older children and adolescents, the complexity of abdominal procedures often arises from coexisting diseases such as congenital heart disease, cancer therapy, or adhesions from previous abdominal surgeries.

To characterize associations between living in primary care shortage areas and graft failure/death for children after liver transplantation.

This was an observational study of all pediatric patients (aged <19 years) who received a liver transplant between January 1, 2005, and December 31, 2015 in the US, with follow-up through January 2019 (N = 5964). One hundred ninety-five patients whose home ZIP code could not be matched to primary care shortage area status were excluded. The primary outcome was a composite endpoint of graft failure or death. We used Cox proportional hazards to model the associations between health professional shortage area (HPSA) and graft failure/death.

Children living in HPSAs had lower estimated graft survival rates at 10 years compared with those not in HPSAs (76% vs 80%; P < .001). In univariable analysis, residence in an HPSA was associated with a 22% higher hazard of graft failure/death than non-residence in an HPSA (hazard ratio [HR], 1.22; 95% CI, 1.09-1.36; P < .001). Black children from HPSAs had a 67% higher hazard of graft failure/death compared with those not in HPSAs (HR, 1.67; 95% CI, 1.29 to 2.16; P = .006); the effect of HPSA status was less pronounced for White children (HR, 1.11; 95% CI, 0.98-1.27; P = .10).

Children living in primary care shortage areas are at increased risk of graft failure and death after liver transplant, and this risk is particularly salient for Black children. Future work to understand how living in these regions contributes to adverse outcomes may enable teams to mitigate this risk for all children with chronic illness.

In recent years a growing number of pediatric liver transplant recipients are reaching adulthood and are transferred to an adult team. Because pediatric to adult transition has become a common event with many particularities, specific clinical protocols are needed to guide professionals in this process. Transition must be seen as a complex process of high vulnerability for the patient. The incorrect assumption that the transition process is only a bureaucratic transfer of information leads to inappropriate transition procedures that result in young patients not ready to move to adult units with guaranteed success. To ensure this success, a correct coordination and transmission of the information, accompaniment by the health professional during the whole process, and the empowerment of the patient are required. To have a successful transition, a person within the pediatric team must be in charge of the process (named worker).

Liver transplantation in children has been through major advances over the years. Improvements in operative techniques and the use of segments of livers from living or cadaveric donors has led to an increase in the number of transplants performed in pediatric patients and as a result a decrease in mortality on the waiting list for this age group. Advances in preoperative and postoperative management, organ preservation, immunosuppressive regimens, more effective organ allocation, and understanding of posttransplant complications like infection and organ dysfunction have had major impact on patients and grafts survival. Biliary atresia is still the leading indication for liver transplantation in the pediatric age group; however, many other indications have been added to the list. Liver transplantation for cancers and dual transplants like liver and kidney, and liver and heart, have become a practice.

Surgical stress, liberation of cytokines associated with re-perfusion injury, and long standing use of immune suppressive medications in children recipients of orthotopic living related liver transplantation (OLRLT) pose cardiovascular risk. Reported cardiovascular adverse effects vary from left ventricular wall thickening, hypertrophic cardiomyopathy to resting ECG abnormalities, asymptomatic ST depression following increased heart rate and ventricular arrhythmias. Twenty-five consecutive children recipients of OLRLT were assessed by conventional 2-D, M-mode echocardiography and Doppler. The mean age ± SD at transplantation and at enrollment in study was 6.3 ± 4.5 and 13.5 ± 5.6 years respectively. All children were on immunosuppressive medications, with tacrolimus being constant among all. Long-term post-transplant echocardiography revealed statistically significant interventricular septal hypertrophy among all (mean thickness 0.89 ± 0.16 cm), (P = 0.0001) in comparison to reference range for age, 24 had pulmonary hypertension (mean mPAP 36.43 ± 5.60 mm Hg, P = 0.0001), and early diastolic dysfunction with a mean Tei index of 0.40 ± 0.10. However cardiac function was generally preserved. Children recipients of OLRLT have cardiac structural and functional abnormalities that can be asymptomatic. Pulmonary hypertension, increased cardiac mass, de novo aortic stenosis and diastolic heart failure were among abnormalities encountered in the studied population. Echocardiography is indispensible in follow-up of children recipients of OLRLT.