Minding the gap—Providing quality transplant care for South African children with acute liver failure

Abstract

Pediatric ALF is rare but life-threatening and may require urgent transplantation. In low and middle-income countries, access to transplantation is limited, deceased organ donation rates are low, and data on outcomes scarce. The Wits Donald Gordon Medical Centre, in Johannesburg, is one of only two centers in South Africa that perform pediatric liver transplant. We describe the etiology, clinical presentation, and outcomes of children undergoing liver transplant for ALF at our center over the past 14 years. We performed a retrospective chart review of all children undergoing liver transplantation for ALF from November 2005 to September 2019. Recipient data included demographics, clinical and biochemical characteristics pretransplant, post-operative complications, and survival. We conducted descriptive data analysis and used the Kaplan-Meier method for survival analysis. We performed 182 primary pediatric liver transplants. Of these, 27 (15%) were for ALF, mostly from acute hepatitis A infection (11/27;41%). Just over half of the grafts were from living donors (15/27;56%), and five grafts (5/27;19%) were ABO-incompatible. The most frequent post-transplant complications were biliary leaks (9/27;33%). There were two cases of hepatic artery thrombosis (2/27;7%), one of whom required re-transplantation. Unadjusted patient and graft survival at one and 3 years were the same, at 81% (95% CI 61%-92%) and 78% (95% CI 57%-89%), respectively. At WDGMC, our outcomes for children who undergo liver transplantation for ALF are excellent. We found workable solutions that effectively addressed our pervasive organ shortages without compromising patient outcomes.

Prognostic factors and scoring systems associated with outcome in pediatric acute liver failure

“…Liver transplantation has interrupted the clinical trajectory of PALF [17,41]. In South Africa's heterogenous population, access to transplantation is limited and dependent on many factors like socio-economic status, geographical location, access to healthcare, transportation availability to health care facilities and many other factors [19]. In our cohort there were many patients who, although referred for transplantation, were too ill to be transplanted.…”

“…This observational single centre study evaluated the prognostic indicators associated with poorer outcomes in pediatric patients with ALF in Gauteng, S.A, which is currently the location of the only pediatric transplant unit in S.A, performing both living related and ABO incompatible liver transplantation in PALF patients [19]. To our knowledge this is the only study on prognostic factors and scoring systems in PALF from Southern Africa.…”

Hepatitis A virus seroprevalence among children and adolescents in a high-burden HIV setting in urban South Africa

“…Our 13 Further to the high cost and morbidity/mortality, Bruckmann et al showed that HAV is currently the leading cause of paediatric acute liver failure requiring transplantation in South Africa, with even further expenses and disease burden to the health sector. 14 The study was limited by participant enrolment in a single urban centre. However, Kalafong Provincial Tertiary Hospital, services a wide community of informal settlement households with poor access to clean water and sanitation.…”

Hepatitis A virus seroprevalence among children and adolescents in a high-burden HIV setting in urban South Africa

“…Furthermore, more www.nature.com/scientificreports/ than 1 in every 10 hepatitis A cases (13.3%) developed complicated hepatitis A or resulted in death 13 . Further to the high cost and morbidity/mortality, Bruckmann et al showed that HAV is currently the leading cause of pediatric acute liver failure requiring transplantation in South Africa, with even further expenses and disease burden to the health sector 14 .…”