Pediatric liver transplantation: a North American perspective

Abstract

Liver transplantation (LT) is an important component in the therapeutic armamentarium of managing end-stage liver disease. In North American children, biliary atresia remains the most common indication for LT compared to hepatitis C in adults, while hepatoblastoma is the most common liver tumor requiring LT, versus Hepatocellular carcinoma in adults. Rejection, lymphoproliferative disease, renal insufficiency, metabolic syndrome, recurrent disease, 'de novo' autoimmune hepatitis and malignancy require careful surveillance and prompt action in adults and children after LT. In children, specific attention to EBV viremia, growth, development, adherence and transition to the adult services is also required. Antibody mediated rejection and screening for donor specific antibodies is becoming important in managing liver graft dysfunction. Biomarkers to identify and predict tolerance are being developed. Machine perfusion and stem cells (iPS) to synthesize organs are generating interest and are a focus for research.

Live vaccines after pediatric solid organ transplant: Proceedings of a consensus meeting, 2018

“…Patients receiving sirolimus were not included in these studies. These are consistent with previously published definitions of “maintenance” immune suppression for pediatric liver transplantation where the goal is often low dose (3‐10 mg prednisone) or cessation of steroid with calcineurin inhibitor monotherapy . The consortium agreed on the following thresholds: tacrolimus trough levels of <8 ng/mL for two consecutive readings or cyclosporine levels of <100 ng/mL for two consecutive readings. prednisone dose equivalent to <2 mg/kg/d or total cumulative dose of <20 mg/d for those >10 kg. …”

“…There are concerns that live viral vaccines could precipitate rejection . Literature review found only one reported case of acute rejection temporally associated with live vaccination, which occurred 21 days after measles‐containing vaccine in a liver transplant recipient (Table ).…”

“…These are consistent with previously published definitions of "maintenance" immune suppression for pediatric liver transplantation where the goal is often low dose (3-10 mg prednisone) or cessation of steroid with calcineurin inhibitor monotherapy. 49 The consortium agreed on the following thresholds:…”

“…Up to one‐third of pediatric liver transplants have a rejection episode . In the setting of allograft rejection, Posfay‐Barbe et al administered MMR and/or VV at least 2 months after completion of treatment for rejection, while others administered MMR and/or VV 6 months post‐rejection.…”

Similarities and Differences in Allocation Policies for Pediatric Liver Transplantation Across the World

“…Liver transplantation (LT) is a life saving treatment for children with decompensated chronic liver disease, unresectable tumors, fulminant liver failure, and in some instances also for inherited metabolic conditions (1)(2). Stepwise innovations in surgical techniques, living donor (LD) LT, as well as the use of reduced size or split grafts have emerged in the last decades, increasing graft utilization for pediatric recipients.…”