ABSTRACTIntroductionBiliary atresia (BA) is the most common indication for liver transplantation (LT) in children. We aimed to identify risk factors associated with survival in young patients with BA in the modern era.MethodsWe performed a retrospective analysis of BA patients aged < 2 years who received their first isolated LT with available data from the United Network for Organ Sharing database (01/2013–12/2022). Factors included in the multivariable Cox regression were graft type, race/ethnicity, insurance status, laboratory pediatric end‐stage liver disease (PELD) score, history of portal vein thrombosis, and intensive care unit (ICU) status.Results1226 BA LT recipients aged < 2 years were included, of whom 501 (40.9%) received deceased donor whole grafts (DDWG), 425 (34.7%) received deceased donor technical variants (DDTV), and 300 (24.5%) received living donor LT (LDLT). LDLT recipients were more likely to be white (p = 0.008) and have private insurance (p < 0.001). Multivariable analysis demonstrated that ICU status (hazard ratio [HR] = 3.23, 95% confidence interval [95% CI]: 1.72–6.08, p < 0.001) and DDTV graft vs. LDLT (HR = 3.03, 95% CI: 1.14–8.04, p = 0.03) were associated with an increased risk of patient mortality. Factors associated with an increased risk of graft loss included ICU status (HR = 1.89, 95% CI: 1.19–3.00, p = 0.007) and both DDWG (HR = 3.37, 95% CI: 1.65–6.87, p = 0.001) and DDTV (HR = 3.47, 95% CI: 1.69–7.14, p = 0.001) grafts vs. LDLT.ConclusionLDLT is associated with improved survival in patients with BA aged < 2 years; however, socioeconomic differences exist between LDLT and non‐LDLT recipients. Efforts to promote early equitable referral to centers offering LDLT are essential for improving outcomes in young children with BA.

Organ procurement injury is an underreported yet preventable cause of allograft loss. In cases where procurement injury occurs, innovative methods for reconstruction are necessary to minimize organ discard rates given the nationwide organ shortage. The liver and suprahepatic inferior vena cava (IVC) are particularly vulnerable to injury during multiorgan procurements when multiple procurements teams are present. We report an extreme case of suprahepatic IVC injury and our method for repair that resulted in successful transplantation and adequate post-transplant graft function.

BACKGROUND:Liver transplantation (LT) is the only potentially curative option for children with unresectable hepatoblastoma (HBL). Although post-transplant outcomes have improved in the contemporary era, the impact of donor graft type on survival remains unclear. METHODS:Using the United Network for Organ Sharing database (02/2002-06/2021), demographics, clinical characteristics, and patient and graft survival were analyzed in children (<18 years) who underwent LT for HBL according to donor graft type. The Kaplan-Meier method, log-rank tests, and Cox regression modeling were used to evaluate the effect of whole, partial, and split deceased donor liver transplantation (DDLT) and living donor liver transplantation (LDLT) on patient and graft survival. RESULTS:A total of 590 pediatric HBL LT recipients (344 whole graft DDLT; 62 partial graft DDLT; 139 split graft DDLT; 45 LDLT) were included. During 2012-2021 the proportion of LDLTs for HBL decreased to about 5% compared with about 11% during 2002-2011. No significant differences were identified by donor graft type in either patient survival (log-rank test, p = .45) or graft survival (log-rank test, p = .69). The results remained similar during the 2002-2011 era, while during the 2012-2021 era, split graft DDLT was associated with decreased graft loss risk versus whole graft DDLT (hazard ratio: 0.48, 95% confidence interval: 0.23-0.99, p = .046) without any other significant between-group differences. CONCLUSIONS:Utilizing non-whole liver grafts can increase access to LT in children with unresectable HBL while ensuring favorable outcomes. LDLT is underutilized in children with HBL in the United States, and efforts to explore LDLT options should be undertaken.

Non-alcoholic steatohepatitis (NASH) is one of the leading indications for liver transplantation (LT) in the United States. As with the current obesity epidemic, the incidence of NASH continues to rise. However, the impact of broad utilization of bariatric surgery (BS) for patients with NASH is unknown, particularly in regard to mitigating the need for LT. Markov decision analysis was performed to simulate the lives of 20,000 patients with obesity and concomitant NASH who were deemed ineligible to be waitlisted for LT unless they achieved a body mass index (BMI) < 35 kg/m2. Life expectancy following medical weight management (MWM) and sleeve gastrectomy (SG) were estimated. Base case patients were defined as having NASH without fibrosis and a pre-intervention BMI of 45 kg/m2. Sensitivity analysis of initial BMI was performed. Simulated base case analysis patients who underwent SG gained 14.3 years of life compared to patients who underwent MWM. One year after weight loss intervention, 9

BACKGROUND:Hepatic undifferentiated embryonal sarcoma (HUES) is the third most common primary hepatic malignancy in children. If unresectable, liver transplantation (LT) is the only curative option. Historically, HUES LT outcomes were not favorable; however, modern-era data are lacking. We aimed to describe LT outcomes in children with HUES and compared with LT outcomes in children transplanted for hepatoblastoma (HBL) and non-malignancy indications. METHODS:Children 18 years or younger with HUES who underwent LT from 1987 to 2021 were identified from the Scientific Registry of Transplant Recipients database. Graft and patient survival were studied in HUES and LT recipients with HBL and non-malignancy indications using Kaplan-Meier analysis. Cox regression was used to compare patient and graft survival among groups, controlling for confounders. RESULTS:Twenty-one children with HUES underwent LT during the study period with a median age at LT of 10 years (IQR: 8-12 years). One and five-year patient survival for HUES recipients was not significantly different from that of recipients with HBL (p = .3) or non-malignancy diagnoses (p = .6). There were no deaths due to HUES recurrence. In multivariable Cox regression, HUES did not increase risk of either patient or graft loss as compared to HBL (HR 2.36, p = .2) or non-malignancy indications (HR 0.74, p = .7). CONCLUSION:LT outcomes are more favorable in patients with HUES than historically described, and similar to LT outcomes of patients with HBL and non-malignancy indications. Transplant should be considered for HUES patients with unresectable localized tumors.

Introduction: Creatinine, bilirubin, and fibrinolysis resistance are associated with multi-organ dysfunction and likely risk factors for prolonged intensive care unit (pICU) stay following liver transplantation (LT). We hypothesize postoperative day-1 (POD-1) labs will predict pICU. Methods: LT recipients had clinical laboratories and viscoelastic testing with tissue plasminogen activator thrombelastography (tPA TEG) to quantify fibrinolysis resistance (LY30) on POD-1. pICU was defined as one week or longer in the ICU. Logistic regression was used to identify the relationship between POD-1 labs and pICU. Results: Of 304 patients, 50% went to the ICU, with 15% experiencing pICU. Elevated creatinine (OR 6.6, P < 0.001) and low tPA TEG LY30 (OR 3.7, P 1/4 0.004) were independent predictors of pICU after controlling for other risk factors. A 9-fold increase in the rate of 90-day graft loss (19% vs 2% p < 0.001) was observed patients who had these risk factors for pICU. Conclusion: Elevated creatine and fibrinolysis resistance are associated with pICU and poor outcomes following LT.

The authors regret that there was an error in the abstract of the original manuscript published. The text should read "3438 children with biliary atresia were listed for transplant during the study period, with 15% of them listed for a primary transplant, 67% for salvage transplant after early failure, and 17% after late failure". The percentages for early and late failure were erroneously swapped in the originally published version. The authors would like to apologise for any inconvenience caused. DOI of original article: 10.1097/HC9.0000000000000175. Primary vs. salvage liver transplantation for biliary atresia: A retrospective cohort studyJournal of Pediatric SurgeryVol. 57Issue 10PreviewBiliary atresia (BA) is the most common cause of end stage liver disease (ESLD) leading to liver transplantation (LT) in children. The current standard of care is to perform a Kasai hepatoportoenterostomy (HPE) for BA early in life (within 3 months of age) in an attempt to restore the flow of bile and reverse cholestasis. While this surgery may delay or even prevent progression to ESLD in some instances, the majority of children with BA experience HPE failure and eventually require a salvage LT [1–8]. Full-Text PDF

Background Each year, children die awaiting LT as the demand for grafts exceeds the available supply. Candidates with public health insurance are significantly less likely to undergo both deceased donor LT and D-LLD LT. ND-LLD is another option to gain access to a graft. The aim of this study was to evaluate if recipient insurance type is associated with likelihood of D-LLD versus ND-LLD LT. Methods The SRTR/OPTN database was reviewed for pediatric LDLT performed between January 1, 2014 (Medicaid expansion era) and December 31, 2019 at centers that performed >= 1 ND-LLD LDLT during the study period. A multivariable logistic regression was performed to assess relationship between type of living donor (directed vs. non-directed) and recipient insurance. Results Of 299 pediatric LDLT, 46 (15%) were from ND-LLD performed at 18 transplant centers. Fifty-nine percent of ND-LLD recipients had public insurance in comparison to 40% of D-LLD recipients (p = .02). Public insurance was associated with greater odds of ND-LLD in comparison to D-LLD upon multivariable logistic regression (OR 2.37, 95% CI 1.23-4.58, p = .01). Conclusions ND-LLD allows additional children to receive LTs and may help address some of the socioeconomic disparity in pediatric LDLT, but currently account for only a minority of LDLT and are only performed at a few institutions. Initiatives to improve access to both D-LLD and ND-LLD transplants are needed.

Background Acute kidney injury (AKI) is common in pediatric patients undergoing liver transplantation (LT), with an incidence 17%-55%. Fluid, metabolic, and acid-base aberrancies are often pronounced pre-operatively and further worsened by events during LT, making intra-operative continuous renal replacement therapy (CRRT) an option for critically ill LT recipients. Methods All pediatric LT performed at our institution who underwent intra-operative CRRT between January 2017 and August 2021 were included. Patient demographics and clinical data including graft outcomes, intra-operative findings, and timing and indications for CRRT were collected from the electronic medical record. Results CRRT was used in nine of the 76 (12%) pediatric LT performed at our center during the study period. Ages at LT ranged from 39 to 17.7 years. Recipients requiring CRRT were more likely to have acute liver failure, status 1A, and higher calculated MELD/PELD scores. CRRT was initiated pre-transplant in three recipients and continued post-transplant in six recipients. Median duration of CRRT was two (range 0-14) days. Indications included hyperammonemia (3/9), acidosis (3/9), fluid overload (6/9), and hyperkalemia (2/9). The CRRT group had a significantly longer post-transplant intensive care unit length of stay in comparison to those that did not require CRRT (median 6, range 3-40 days vs. median 3, range 0-121 days, p = .02], but there were no significant differences in reoperations, hospital length of stay, or recipient or graft survival. Conclusions We demonstrate that CRRT can be safely performed in pediatric LT recipients, including young infants through adolescents.