Disclosures Donor selection in pediatric liver transplant I have - - PowerPoint PPT Presentation

• 9/30/2016
• 1

Donor selection in pediatric liver transplant

Garrett R. Roll, MD Assistant Professor of Surgery

Disclosures

I have nothing to disclose

Overview

Graft types: Living donor (LD) Deceased donor (DD) Deceased donor split (DD S) ABO incompatible liver transplant Graft availability (not type) is most important Large single center reports from other countries Graft selection in the United States

Basics

Biliary complications are more common

Small size of the biliary structures Use of partial liver grafts with multiple bile ducts Higher risk of hepatic artery thrombosis

Children compete with adults Growth failure… Organ availability, especially for very small children is limited and not uniform

• 9/30/2016
• 2

Where are we now?

~600 transplants per year United States graft mix: DD 52% DD S 33% LD 15%

Kamath and Olthoff 2010

As we see in the adult LDLT literature,

• ur data dominated

by whole organ experience

Where are we now?

Kamath and Olthoff 2010

2014 OPTN annual report

From 2004 to 2014: Waiting time is shorter Transplanted in a year of listing: 29% to 44% Candidates removed in 2014: 80% Transplanted 10% Improved 5% Died waiting 2% Too sick for transplant

OPTN Annual Rep 2014

Data quality…

Single center or database studies Studies include multiple eras shifting practices landmark studies: older eras Most data describes outcomes from the time of transplant (selection bias) Data is difficult to generalize NOTE:

• 9/30/2016
• 3

Specific graft types

Deceased donor (DD) Split (DD S) Living donor (LD)

Graft basics - LD

Cannot meet the organ demand the West Shortest waiting time Cultural variation Donor’s health must be considered Knowledge and experience continues to grow Early reports of worse outcomes after LD have improved in recent eras

Graft basics - LD

Braun H et al, Trans 2016

Left lobe grafts minimize donor risk Have to balance the risk between donor and recipient Adult to adult LD

Would not do LD if we had unlimited DD organs

If DD available, there is no recipient benefit

LD : More complex, puts donor at risk

And, no benefit to the donor

Graft basics - LD

Benefit comes from shorter waiting time BUT WE DO NOT HAVE ENOUGH DD ORGANS

• 9/30/2016
• 4

1 6 11 16 21 26 31 36 41 1 2 3 4 5 Match MELD Quintile (for a DDLT at that DSA) Adjusted Odds Ratio for LDLT

Access to deceased donors influences LDLT Acceptable risk of death?

Providers: “1% mortality” Public:

Lansom JD et al 2014

When asked… Public perception is that some risk is acceptable

Worldwide deaths

• f living donors

Center specific risk of death maybe lower

SG Lee 4000 LDLT without a death CL Chen 1200 LDLT without a death

Cheah YL et al. Liver Transpl 2013

Total donor deaths = 34

Risk of death 0.1 to 0.5%

Deceased donor whole organ (DD)

Size is important Min donor weight (1/2 weight) Longest waiting time Very young donors may yield worse outcomes Ethically: the most straightforward

Graft basics - DD

Least technically challenging Location/cold time Colorado

• 9/30/2016
• 5

Deceased donor split (DD S)

Historically higher risk complications Adult recipient More complex logistics Vessel allocation

Graft basics – split

Size in important Max donor weight (10:1 rule)

Graft basics – DD S

How to think about donor options

(Based on data of outcomes from the time of transplant)

Complications Availability DD LD DD S

Graft preference

Based on outcomes from the time of transplant: Graft selection in children < 2 years

Roberts JP, Herbert-Shearon T et al 2004

• 9/30/2016
• 6

Brazil

Recent retrospective cohort study

670 pediatric liver transplants 89% LD 80%LLS, 13%LL, 1% RL 6% DD S

Feier, Seda-Neto et al 2016

5% DD

Brazil

Biliary complication HAT Living donor 17% 4% DD 16% 5%

Feier, Seda-Neto et al 2016

Brazil

Feier, Seda-Neto et al 2016

Risk factors for bile leak or stricture

United Kingdom

Median donor age: 33 Range: 15-63

• 9/30/2016
• 7

United Kingdom United Kingdom United Kingdom

Waitlist deaths per year

United Kingdom

Attempting to reduce waiting time even further Subgroup analysis: extended criteria donors

• 9/30/2016
• 8

United Kingdom

Thoughtful vessel allocation

Small RHA can increase risk in the adult Size mismatch Short length (+/- interposition graft) Reconstruct the CHA stem during the split Send the reconstructed artery to the adult hospital Child generally gets the PHA

ABO incompatible

Rana et al 2016

More recent Japanese literature LDLT literature suggest equivalent outcomes

Initial poor Outcomes Plasma exchange OKT3

ABO incompatible

Two eras Plasma exchange and OKT3 Versus Anti ABO antibody titers 10,728 ABO identical 1,911 ABO compatible 540 ABO incompatible

Rana et al 2016

• Re-examined in 2016

ABO incompatible

Anti ABO titers Improved outcomes in Status 1 recipients over time

• 9/30/2016
• 9

Summary: Graft failure rates

Conclusions

ABOi and LDLT are very important for children under 2 Availability and local practice are the most important factors in graft selection (not graft type)

Complications Availability DD LD DD S

Huge variation in practice, but good outcomes are being achieved with all graft types