� 9/30/2016 Disclosures Donor selection in pediatric liver transplant I have nothing to disclose Garrett R. Roll, MD Assistant Professor of Surgery Overview Basics Graft types: Growth failure… Living donor (LD) Deceased donor (DD) Children compete with adults Deceased donor split (DD S) Graft selection in the United States Biliary complications are more common Small size of the biliary structures Large single center reports from other countries Use of partial liver grafts with multiple bile ducts Higher risk of hepatic artery thrombosis ABO incompatible liver transplant Organ availability, especially for very small children is Graft availability (not type) is most important limited and not uniform � 1
� 9/30/2016 Where are we now? Where are we now? ~600 transplants per year United States graft mix: As we see in the DD 52% adult LDLT literature, our data dominated DD S 33% by whole organ experience LD 15% Kamath and Olthoff 2010 Kamath and Olthoff 2010 Data quality… 2014 OPTN annual report From 2004 to 2014: Single center or database studies Waiting time is shorter Studies include multiple eras Transplanted in a year of listing: 29% to 44% shifting practices landmark studies: older eras Candidates removed in 2014: Most data describes outcomes from the time of transplant (selection bias) 80% Transplanted 10% Improved NOTE: 5% Died waiting Data is difficult to generalize 2% Too sick for transplant OPTN Annual Rep 2014 � 2
� 9/30/2016 Graft basics - LD Specific graft types Shortest waiting time Deceased donor (DD) Cultural variation Cannot meet the organ demand the West Donor ’ s health must be considered Split (DD S) Knowledge and experience continues to grow Living donor (LD) Early reports of worse outcomes after LD have improved in recent eras Graft basics - LD Graft basics - LD Have to balance the Benefit comes from shorter waiting time risk between donor and recipient 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 Adult to adult LD Left lobe grafts minimize donor risk BUT WE DO NOT HAVE ENOUGH DD ORGANS Braun H et al, Trans 2016 � 3
� 9/30/2016 Access to deceased donors influences LDLT Acceptable risk of death? When asked… 41 Providers: “1% mortality” Adjusted Odds Ratio for LDLT 36 Public: 31 26 21 16 11 6 1 1 2 3 4 5 Match MELD Quintile (for a DDLT at that DSA) Public perception is that some risk is acceptable Lansom JD et al 2014 Graft basics - DD Worldwide deaths of living donors Deceased donor whole organ (DD) Total donor deaths = 34 Longest waiting time Risk of death 0.1 to 0.5% Size is important Min donor weight (1/2 weight) Center specific risk of death maybe lower Ethically: the most straightforward � SG Lee 4000 LDLT without a death Least technically challenging � CL Chen 1200 LDLT without a death Very young donors may yield worse outcomes Location/cold time Colorado Cheah YL et al. Liver Transpl 2013 � 4
� 9/30/2016 Graft basics – split Graft basics – DD S Deceased donor split (DD S) Historically higher risk complications Adult recipient More complex logistics Vessel allocation Size in important Max donor weight (10:1 rule) How to think about donor options Graft preference (Based on data of outcomes from Based on outcomes from the time of transplant: the time of transplant) Graft selection in children < 2 years DD S Complications LD DD Availability Roberts JP, Herbert-Shearon T et al 2004 � 5
9/30/2016 � Brazil Brazil Recent retrospective cohort study 670 pediatric liver transplants Biliary HAT 89% LD 80%LLS, 13%LL, 1% RL complication 6% DD S Living donor 17% 4% 5% DD DD 16% 5% Feier, Seda-Neto et al 2016 Feier, Seda-Neto et al 2016 Brazil United Kingdom Risk factors for bile leak or stricture Median donor age: 33 Range: 15-63 Feier, Seda-Neto et al 2016 6 �
� 9/30/2016 United Kingdom United Kingdom United Kingdom United Kingdom Subgroup analysis: extended criteria donors Waitlist deaths per year Attempting to reduce waiting time even further � 7
� 9/30/2016 United Kingdom ABO incompatible Thoughtful vessel allocation Child generally gets the PHA Initial poor Outcomes Small RHA can increase risk in the adult Size mismatch Plasma exchange Short length (+/- interposition graft) OKT3 Reconstruct the CHA stem during the split More recent Japanese literature LDLT literature Send the reconstructed artery to the adult hospital suggest equivalent outcomes Rana et al 2016 ABO incompatible ABO incompatible Anti ABO titers Re-examined in 2016 � Improved outcomes in Status 1 recipients over time 10,728 ABO identical 1,911 ABO compatible 540 ABO incompatible Two eras Plasma exchange and OKT3 Versus Anti ABO antibody titers Rana et al 2016 � 8
� 9/30/2016 Summary: Conclusions Graft failure rates DD S Complications LD DD Availability Huge variation in practice, but good outcomes are being achieved with all graft types Availability and local practice are the most important factors in graft selection (not graft type) ABOi and LDLT are very important for children under 2 � 9
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