Nine to twenty-nine percent of pediatric liver transplant recipients require retransplantation. No previous pediatric study has proposed a prognostic scoring system. We have used the United Network for Organ Sharing transplantation database to conduct a retrospective cohort study of patients who were less than 18 years of age when they received their retransplant (n ϭ 1130). Using a random two-thirds of the subjects, we developed a prognostic scoring system by performing a multivariate Cox analysis with non-laboratory clinical characteristics. The scoring system was verified in the remaining one-third of the subjects. Stratifying the verification group into risk groups by prognostic score demonstrated its predictive value. Those in the low-risk category had survival similar to that of primary liver transplant recipients. Those in the high-risk category had 2.4 (95% confidence interval: 1.6-3.7) times the risk of death or retransplantation as those in the low-risk category. Risk factors in the scoring system included being on life support at the time of retransplant, receiving a split liver graft, and having an original diagnosis of neonatal cholestasis, familial cholestasis, paucity of bile ducts, or congenital abnormalities. Protective factors in the scoring system included older age at the time of transplantation and having acute rejection contribute to graft failure. In conclusion, with simple clinical characteristics, this scoring tool can modestly discriminate between those children at high risk and those children at low risk of poor outcome after liver retransplantation. Liver Transpl 15:199-207, 2009 Hepatic retransplantation is the only option for survival when a transplanted liver fails. Retransplantation accounts for 10% to 22% of liver transplants worldwide across all ages, 1 and in previous single-center series, 9% to 29% of pediatric liver transplant recipients were eventually retransplanted.2-9 Given the scarcity of donor organs, the ethics of retransplantation have been controversial. 10,11 In pediatrics, the more frequent use of split organs and living related donors somewhat attenuates the zero-sum game dynamics of organ donation. Nonetheless, understanding the outcomes of retransplantation in children is paramount for caring for these complicated patients and for deciding how to ethically distribute the scarce resource of donated organs.The outcomes of retransplantation have been examined in greater depth in adults than in children. Prognostic models have been created for adults undergoing retransplantation, 1,10,12-14 but none has been created for children. In at least 1 previous series, it has been shown that pediatric retransplant patients have better outcomes than adult patients. 15 Many series have evaluated the outcomes of children undergoing retransplantation at single centers, and recently a single multicenter study involving the Studies of Pediatric Liver Transplantation (SPLIT) registry was published. 3,8,9,[16][17][18][19][20][21][22] The single-center reports lacked a sufficient num...

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Objective-To examine the clinical significance of elevated conjugated bilirubin (CB) levels in newborns.Study design-This retrospective study evaluated a birth cohort of 271,186 full-term newborns born within a Northern California hospital network from [1995][1996][1997][1998][1999][2000][2001][2002][2003][2004]. All CB and direct bilirubin (DB) levels were available in a database and were correlated with the patients' in and out patient ICD-9 diagnoses.Results-The 99 th percentile for CB is 0.5 mg/dL, and the 99 th percentile for DB is 2.1 mg/dL. CB levels between 0.5-1.9 mg/dL can be associated with infection, but most often remain unexplained. Liver and biliary disease become increasingly likely as CB levels increase, for CB ≥5 mg/dL 47% have biliary disease and 43% have liver disease.Conclusions-CB and DB levels are not interchangeable. In newborns with CB levels ≥0.5 mg/ dL and <2 mg/dL, infection must be ruled out and the newborn should be followed. In newborns with levels ≥2 mg/dL, a more in-depth assessment of the hepatobiliary system is indicated. Keywords conjugated bilirubin; epidemiology; newborn; cholestasis; diagnostic test Neonatal jaundice occurs in about two thirds of all newborns.(1) The vast majority of jaundiced newborns have elevated unconjugated bilirubin levels, most often due to hemolytic causes. A small minority have cholestasis with causes including congenital abnormalities and infectious, metabolic, iatrogenic and idiopathic disorders.(2) Identifying these newborns cholestasis from the masses of jaundiced newborns can be difficult but is important for early diagnosis and treatment. For this reason, conjugated (CB) and directreacting bilirubin levels (DB) are often measured. Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. However, CB and DB are inherently different. Unconjugated bilirubin is the breakdown product of heme. In the liver, it is converted to CB by the conjugation of glucuronic acid. A small portion, termed delta bilirubin, is CB covalently bound to albumin. Direct bilirubin (DB) measurements estimate the total concentration of the conjugated and the delta bilirubin. The method used today in most laboratories takes advantage of unconjugated bilirubin being a poor reactant with a diazo reagent without an accelerant.(3) On the other hand, CB will react "directly" with the reagent without an accelerant. However, in high concentrations some unconjugated bilirubin will react with the diazo reagent without addition of the accelerant causing DB measurements to overestimate the concentration of CB. CB measurements are generally made u...

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