A paradigm shift in the intention‐to‐transplant children with biliary atresia: Outcomes of 101 cases and a review of the literature

Abstract

For children with BA who do not benefit from Kasai surgery, the only therapeutic option is liver replacement and transplantation. The very decision to proceed for transplantation is a crucial point in time because it is the first step toward the preparation for the transplantation. The former time point is defined in this analysis as “intent‐to‐transplant” care pathway. In the life of every BA candidate for liver replacement, this point in time varies and mostly depends on the decision of their primary caring teams—about when to switch from supportive care to transplant, and thus to refer to a transplant center. This intent‐to‐transplant analysis of a series of 101 consecutive infants that were referred to a single transplant team showed that excellent overall outcome (97% survival) has been achieved overall. However, three deaths occurred that were clearly related to a late referral. This analysis and recent observations from other centers strongly support that the timing for referring these children to a transplant center and/or deciding to list them on the waiting list is currently too late and should be anticipated to what it is currently. This paradigm shift in the intention‐to‐transplant children is likely necessary for giving a better chance to an increased number of children and impacts positively on the general outcome. Networking and defining new tools for a rapid recognition of the infants who need early transplantation are necessary; centralization of these children may be helpful to achieve better outcomes than currently observed.

Meta-analysis and meta-regression of outcomes for adult living donor liver transplantation versus deceased donor liver transplantation

“…Specific factors contributing to longer waiting time for LDLT recipients in the U.S. were beyond the scope of our study, but it is likely that variable local access to LDLT in different states and additional time for LDLT referral and donor evaluation are involved. Shorter waiting time for LDLT recipients may specifically benefit patient populations that may be disadvantaged in current allocation schemes: children, women, and patients with HCC 46‐48 …”

“…Shorter waiting time for LDLT recipients may specifically benefit patient populations that may be disadvantaged in current allocation schemes: children, women, and patients with HCC. [46][47][48] LDLT was associated with an increased incidence of arterial complications in the early era. 49,50 However, in this meta-analysis, no difference in risk of HAT was observed between LDLT and DDLT recipients.…”

Anatomy of reducing left liver lobe grafts and monosegmental liver transplantation: Tell it as it is

“…One paradox of paediatric transplantation is that the outcome after surgery has improved so significantly, to the point where in some aetiological groups with difficult graft allocation, the mortality is higher during the waiting time, than it is after transplantation. 5 Preparing smaller grafts from the current donor pool, including from living donors, would be an optimal solution as it would shorten the graft allocation/transplantation process and allowing In 2018, the first laparoscopic preparation of a monosegment-II graft was reported by Hong et al, 6 followed rapidly by a second report by Li et al 7 in 2020; both teams used real-time IndoCyaninGreen (ICG) fluorescence cholangiography to help delineate anatomical landmarks. This third report by Rela et al 8 confirms the feasibility of the approach and the usefulness of ICG fluorescence guidance for anatomical delineation.…”

“…One paradox of paediatric transplantation is that the outcome after surgery has improved so significantly, to the point where in some aetiological groups with difficult graft allocation, the mortality is higher during the waiting time, than it is after transplantation 5 …”

In vitro fertilization: an unexpected finding in a cohort of patients with biliary atresia

“…BA patients have an excellent 5-year overall survival of 93% after KPE with or without subsequent LT ( 7 ), but early referral to a transplant center is essential, especially if cholestasis persists after KPE. However, the time taken to refer these children to a transplant center and/or to decide to list them for LT is currently too long and should be shortened ( 8 ). A paradigm shift in the intention to transplant is likely necessary, as late referral is associated with increased morbidity and mortality in affected patients.…”