Pediatric Liver Transplant Outcome Using Severe Hypernatremic Donors M. Uribe, A. Alba, G. González, B. Hunter, C. Heine, R. Íñiguez, S. Cavallieri, L. Flores, P. Soto, H. Auad, R. Zuleta, and C. Acuña ABSTRACT Introduction. Pediatric liver transplantation is limited by donation. In the last 5 years, urgent conditions have forced transplant teams to accept donors with minor suboptimal conditions, termed “extended donor criteria.” Among those, the risk of using severe hypernatremic donors (SHD) for liver transplant is not yet well established. The aim of this study is to report the outcome of pediatric patients receiving grafts from SHD. Methods. Clinical records of patients transplanted in the last 3 years at Hospital Luis Calvo Mackenna, Santiago, Chile, were reviewed. Outcome was evaluated in terms of patient and graft survival and complications potentially associated to the donor condition. Results. Five of 33 deceased donor transplants presented with SHD. All recipients were waiting transplant in an acute condition, one of them in acute liver failure (ALF). No living related donor was available. Donors’ serum sodium was 169 to 193 mEq/L before medical management and between 157 and 172 mEq/L at procurement. One patient died from sepsis related to biliary complications, and the patient suffering ALF developed primary graft nonfunction, received a second transplant 2 weeks later, and recovered to stable medical condition. No other complication was registered in these patients. Discussion. Our findings allow us to postulate that hypernatremic deceased donors may be used for pediatric liver transplant under special circumstances.
L
IVER TRANSPLANTATION is limited by the number and opportunity of donors, worldwide and also in Chile.1 As it may be an urgent procedure, and the demand is increasing every year, the scarcity of donors has led to relax traditional restrictions to donation and the concept of extended donor criteria (EDC) or marginal donor has arisen.2e4 Potential donors with severe hypernatremia (SHD; Na 165 mEq/L) are excluded or possible considered as EDC, because this condition is associated to primary graft failure in recipients in some reports.5,6 The pathophysiologic mechanism explaining this association has not yet being established. Recent publications in adults have reported the experience of using SHD without any difference in complications or survival of the recipients.7 The aim of this study is to present the experience of using EDC with SHD in pediatric liver recipients in a single center in Chile.
METHODS Information was collected from clinical reports of all pediatric liver transplants between 2008 and 2011 in Hospital Luis Calvo Mackenna. Of 43 transplants performed, 10 grafts were from living donors and 33 from deceased donors. Potential donors with hypernatremia were treated with desmopressin and hypotonic solutions. Serum sodium was registered at the time of donation and at procurement, after treatment of hypernatremia. Clinical characteristics, complications, and outcome of the recipients were analyzed.
From the Hospital Luis Calvo Mackenna (M.U., A.A., G.G., B.H., C.H., R.Í., S.C., L.F., P.S., H.A., R.Z., C.A.) and Universidad de Chile, Santiago, Chile. Address reprint requests to M. Uribe, MD, Pediatric Liver Transplant Program, Hospital Luis Calvo Mackenna, Lo Fontecilla 441, Las Condes, Santiago, Chile. E-mail: [email protected]
0041-1345/13/$esee front matter http://dx.doi.org/10.1016/j.transproceed.2013.08.078
ª 2013 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
3726
Transplantation Proceedings, 45, 3726e3727 (2013)
PEDIATRIC TRANSPLANT USING SEVERE HYPERNATREMIC DONORS
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Table 1. Clinical Characteristics of 5 Recipients of Liver Transplant From Severe Hypernatremic Donors in Hospital Luis Calvo Mackenna, Chile Diagnosis
Age (y)/gender
Initial Na (mEq/L)
Final Na ( mEq/L)
Graft Primary Nonfunction
Death
a-1- antitripsin deficit
7/F 1.9/F 11/F 10/M 6/M
193 172 178 182 169 178 (172e193)
157 172 170 164 158 164 (157e172)
No No No No Yes
No Yes No No No
Biliary atresia Autoimmune hepatitis Hepatoblastoma Acute liver failure Median Range
Cause
Sepsis
RESULTS
REFERENCES
Thirty-three patients received livers from deceased donors, 5 of them with SHD. All recipients were in a life-threatening condition before transplantation, and no living donor was available. Donors’ serum sodium was 169 to 193 mEq/L before medical management and between 157 and 172 mEq/L at procurement (Table 1). Indications for transplant were severe decompensated chronic liver disease in 4 cases and acute liver failure (ALF) in 1. This patient required a second transplant due to primary nonfunction. One patient died due to biliary and infectious complications.
1. Uribe M, et al. Epidemiology and results of liver transplantation for acute liver failure in Chile. Transplant Proc. 2003;35(7):2511e2512. 2. Lopez-Navidad A, Caballero F. Extended criteria for organ acceptance. Strategies for achieving organ safety and for increasing organ pool. Clin Transplant. 2003;17(4): 308e324. 3. Alkofer B, et al. Extended-donor criteria liver allografts. Semin Liver Dis. 2006;26(3):221e233. 4. Harring TR, O’Mahony CA, Goss JA. Extended donors in liver transplantation. Clin Liver Dis. 2011;15(4):879e900. 5. Castaneda-Martinez PD, et al. Anesthetic risk factors associated with early mortality in pediatric liver transplantation. Transplant Proc. 2010;42(6):2383e2386. 6. Al-Sarraf AJ, et al. Central pontine myelinolysis after orthotopic liver transplantda rare complication. Exp Clin Transplant. 2010;8(4):321e324. 7. Mangus RS, et al. Severe hypernatremia in deceased liver donors does not impact early transplant outcome. Transplantation. 2010;90(4):438e443. 8. Gastaca M. Extended criteria donors in liver transplantation: adapting donor quality and recipient. Transplant Proc. 2009;41(3): 975e979. 9. Uribe M, et al. ABO-incompatible liver transplantation: a new therapeutic option for patients with acute liver failure in Chile. Transplant Proc. 2005;37(3):1567e1568. 10. Uribe M, et al. Pediatric liver transplantation: ten years of experience in a multicentric program in Chile. Transplant Proc. 2005;37(8):3375e3377. 11. Uribe M, et al. Chilean experience in liver transplantation for acute liver failure in children. Transplant Proc. 2010;42(1): 293e295.
DISCUSSION
The use of expanded criteria donors due to hypernatremia in pediatric liver transplant was not associated with increased morbidity or mortality and can expand the donor pool in urgent cases. This was especially important in the ALF patient, as he developed primary graft nonfunction and required retransplantation. The first liver provided a stable bridge for a patient in a life-threatening condition, as other alternatives have been used.8,9 As we have previously reported, ALF accounts for 20% of causes of pediatric liver transplant in our country, and the low rate of donation has compelled us to use living related donors or EDC with good results.10,11 Our findings allows us to postulate that hypernatremic deceased donors may be used for pediatric liver transplantation under special circumstances.
L
IVER TRANSPLANTATION is limited by the number and opportunity of donors, worldwide and also in Chile.1 As it may be an urgent procedure, and the demand is increasing every year, the scarcity of donors has led to relax traditional restrictions to donation and the concept of extended donor criteria (EDC) or marginal donor has arisen.2e4 Potential donors with severe hypernatremia (SHD; Na 165 mEq/L) are excluded or possible considered as EDC, because this condition is associated to primary graft failure in recipients in some reports.5,6 The pathophysiologic mechanism explaining this association has not yet being established. Recent publications in adults have reported the experience of using SHD without any difference in complications or survival of the recipients.7 The aim of this study is to present the experience of using EDC with SHD in pediatric liver recipients in a single center in Chile.
METHODS Information was collected from clinical reports of all pediatric liver transplants between 2008 and 2011 in Hospital Luis Calvo Mackenna. Of 43 transplants performed, 10 grafts were from living donors and 33 from deceased donors. Potential donors with hypernatremia were treated with desmopressin and hypotonic solutions. Serum sodium was registered at the time of donation and at procurement, after treatment of hypernatremia. Clinical characteristics, complications, and outcome of the recipients were analyzed.
From the Hospital Luis Calvo Mackenna (M.U., A.A., G.G., B.H., C.H., R.Í., S.C., L.F., P.S., H.A., R.Z., C.A.) and Universidad de Chile, Santiago, Chile. Address reprint requests to M. Uribe, MD, Pediatric Liver Transplant Program, Hospital Luis Calvo Mackenna, Lo Fontecilla 441, Las Condes, Santiago, Chile. E-mail: [email protected]
0041-1345/13/$esee front matter http://dx.doi.org/10.1016/j.transproceed.2013.08.078
ª 2013 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
3726
Transplantation Proceedings, 45, 3726e3727 (2013)
PEDIATRIC TRANSPLANT USING SEVERE HYPERNATREMIC DONORS
3727
Table 1. Clinical Characteristics of 5 Recipients of Liver Transplant From Severe Hypernatremic Donors in Hospital Luis Calvo Mackenna, Chile Diagnosis
Age (y)/gender
Initial Na (mEq/L)
Final Na ( mEq/L)
Graft Primary Nonfunction
Death
a-1- antitripsin deficit
7/F 1.9/F 11/F 10/M 6/M
193 172 178 182 169 178 (172e193)
157 172 170 164 158 164 (157e172)
No No No No Yes
No Yes No No No
Biliary atresia Autoimmune hepatitis Hepatoblastoma Acute liver failure Median Range
Cause
Sepsis
RESULTS
REFERENCES
Thirty-three patients received livers from deceased donors, 5 of them with SHD. All recipients were in a life-threatening condition before transplantation, and no living donor was available. Donors’ serum sodium was 169 to 193 mEq/L before medical management and between 157 and 172 mEq/L at procurement (Table 1). Indications for transplant were severe decompensated chronic liver disease in 4 cases and acute liver failure (ALF) in 1. This patient required a second transplant due to primary nonfunction. One patient died due to biliary and infectious complications.
1. Uribe M, et al. Epidemiology and results of liver transplantation for acute liver failure in Chile. Transplant Proc. 2003;35(7):2511e2512. 2. Lopez-Navidad A, Caballero F. Extended criteria for organ acceptance. Strategies for achieving organ safety and for increasing organ pool. Clin Transplant. 2003;17(4): 308e324. 3. Alkofer B, et al. Extended-donor criteria liver allografts. Semin Liver Dis. 2006;26(3):221e233. 4. Harring TR, O’Mahony CA, Goss JA. Extended donors in liver transplantation. Clin Liver Dis. 2011;15(4):879e900. 5. Castaneda-Martinez PD, et al. Anesthetic risk factors associated with early mortality in pediatric liver transplantation. Transplant Proc. 2010;42(6):2383e2386. 6. Al-Sarraf AJ, et al. Central pontine myelinolysis after orthotopic liver transplantda rare complication. Exp Clin Transplant. 2010;8(4):321e324. 7. Mangus RS, et al. Severe hypernatremia in deceased liver donors does not impact early transplant outcome. Transplantation. 2010;90(4):438e443. 8. Gastaca M. Extended criteria donors in liver transplantation: adapting donor quality and recipient. Transplant Proc. 2009;41(3): 975e979. 9. Uribe M, et al. ABO-incompatible liver transplantation: a new therapeutic option for patients with acute liver failure in Chile. Transplant Proc. 2005;37(3):1567e1568. 10. Uribe M, et al. Pediatric liver transplantation: ten years of experience in a multicentric program in Chile. Transplant Proc. 2005;37(8):3375e3377. 11. Uribe M, et al. Chilean experience in liver transplantation for acute liver failure in children. Transplant Proc. 2010;42(1): 293e295.
DISCUSSION
The use of expanded criteria donors due to hypernatremia in pediatric liver transplant was not associated with increased morbidity or mortality and can expand the donor pool in urgent cases. This was especially important in the ALF patient, as he developed primary graft nonfunction and required retransplantation. The first liver provided a stable bridge for a patient in a life-threatening condition, as other alternatives have been used.8,9 As we have previously reported, ALF accounts for 20% of causes of pediatric liver transplant in our country, and the low rate of donation has compelled us to use living related donors or EDC with good results.10,11 Our findings allows us to postulate that hypernatremic deceased donors may be used for pediatric liver transplantation under special circumstances.
