Faculty Bibliography

INTRODUCTION/BACKGROUND:Biological parental donations provide the best option for many pediatric recipients, yielding unique immunological benefits that may enable minimization of immunosuppression in transplanted children. However, living related maternal donation in the postpartum period may introduce an increased risk of donor complications due to the physiological changes of pregnancy and childbirth, and the optimal timing of postpartum living donation is unknown. METHODS:Using US national registry data, we characterized donor and recipient outcomes for pediatric living donor liver transplants performed between 2004 and 2022 where a biological mother donated to a child ≤ 24 months old. RESULTS:Our study population included 256 donor-recipient pairs, with biliary atresia representing the most common indication for transplantation (68.0%). Donors had a median [IQR] age of 30 [25, 34] years, and the median [IQR] time from birth to donation was 9.0 [6.8, 13.0] months. 6.3% of donors experienced a biliary or other complication. When stratifying by donors who donated ≤ 6 vs. > 6 months postpartum, we found no significant differences in donor complications or readmission. Stratified analyses were also comparable for recipient mortality, graft survival, and rejection-free survival. Donors ≤ 6 months postpartum (n = 64) were more likely to experience reoperation than mothers who donated > 6 months postpartum (n = 192) (6.2% vs. 1.0%, p = 0.04). CONCLUSIONS:While maternal living donor liver transplantation is safe for most donors, there is a higher risk of reoperation when donation is performed ≤ 6 months postpartum. Surgeons should be aware that these donors are a higher risk population, requiring discussion upon consent and warranting close post-operative monitoring.

BACKGROUND AND AIM/OBJECTIVE:Optimizing health and quality of life for pediatric liver transplant (LT) recipients requires balancing protection of the liver graft with overall burden of treatments on the child. Since the AASLD's 2013 guidelines, strategies for achieving this balance have evolved, with a particular focus on mitigating long-term complications. Advances include operative and intensive care strategies for reducing complications, minimizing exposure to immunosuppression and its long-term adverse effects for other organs, infection prevention with prophylaxis and vaccination, optimizing support of early nutrition and development, and improving support around transition from pediatric to adult care. This document aims to provide an evidence-based guideline to comprehensive care of pediatric LT recipients, starting at transplant and continuing as they advance to adulthood. METHODS:A multidisciplinary writing group of pediatric liver transplant experts and a medical librarian was convened by AASLD, with guidance by its Practice Guidelines Development Policy, and in collaboration with the North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the American Society of Transplantation (AST). We conducted a systematic global literature review, formulated key clinical questions, and developed recommendations. Each recommendation was graded using the Oxford Centre for Evidence-Based Medicine framework and categorized by strength through a consensus voting process. CONCLUSION/CONCLUSIONS:All recommendations are based on best-available evidence and reflect expert consensus. Most of the evidence basis remains retrospective or observational data, or extrapolation from related populations. To continue improving long-term outcomes after pediatric liver transplant, multi-disciplinary, multi-center collaboration to strengthen the evidence will be essential.

BACKGROUND:Despite major advances in surgical and medical management, only one-third of pediatric liver transplant (LT) recipients remain morbidity-free at 10 years. The Society of Pediatric Liver Transplantation (SPLIT) published a research agenda over 10 years ago, and much progress has been made since then. An updated consensus-driven SPLIT research agenda could guide future research and funding priorities. We aimed to identify and prioritize key research needs across the continuum of pediatric LT care using a modified Delphi consensus approach. METHODS:We conducted a three-round modified Delphi process among SPLIT members. In round 1, participants submitted open-ended research priorities. In round 2, the Steering Committee synthesized these into 156 unique statements for rating. The third and final round included revision and rerating of 42 statements. Consensus was defined as a median importance rating ≥7 on a 9-point Likert scale. RESULTS:Sixty-nine multidisciplinary experts participated in round 1, with <30% attrition across rounds. The panel identified 46 high-priority research topics, organized into 7 domains: (1) end-stage disease and waitlist management; (2) transplant access, allocation, and organ utilization; (3) perioperative management; (4) immunosuppression management; (5) transplant complications; (6) long-term health and transition to adulthood; and (7) special populations. Highest-ranked research priorities included (1) developing an updated LT waitlist allocation scoring tool, (2) identifying novel biomarkers to guide immunosuppression minimization/withdrawal, and (3) developing new organ preservation strategies to increase the availability of high-quality organs for pediatric LT candidates. CONCLUSIONS:SPLIT members identified 46 consensus research priorities that define the next frontier of pediatric LT research and provide a roadmap for investigators, funders, and health systems to improve survival and lifelong health in children after LT.

Transition of care from pediatric to adult providers occurs during a time of increased risk, especially in the liver transplant population where close follow-up and adherence to immunologic therapies are critical to patient and graft survival. While there is a substantial body of literature supporting the need for improved transition from pediatric to adult care, concrete steps on how to implement a clinic and partner with adult colleagues are lacking. This article aims to provide a flexible pathway for transition clinics that can be tailored to an institution's unique needs while also advocating for system-wide change to better support transitions in care, specifically through the lens of the United States health care system.

Pediatric healthcare delivery systems are increasingly employing navigators, community health workers, and social workers to improve child and household access to healthcare and social services, with the goal of decreasing healthcare inequities. However, navigation strategies are understudied in pediatric liver transplantation. We used human-centered design methods, eliciting the perspectives of caregivers and transplant team members, to design a navigator role for pediatric liver transplantation. We enrolled 10 caregivers reporting household social risks and 6 transplant practitioners from 7 US transplant centers. We conducted 8 virtual focus groups between September 12, 2023, and January 31, 2024, to define gaps in care and ideate on how lay navigators could mitigate those challenges. We utilized design tools to elicit stakeholders' values and preferences. We recorded the focus groups and qualitatively analyzed audio transcripts to thematically identify essential job functions. Most caregivers reported earning an annual household income <$59,000 (70.0%), living below the federal poverty line (55.6%), and experiencing financial strain (80.0%). Caregivers wanted navigators to help them: (1) access community-based resources, (2) build longitudinal relationships with the healthcare team, (3) prepare them for appointments, (4) communicate with their child's school, and (5) address cultural differences between families and transplant practitioners. The transplant team wanted navigators to help caregivers: (1) address families' socioeconomic resource needs, (2) coordinate appointment scheduling, and (3) facilitate cultural and language-concordant care. Using structured design methodology, we designed a prototype navigator role for pediatric liver transplant care teams. Future studies should test the effectiveness of this navigator role in improving posttransplant outcomes.

Pediatric healthcare delivery systems are increasingly employing navigators, community health workers, and social workers to improve child and household access to healthcare and social services, with the goal of decreasing healthcare inequities. However, navigation strategies are understudied in pediatric liver transplantation. We used human-centered design methods, eliciting the perspectives of caregivers and transplant team members, to design a navigator role for pediatric liver transplantation. We enrolled 10 caregivers reporting household social risks and 6 transplant practitioners from 7 US transplant centers. We conducted 8 virtual focus groups between September 12, 2023, and January 31, 2024, to define gaps in care and ideate on how lay navigators could mitigate those challenges. We utilized design tools to elicit stakeholders' values and preferences. We recorded the focus groups and qualitatively analyzed audio transcripts to thematically identify essential job functions. Most caregivers reported earning an annual household income <$59,000 (70.0%), living below the federal poverty line (55.6%), and experiencing financial strain (80.0%). Caregivers wanted navigators to help them: (1) access community-based resources, (2) build longitudinal relationships with the healthcare team, (3) prepare them for appointments, (4) communicate with their child's school, and (5) address cultural differences between families and transplant practitioners. The transplant team wanted navigators to help caregivers: (1) address families' socioeconomic resource needs, (2) coordinate appointment scheduling, and (3) facilitate cultural and language-concordant care. Using structured design methodology, we designed a prototype navigator role for pediatric liver transplant care teams. Future studies should test the effectiveness of this navigator role in improving posttransplant outcomes.

Pediatric liver transplant outcomes exhibit disparities, necessitating identification of modifiable risk factors to develop targeted interventions. We characterized associations between household material economic hardship (e.g., financial barriers to housing or food) and pediatric liver transplant outcomes. We recruited pediatric liver transplant recipients <18 years at the time of transplant across 8 U.S. centers. Our primary exposure was >/=1 household material economic hardship (i.e., food insecurity, housing instability, transportation challenges, or utility concerns), measured using the Accountable Healthcare Communities screening tool. Outcomes included 90-day and 1-year (1) total inpatient-bed days, and (2) episodes of T-cell mediated rejection (TCMR). Of the 77 participants (36% female), 34% reported household material economic hardship. Such hardship was associated with increased total inpatient bed-days within 90 days (ratio estimate: 1.45, 95%CI: 1.08, 1.96); the association persisted after adjusting for health literacy, insurance, and transplant center (ratio estimate: 1.37, 95%CI: 1.02, 1.84). Household material economic hardship was associated with total inpatient bed-days within 1-year post-transplant (ratio estimate: 3.2, 95%CI: 1.1, 10.1); associations diminished in multivariable analyses (ratio estimate: 2.2, 95%CI: 0.7, 6.9). Household material economic hardship was associated with increased risk of TCMR within 1 year of transplant (RR: 2.1, 95%CI: 1.1, 4.2); the association diminished in propensity-score matched analyses (RR: 1.4, 95%CI: 0.9, 2.3). Our findings highlight the adverse influence of household material economic hardship on pediatric liver transplant outcomes within the first year. Targeted social risk assistance and adjustment strategies offer actionable avenues to mitigate these challenges and enhance outcomes in pediatric liver transplant recipients.

Racial, ethnic, and socioeconomic disparities exist in the prevalence and natural history of chronic liver disease, access to care, and clinical outcomes. Solutions to improve health equity range widely, from digital health tools to policy changes. The current review outlines the disparities along the chronic liver disease health care continuum from screening and diagnosis to the management of cirrhosis and considerations of pre-liver and post-liver transplantation. Using a health equity research and implementation science framework, we offer pragmatic strategies to address barriers to implementing high-quality equitable care for patients with chronic liver disease.

BACKGROUND:An increasing number of pediatric solid organ transplant (SOT) recipients are surviving into adolescence and young adulthood. The transition from pediatric to adult-oriented care occurs during a unique and vulnerable period. METHODS:Presented here is a structured approach to healthcare transition (HCT) for adolescent and young adult SOT recipients aimed at optimizing independence in order to assist young patients with adherence, self-management, and improved quality of life. RESULTS:Close attention must be paid to neurocognitive development, mental well-being, and social determinants of health. CONCLUSIONS:These efforts require a multidisciplinary team approach as well as collaboration between pediatric and adult providers in order to achieve these goals and patient longevity.