Hepatitis C virus infection in pediatric liver transplantation.

To determine the prevalence of antibodies to hepatitis C virus (HCV) and the short-term evolution of HCV infection in children undergoing orthotopic liver transplantation, we retrospectively studied the sera and medical records of 149 children surviving from 9 months to 5 years after OLT. Fourteen children (9.4%) were found to be positive for anti-HCV with second-generation ELISA and RIBA tests. They were individualized in 2 distinctive groups. In 5 children, anti-HCV was present before OLT, and in 1 patient only HCV RNA was detected at that time. All 6 patients were positive for anti-HCV after OLT. In the other 8 children, anti-HCV and HCV RNA were only detected after OLT and likely reflect infection during or shortly after OLT. The antibody reactivities against the 3 antigens included in the second-generation RIBA test varied in a given patient throughout follow-up and between these 2 groups of children. In all patients, serum transaminase (ALT) activities returned to normal levels when prednisone therapy was lowered and given every other day. These results indicate that the search for HCV infection in these children is necessary in the differential diagnosis of other liver complications in order to avoid excessive immunosuppressive treatment.

Alagille syndrome. The widening spectrum of arteriohepatic dysplasia.

Alagille syndrome was described more than 35 years ago as a genetic entity characterized by five major features: chronic cholestasis resulting from paucity of interlobular bile ducts, peripheral pulmonary stenosis, butterflylike vertebral arch defect, posterior embryotoxon, and peculiar facies. Recently, JAGGED1 has been identified as a responsible gene by demonstration of mutations in AGS patients. Studies of the JAGGED1 expression pattern demonstrate that minor features and almost all the elements in the long list of manifestations described in AGS patients are not coincidental. This finding suggests that the definition of AGS may be reconsidered in the light of JAGGED1 mutations.

Rationale for monitoring cyclosporine concentration at 2 hours after administration in infants posttransplantation.

Therapeutic drug monitoring is critical to avoid overimmunosuppression or underimmunosuppression in young pediatric transplant recipients. The objective of this study was to examine cyclosporine (CsA) trough (C0) and 2-hour post-dose (C2) concentrations in the early period after liver transplantation (OLT) to determine whether CsA C2 monitoring is justified. Seventeen infants younger than 2 years treated with CsA (Neoral) were monitored at C0. The biopsy-proved acute rejection rate was 65% at 3 months post-OLT. No correlation was observed between values at C0 and C2. Poor absorption of CsA was observed in most infants during the first 2 weeks post-OLT, as well as interindividual variability in CsA clearance. Exposure to CsA could not be estimated using either C0 or C2 determinations in the early post-OLT period. As a marker of poor absorption, C2 is useful but does not indicate delayed or rapid clearance of drug without simultaneous measurement of concentration at C0. We suggest the use of both C0 and C2 monitoring, or AUC monitoring on an individual basis during at least the first 2 weeks post-OLT.

Neonatal cholestasis as the presenting feature in cystic fibrosis.

Between 1960 and 1994 cystic fibrosis was found in nine out of 1474 infants investigated for neonatal cholestasis. Four had delay in passing meconium. In all patients cholestatic jaundice was present during the first 48 hours and in three patients cholestasis was complete, mimicking biliary atresia. Serum cholesterol concentrations were normal in all but two children. Sweat chloride was repeatedly above 95 mmol/l in all instances. Three children had another condition enhancing the risk of cholestasis (alpha1-antitrypsin deficiency, hypopituitarism, perinatal asphyxia, and total parenteral nutrition). Liver histology displayed portal fibrosis and inflammation with bile duct proliferation; mucous plugs in bile ducts were observed in only one patient. Only one child died from cirrhosis. These results indicate that cystic fibrosis is not a major cause of neonatal cholestasis. However early signs of intestinal obstruction and low concentrations of serum cholesterol may indicate cystic fibrosis, regardless of liver histology. Neonatal cholestasis has no prognostic value concerning evolution to cirrhosis.

HBV infection in pediatric liver transplantation.

When hepatitis B virus (HBV) infection precedes orthotopic liver transplantation (OLT), an important issue is to avoid post-OLT HBV infection of the transplanted liver. When HBV infection is found after OLT, the main objective is to prevent the complication of cirrhosis. A study of HBV infection in 162 liver-transplanted children followed at Hôpital de Bicêtre is presented here. One hundred forty-one of these children were completely vaccinated against HBV; 89% of them still disposed of protective titers of serum antibodies to hepatitis B surface antigen (anti-HBs) (> 10 IU/L) 6-60 months after OLT. Four children had a HBV-associated liver disease that required OLT. In these children a passive immunoprophylaxis maintaining serum anti-HBs levels > 100 IU/L allowed three of them to remain free of serum hepatitis B surface antigen (HBsAg) and HBV-DNA during follow-up at 10, 20, and 36 months. Four other children have been found to be HBsAg+ after OLT, but it was not clear whether the source of HBV was a reactivation or a de novo infection. Low doses of cyclosporin and prednisone were administered, in order to avoid the complications of HBV infection. Liver needle biopsies in three of these patients 37, 42, and 46 months after OLT showed a moderate chronic active hepatitis and mild fibrosis. Immunostaining for HBs and hepatitis B core (HBc) antigens indicated active viral replication.(ABSTRACT TRUNCATED AT 250 WORDS)

Outcome of liver disease in children with Alagille syndrome: a study of 163 patients.

BACKGROUND AND AIMS: Various opinions have been expressed as to the long term prognosis of liver disease associated with Alagille syndrome (AGS). PATIENTS AND METHODS: We reviewed the outcome of 163 children with AGS and liver involvement, investigated from 1960 to 2000, the end point of the study (median age 10 years (range 2 months to 44 years)) being death, liver transplantation, or the last visit. RESULTS: At the study end point, of the 132 patients who presented with neonatal cholestatic jaundice, 102 remained jaundiced, 112 had poorly controlled pruritus, and 40 had xanthomas; cirrhosis was found in 35/76 livers, varices in 25/71 patients, and liver transplantation had been carried out in 44 patients (33%). Forty eight patients died, 17 related to complications of liver disease. Of 31 patients who did not present with neonatal cholestatic jaundice, five were jaundiced at the study end point, 17 had well controlled pruritus, and none had xanthomas; cirrhosis was found in 6/18 patients, varices in 4/11, and none underwent liver transplantation. Nine patients died, two of liver disease. In the whole series, actuarial survival rates with native liver were 51% and 38% at 10 and 20 years, respectively, and overall survival rates were 68% and 62%, respectively. Neonatal cholestatic jaundice was associated with poorer survival with native liver (p=0.0004). CONCLUSIONS: The prognosis of liver disease in AGS is worse in children who present with neonatal cholestatic jaundice. However, severe liver complications are possible even after late onset of liver disease, demanding follow up throughout life.

Risk of gastrointestinal bleeding during adolescence and early adulthood in children with portal vein obstruction.

OBJECTIVE: To estimate the risk of bleeding during adolescence and early adulthood in a group of children with portal vein obstruction who had not undergone an effective treatment beforehand. STUDY DESIGN: Children (n = 44) were followed up from age 12 years to a mean age of 20 years (range, 15-34 years). Actuarial risk of bleeding, related to previous occurrence of gastrointestinal bleeding and to pattern of varices at age 12, was calculated yearly. RESULTS: Twenty-four children presented with gastrointestinal bleeding after age 12, and 20 did not bleed. The overall actuarial probability of bleeding was 49% at age 16 and 76% at age 24. Probability of bleeding at age 23 was higher in children who had bled before age 12 than in children who had not bled (93% vs 56%; P =.007). Probabilities of bleeding at age 18 and at age 23 were 60% and 85%, respectively, in patients who had grade II or III esophageal varices at age 12. The 9 children without varices or with grade I varices only on endoscopy did not bleed between the ages of 12 and 20 years. CONCLUSIONS: Children with portal vein obstruction have a >50% risk of bleeding during adolescence; the pattern of varices on endoscopy at age 12 may have a prognostic value.

Transient neonatal cholestasis: origin and outcome.

We studied, retrospectively, 92 children who were first seen with neonatal cholestasis and who were followed up until liver test results normalized. Among the 92 children, 81 displayed factors responsible for chronic and/or acute perinatal distress. Onset of jaundice was recorded at a mean age of 7 days, and mean duration was 3.5 months. Stools, initially discolored in 39 children, were normally colored at a mean age of 1.7 months. Hepatomegaly present in 90 children resolved at a mean age of 13 months. Liver test results were normal at the age of 1 year in 83 children and normalized at a mean age of 10 months. Liver histologic examination, performed in 70 children, showed moderate portal and lobular fibrosis, multinucleated giant hepatocytes, and hematopoietic foci; findings in follow-up liver biopsy specimens from 15 children were normal or improved. Spontaneously resolving forms of neonatal cholestasis may result from the association of several factors, including immaturity of bile secretion and perinatal disease leading to hepatic hypoxia or ischemia.

Outcome of cystic fibrosis-associated liver cirrhosis: management of portal hypertension.

BACKGROUND/AIM: Variceal bleeding is the most severe complication in patients with cystic fibrosis-associated liver cirrhosis, who often do not have severe respiratory failure. The advent of liver transplantation has broadened the treatment options. The purpose of this study was to report our experience with the management of portal hypertension. METHODS: Clinical and biochemical features, outcome of liver disease and management of portal hypertension were analyzed retrospectively in 44 children with cystic fibrosis-associated liver cirrhosis. RESULTS: The mean age at diagnosis of liver cirrhosis was 9 years. Eighty-six per cent of the children developed esophageal varices, 50% of whom bled early in their second decade. Injection sclerotherapy of esophageal varices did not prevent recurrence of bleeding in five of seven children. Elective surgical portosystemic shunting was successfully performed in nine of 11 patients considered being at high risk of bleeding or with recurrent bleeding episodes but without severe pulmonary failure and liver dysfunction, allowing prolonged post-operative survival up to 15 years. Two of three children who underwent isolated liver transplantation for severe portal hypertension died post-operatively. CONCLUSIONS: Management emphasis in cystic fibrosis patients with liver cirrhosis should be on control of bleeding and variceal decompression. These results suggest that surgical portosystemic shunting may be considered to relieve portal hypertension in patients without progressive liver failure and severe lung disease as an alternative to liver transplantation. With this policy, patients may be stabilized for many years until progression of liver or lung diseases indicates liver or lung-liver transplantation.