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Clinician-to-Clinician Update
To schedule a pediatric liver care or transplant consultation, referral or appointment:
For living-donor liver transplant consultation or referral:

Gastroenterology, Hepatology and Nutrition or Transplant, Solid Organ (Liver, Kidney and Intestine)
M Health Fairview Discovery Pediatric Specialty Clinic
2512 Building
2512 S 7th St., Floor 3
Minneapolis, MN 55454 

Solid Organ Transplant
M Health Fairview University of Minnesota Medical Center - East Bank
500 Harvard St. SE
Minneapolis, MN 55455 

For our pediatric liver failure care teams, go here.

Surgical Innovation and Team Care Improve Pediatric Liver Transplant

In 2017, 599 pediatric liver transplants were performed at 21 U.S. transplant centers.1 Among patients currently on the liver donor wait list, children ages 1 to 5 years and those 11 years or older make up the largest age groups.1 The leading indications for liver transplantation are extrahepatic or intrahepatic cholestasis, metabolic diseases, and acute liver failure.2 

Liver transplantation has been successful for children with end-stage liver disease, with overall 5-year survival rates approaching 90%3, but the demand for whole livers exceeds supply. To increase access to pediatric liver transplantation, surgeons have developed variant techniques, including reduced-size liver transplant and split liver transplant procedures. Reduced-size liver transplants entail the use of a portion of the adult living donor’s liver for a pediatric patient, whereas in split liver transplant, a deceased donor’s organ is split and placed in 2 smaller recipients. A partial liver graft that provides sufficient hepatocyte mass and appropriate arterial and portal inflow and corresponding venous and biliary drainage can serve the function of a whole organ. 

These variant surgical techniques are technically more difficult, but they have given patients more options and have reduced their time on transplant wait lists. In the future, alternative approaches, including the use of artificial liver assist devices, cellular transplantation, and genetic modification of hepatocytes, may help decrease the number of children who die while waiting for a suitable organ or even eliminate the need for liver transplantation.4 

Boris Sudel, MD, and a patient
Pediatric gastroenterologist Boris Sudel, MD,
in the clinic. Pediatric gastroenterologists play
central roles in the liver transplant care team.
(Patient model pictured.)
Medical management of the transplant patient requires the expertise of multidisciplinary teams of specialists and subspecialists, and the comprehensive, integrated care provided at high-volume centers is central to optimizing graft success. For patients with liver disease or disorders, care begins with pediatric hepatologists and gastroenterologists. The goal is to optimize the child’s health in preparation for the transplant. Nutrition is key. Children with cholestatic liver disease require more calories than healthy children do to achieve adequate physical development and growth. Aggressive nutritional support before liver transplantation improves patient and graft survival. In a study of 119 pediatric liver transplant recipients, the incidence of infections was nearly twice as high (61% vs. 37%) in the patients who were malnourished than in those with normal nutrition. Surgical complications, such as vascular complications, bile leak, and intestinal perforation, were also significantly more frequent in the malnourished children (46% vs. 23%).5 

After surgery, the long-term care objectives are to support nutrition and to help these patients achieve appropriate physical growth, bone metabolism, endocrine function, and psychosocial development. To support these goals, the pediatric liver transplant team at the M Health Fairview University of Minnesota Masonic Children’s Hospital includes surgeons, pediatric gastroenterologists, a hepatologist, a neuropsychologist and psychologist, care coordinators, physical and occupational therapists, and registered dietitians. Consultation is available from pediatric cardiologists, nephrologists, endocrinologists, and other subspecialists. The surgical team, led by Srinath Chinnakotla, MD, performs whole-liver transplants as well as split-liver transplants, ABO-incompatible graft procedures, and living-donor transplants. Between Jan. 1, 2016, and June 30, 2018, this transplant center performed 19 pediatric liver transplants, achieving a patient survival rate of 94.7% at 1-year postprocedure.6 

References

  1. Scientific Registry of Transplant Recipients. OPTN/SRTR 2017 Annual Data Report: Liver. Health Resources and Services Administration website. https://srtr.transplant.hrsa.gov/annual_reports/2017/Liver.aspx. Accessed Nov. 1, 2019. 
  2. Spada M, Riva S, Maggiore G, et al. Pediatric liver transplantation. World J Gastroenterol. 2009 Feb 14; 15(6): 648-674. 
  3. Diamond IR, Fecteau A, Millis JM, Losanoff JE, Ng V, Anand R, Song C. SPLIT Research Group. Impact of graft type on outcome in pediatric liver transplantation: a report from Studies of Pediatric Liver Transplantation (SPLIT). Ann Surg. 2007 Aug;24 (2):301-310.
  4. Abramson O, Rosenthal P. Current status of pediatric liver transplantation. Clin Liver Dis. 2000 Aug;4(3):533–552. 
  5. Moukarzel AA, Najm I, Vargas J, et al. Effect of nutritional status on outcome of orthotopic liver transplantation in pediatric patients. Transplant Proc. 1990;22:1560–1563. 
  6. Scientific Registry of Transplant Recipients. University of Minnesota Medical Center, Fairview (MNUM). [Transplant Center data.] https://www.srtr.org/transplant-centers/university-of-minnesotamedical-center-fairview-mnum/organ=liver&recipientType=ped Accessed Nov. 1, 2019.

When to refer

The pediatric transplant program at University of Minnesota Masonic Children’s Hospital is one of the oldest and most respected programs in the world. Our team of specialists has performed more than 353 pediatric liver transplants since the program began in 1964. 

Multidisciplinary, Collaborative Care

The liver transplant team comprises gastroenterologists, hepatologists, a neuropsychologist, transplant surgeons, care coordinators, dietitians, social workers, and other specialists who work together closely to care for infants, children, and adolescents with advanced liver disease and those who need a transplant. Our physicians collaborate with colleagues in pediatric cardiology, nephrology, endocrinology, ophthalmology, and other specialist areas to provide comprehensive care. Other members of the team include pharmacists, who adapt adult medications for pediatric dosing and recommend administration protocols; nurses, who coordinate care and assist the families; and psychologists, social workers, and dietitians. 

Our pediatric gastroenterologists, hepatologists, and team member dietitians and care coordinators treat the disorders that can lead to liver transplant. For information on services offered, go here

Living Donor Program and Transition Program

Our transplant team has been performing living-donor liver transplants since 1997. Our Living Donor Transplant Program helps make liver grafts available to children, reducing their time on transplant wait lists. We offer living-donor liver transplants to most pediatric patients referred to us. An adult family member or friend can donate a piece of his or her liver to a pediatric transplant patient if there is a blood and tissue match. For more information about this program, go here

When it’s time for our adolescent transplant patients to begin managing their own care, our transition program, which is implemented during clinic visits, ensures that they are ready to be independent.

To find current clinical trials available through  M Health providers, visit studyfinder.umn.edu.

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We are available to consult about your patients, with or without referral.

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Our goal, whenever possible, is to see your patient within 5 days if requested.

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Through our Physician Referral Service, you can make a referral, request a consult, or admit a patient through our main number: 888-318-3627 (Adults) or 888-543-7866 (Pediatrics)

If you have feedback about Consult, please contact us at consult@mhealth.org.