Liver transplantation for pulmonary vascular complications of pediatric end-stage liver disease

• Published in: Journal of pediatric surgery Vol. 43; no. 10; pp. 1813 - 1820
• Main Authors: Iqbal, Corey W, Krowka, Michael J, Pham, Tuan H, Freese, Deborah K, El Youssef, Mounif, Ishitani, Michael B
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01-10-2008
• Subjects: Adolescent; Age of Onset; Biliary Atresia - complications; Biliary Atresia - surgery; Child; Child, Preschool; Combined Modality Therapy; Comorbidity; End-stage liver disease; Epoprostenol - therapeutic use; Fatal Outcome; Female; Follow-Up Studies; Hepatopulmonary syndrome; Hepatopulmonary Syndrome - etiology; Hepatopulmonary Syndrome - surgery; Hepatopulmonary Syndrome - therapy; Humans; Hypertension, Portal - etiology; Hypertension, Portal - surgery; Hypertension, Pulmonary - drug therapy; Hypertension, Pulmonary - etiology; Hypertension, Pulmonary - surgery; Hypertension, Pulmonary - therapy; Hypoxia - etiology; Hypoxia - therapy; Infant; Infant, Newborn; Liver Failure - complications; Liver transplant; Liver Transplantation - statistics & numerical data; Male; Oxygen Inhalation Therapy; Pediatrics; Portal hypertension; Portopulmonary hypertension; Postoperative Complications; Retrospective Studies; Surgery; Liver transplant; Portopulmonary hypertension; Hepatopulmonary syndrome; End-stage liver disease; Portal hypertension
• ISSN: 0022-3468; 1531-5037
• DOI: 10.1016/j.jpedsurg.2008.04.002

Abstract Purpose Hepatopulmonary syndrome (HPS) and portopulmonary hypertension (PPH) are poorly understood pulmonary complications of end-stage liver disease (ESLD). We present a case series of children with HPS and PPH. Methods After institutional review board approval, query of our medical database identified children 0 to 18 years of age with ESLD diagnosed with HPS or PPH. Data were collected via chart review. Results We identified 7 children with either HPS (n = 5) or PPH (n = 2). Patients with HPS presented with progressive dyspnea over a mean of 7 months (range, 4-12 months) at a mean of 13 years (range, 5-17 years) of age. Pulmonary shunting by albumin perfusion scan averaged 41% (range, 20%-66%) with an initial mean resting Sp o2 of 88% (range, 84%-94%) and mean Sp o2 during exertion of 79% (range, 60%-89%). Four patients required supplemental O2 and, upon United Network for Organ Sharing (UNOS) appeal, received pediatric model for ESLD (or Child-Pugh) score exceptions, enabling them to undergo orthotopic liver transplant (OLT) within 1-2 months. The fifth patient was initially rejected by the UNOS regional review board, but 6 months of worsening hypoxemia led to OLT 2 months after successful UNOS appeal. All patients with HPS undergoing OLT experienced complete resolution of hypoxemia within 8 months. Both children with PPH were treated with intravenous epoprostenol, which lowered or stabilized mean pulmonary artery pressure and bridged them to OLT within 7 months of listing. Overall, there were no pulmonary complications; however, 1 patient with PPH expired shortly after OLT. The remaining patients are alive at a median follow-up of 27 months (range, 6-96 months). Conclusion Hepatopulmonary syndrome and PPH are uncommon complications of ESLD in children. Epoprostenol can bridge PPH patients to OLT. OLT leads to rapid resolution of HPS and PPH and currently represents the only successful treatment for these children.