Thomas Heffron, MD, Pediatric Liver Surgeon at Presbyterian St. Luke’s Medical Center in Denver, Colorado talks about living donor liver transplants for children and babies.
When people think of liver transplants, they do not really think of babies and children.
Dr. Heffron: The most common problem in children is biliary atresia. There are about 600 pediatric liver transplants a year, and about 70% are biliary atresia. That is when the child’s bile ducts do not form right, and they need a liver transplant to take care of it. That is the most common. The youngest child that I successfully transplanted was eight days and 2.8 kilos all the way up to some teenagers who are now are 100 kilograms.
So, when someone’s eight days old, where do you get a liver?
Dr. Heffron: You can get a liver from a living donor. Usually the Mom or Dad. The way you fit it into children depends on how wide it is because that is how wide your chest cavity and abdominal cavity is. Or you can take it from a child that has died, and you take a piece of that liver.
Is it more intricate for a child or is it almost the same?
Dr. Heffron: It is a different set of problems for children. With smaller children one of the biggest problems with a liver transplant is hepatic artery thrombosis, where the artery clots. If you are sewing small arteries, you must use magnification. When we first started doing living donor liver transplants 25% lost the grafts and they had to be re-transplanted because the artery clotted. That is the first series we published in 1989. Then we published a second series and we brought it down to 3% in tiny babies. In the last series, in over 300 children we had a rate of .6% or six out of 1,000. So, we have gotten better and better through practice, but also there are better lights, the magnification is six times better, things like that.
Do you do more living donor transplants or do you do more cross blood types?
Dr. Heffron: With kidneys it is hard to cross blood groups. People do that, but they must do a lot of immunological contortions to make that happen. But livers do not care, they either know it or they do not recognize it. You can cross blood groups in children or adults with excellent results. I wrote a paper with our team at Children’s Hospital of Atlanta in 2007 where we crossed 16 patients with close to 100% survival and no side effects. When we have put a liver in an adult or child crossing blood types and we have 100% survival. It’s not because I’m a great immunologist, it’s because people don’t mount antibodies against different blood types in the liver. So, we get anti-idiotypic antibodies and if it is significant, they should be 1 to 250 or 1 to 500. They are all roughly 1 to 7, which is enough.
Why wouldn’t you just cross blood types?
Dr. Heffron: The rule is you can only cross blood groups with a MELD score – which is how sick your liver is – greater than 30, which means you have an 80% chance to be dead in three months. So, if you are acutely ill, they make it easier to get livers. But I would cross into anyone that I could.
Do you think that will be the future?
Dr. Heffron: It is already the future in Japan and Korea where they do not have enough cadaveric organs or livers from dead people. They cross blood types because, if you have a living donor for your brother, sister, wife or husband and you are the wrong blood type, if they don’t get it, they’re dead. So, they routinely cross there with similar results.
So, you have seen a lot of change over the years since you have been doing this?
Dr. Heffron: I have seen a lot of change, but liver transplants have pretty much stayed the same. The immunosuppression’s the same. Technically we are better now than when I started. I finished my fellowship in 1990 and back then the survival rate was about 65%. Now the survival rate in extremely sick people is about 95%.
So, what is the next big thing when it comes to liver transplants?
Dr. Heffron: I am not sure there is a next big thing. I think it will be getting better in what we already have. The next big thing ideally would be to use small livers or a small piece of liver for a larger transplant, and we have not figured out how to do that yet. In pediatric liver transplants, the great thing is that you can transplant a small child with a left lateral segment from a mom, dad, aunt, uncle or unrelated – it does not matter. The risk to the donor dying if you take the left lateral segment is about 1 out of 10,000. If you take the right side the risk of dying is about 1 out of 300 because the right side of your liver is about 65%.
Do livers regenerate quickly in babies?
Dr. Heffron: If you take the right side of somebody’s liver because of a tumor or liver transplant, it will grow back about 85% in a week if you are normal. The older you are, the slower it grows back. If you have a damaged liver, you cannot have your gallbladder removed without going into liver failure.
Talk about the new register rule where babies’ livers go to babies.
Dr. Heffron: I think that has helped children get livers quicker. But for small babies, you can always do a live donor with excellent results and as good or better than full size or cadavery grafts.
Is it that important to have that?
Dr. Heffron: I think it is important because it gives them a better shot and with smaller babies sometimes their reserve is not so great, so they need to get a liver. And not every child or adult has a family situation that enables them to get one. One of the things we learned when I was at Children’s Hospital in Atlanta is we did not need to have anybody die on the list waiting to get a liver and the reason is, in the south, it’s easier to get a liver because the MELD score is lower. But also, by doing live donors and crossing blood groups, when I would get someone who is sick, we would do that preferentially if they need one right away. We did that for acute liver failure, where the brain swells, and they are dead in two days if they do not get one. We did that for re-transplantation. That survival rate across the country was 60%. When I used live donors and crossing blood groups, our survival rate was 94%. For acute liver failure across the country, the survival’s about 60% percent. Ours is 95% because we get a good liver to the child before they get too sick. So, I think that is what we have to offer for live donors. I have used them in the hardest situations, and we have really good results because we have done a lot of them. We are really excited here at Presbyterian St. Luke’s. I think we have a fantastic team and we are really looking forward to helping a lot of children. It is nice to help adults, but children add something more. I got a call about two weeks ago from a girl who was 8 when I transplanted her. We split a liver, gave the left side to a small child and the right side to the 8-year-old. Now some 20 some years later she just turned 30, she is in Atlanta and writing a documentary about what happened to her and how it affected her. But she is perfect. You cannot pick her out from anyone else except she is a little prettier than some 30-year-olds. But you could never tell she had a liver transplant. I think that is what is great about liver transplants, even more than kidneys. With kidney transplants, you to stay in immunosuppression forever. With livers, after a couple of years you cannot pick out a liver transplant recipient from anybody else. They get all their muscle mass back. They get everything back.
How does it feel when you get a call from a liver transplant recipient that you have not seen in 30 years?
Dr. Heffron: That was great. We had another child that I transplanted for acute liver failure who was on the ventilator bolted with a neuro monitor in their brain. The mom was about ready to deliver and the dad too. So, livers are like noses. Everybody has a little different shape and some people do not have left lateral segments, they just have a little nubbin. So the dad had a little nubbin of a left lateral segment and actually the Aunt flew in from Baltimore at 10:00 that night and at 1:00am I had her on the operating room table, and by 6:00am she had transplanted her left lateral segment into her nephew. The Nephew just started at Hofstra this year and the Aunt just took him to Europe for a trip this summer.
How many liver transplants do you do? Do you do them weekly?
Dr. Heffron: If you do 30 a year, you are in the top two or three in the country for pediatricians. We average about 25 a year. We were always in the top five at Children’s Hospital when I was there.
Is survival for these babies sometimes dependent on where they live because of what the rules are in that state?
Dr. Heffron: It depends on how good their doctors are and how they get to somebody. Usually if they get somewhere with a good program, they can have a good result. But it is like anything else, you must have a family to help you before and afterwards. One thing we are trying to do to make sure that all children have access is that Amber, a hepatologist, and I go to areas that are underserved as far as liver transplants. So, we go to Montana and New Mexico. People with liver disease can come to our program especially with a Life Donor. You can schedule it. So, I think that is one way we are helping children in other areas be better served so they have more knowledge about it.
Interview conducted by Ivanhoe Broadcast News.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
If you would like more information, please contact:
Mari Abrams
Mari.Abrams@Healthonecares.Com
Sign up for a free weekly e-mail on Medical Breakthroughs called First to Know by clicking here
