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Improved Outcomes for Liver Transplantation with Biliary Atresia
Dr. James Daniel discusses improved outcomes for liver transplantation with Biliary Atresia.
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Learn more about James Daniel, MD
James Daniel, MD
James Daniel, MD is the Co-Director of the Brendan Tripp Elam Transplant Center; James F. Daniel Endowed Chair in Liver Care.Learn more about James Daniel, MD
Transcription:
Improved Outcomes for Liver Transplantation with Biliary Atresia
Melanie Cole, MS (Host): Welcome to Transformational Pediatrics with Children’s Mercy Kansas City. I'm Melanie Cole, and today we’re discussing improved outcomes for liver transplantation with biliary atresia. Joining me is Dr. James Daniel. He’s the co-director of the Brendan Tripp Elam Transplant Center and the James F. Daniel endowed chair in liver care with Children’s Mercy. Dr. Daniel, it’s a pleasure to have you join us today. This is a fascinating study. Tell us what prompted the research on improved outcomes for liver transplantation with biliary atresia. Tell us about it.
James Daniel, MD (Guest): Well, I think the main reason we did the study was to make sure we’re doing a good job. We also wanted to see if we could identify risk factors that would effect outcome. We want to do a good job with these kids. So knowing what they have going into transplant that could affect their outcomes is very important.
Host: Certainly is. So tell us about the study itself. What did it examine? What was the design? Give us some details.
Dr. Daniel: We are part of a large registry. There are approximately 40 pediatric liver transplant centers in the United States and a couple outside the United States that share data. This data’s collected, and we can go back at a later time and look at the data and compare. So what we did is we looked at data that went back all the way to 1995. We were able to look at 2,000 patients that had liver transplantation for biliary atresia. The design on this study was to look at and compare prior to 2002 when the allocation system in the United States changed. Now for a lot of people doing liver transplantation in children, we had the feeling that our kids were sicker and sicker and sicker by the time they came to transplant, yet we still felt like we were doing a pretty good job. So we wanted to look back over the last basically 20 years. See what had been going on with these patients. Were we making improvements? What were the things that effected their outcomes? So we had a large data group—2,000 patients, a little bit more than 2,000—and we were able to look back over a couple of decades. So it was a very important study to do.
Host: What were some of those risk factors present that effected the outcomes? What did you see?
Dr. Daniel: The main risk factors that we found that effected outcomes have changed a little bit since 1995. From 1995 to 2005, one of the bigger risk factors was nutrition. The kids weren’t growing well and that put them at a disadvantage when they had the liver transplant. Since that time, we’ve been able to do things to improve their nutrition. We get very aggressive using tube feeds or IV nutrition. In fact, now that when we look at it, that risk factor has dropped out. Still the biggest risk factor that we see is infections after transplantation. There's still the main cause of mentality. We also see that little patients—if you're small or get a small donor organ—that tends to have an effect on you. One of the things that came out from this study was the way we do the donor also effects the outcomes. There's different ways to get donor organs. You can get a donor partial liver from an adult that’s alive—that’s called living donor—or you can get a donated organ from someone’s who has died. Then you can either take the whole organ or you can take part of it depending on the size and what you need. We found that when you take part of it, it does increase the risk of having a little more adverse outcome. So those are the kind of things we learn from the study. That things have improved in some areas. Yet some areas we know there's still work to be done.
Host: Certainly, there is, but that makes a lot of sense Dr. Daniels. So what was the role of the Society of Pediatric Liver Transplantation in this study? Did they play a role?
Dr. Daniel: Oh yes. They're the data holders, I guess would be a good way to say it. They're the ones that have the registry. We started this registry in the mid-1990s, and it was originally funded through a pharmaceutical organization. Then it had an NIH grant. Now it’s just a collaborative where everybody contributes. It enables us to get a tremendous amount o data on liver transplant patients, pediatric patients specifically. So the society’s input is huge. Now, the society has changed over the last 20 years. We’re doing more advocacy. Now we’re trying to make sure that the kids get an ample opportunity to get a liver. We’re making sure parents are involved and there's adequate education. It’s really turned into a very good society. We’ve started off just as a registry, but now we’re broadening out. We’re doing education. We’re doing advocacy, and we’re still collecting the data.
Host: So are there some results you haven’t mentioned that you’d like other providers to know about?
Dr. Daniel: Yeah. We’re doing a good job. If you look at patient mortality, currently about 95% of the patients that we transplant for biliary atresia survive. If you look at how the graft—the donated organ—does, it’s about 90% survive. So those are good numbers. You can pretty much tell your parents you’ve got a nine out of ten chance of having this turn out pretty well. So that’s nice. When we first started doing liver transplantation in the 70s, it was not even close to that. It’s improved and continues to improve. So that’s a nice finding.
Host: Well, it certainly is. As we’re talking about donor livers—And you mentioned that since there's a shortage for the pediatric and adult patients and they're waiting longer for transplantation and they're sicker when they come to you then they were in the past, how have these improvements in medical and surgical management help patients to do better? How is this research, how do you see it translating to patient care? What does this mean to them?
Dr. Daniel: Yeah, that’s a good question. I think we’re better off with many of the things that we do in transplantation. The way we use our medications to prevent rejection has improved over the last couple of decades, so that’s a big factor. The surgical techniques have definitely improved. I think the surgeons understand better how to put the new liver in, how to make sure that the blood vessels and the bile ducts and everything get connected appropriately. When you look at the complications of the blood vessels for example, those complications have gone down. We’re making really good progress I think both surgically and medically. There are sicker patients, they're getting transplanted at about the same age that they have been previously, but they're overall doing better because I think everybody that takes care of these kids are doing a better job.
Host: Certainly, as you say, improvements in the last 20 years have really skyrocketed. When we look to the future, Dr. Daniel, the future of liver transplantation and certainly we think of those ongoing issues such as the shortage of donor organs that’s fueled this search for alternative therapies for liver failure and alternative ways to get liver donations, where do you see this going in the future? Whether you're talking about synthetic or—What do you see happening on the horizon in the next 10 or 20 years?
Dr. Daniel: Well, I think we have to do a better job with our own livers. We need to make sure that we don’t let livers get diseased and damaged. A good example of this is hepatitis C. That was the leading cause of needing a liver transplantation in adults a decade ago. It’s slowly going down the list because we can now treat hepatitis C. We’re currently seeing a lot of research being done in turning the liver around when it gets scarred. That is getting rid of the scar tissue. That’s going to be a major factor. So we need to prevent diseases. When people do get diseased livers, we need to make sure that we can reverse the process. That’s going to have a big impact. We’ll still need more livers. I think advocacy from all sorts of groups and people need to occur so that people are not dying and wasting a liver. There’s a lot of reasons why people don’t donate, but we’ve got to get good education to make sure that we still have a good supply of donated livers. They really can save multiple lives.
Host: Well they certainly can. As we wrap up, what’s the take away for physicians? How will this change the way they practice and what would you like them to know about the importance of improved outcomes for liver transplantation with biliary atresia in pediatrics?
Dr. Daniel: Well, that’s a good question. I think what I would like people to know is that with everything that we’ve been doing over the last couple of decades, things are getting better. When children get liver disease, like biliary atresia, we can pretty much tell the family things are going to be okay. We just have to hang in there. It may be hard, but we’re going to be alright. Everybody needs to advocate for donor livers, and we need to continue to support the research that goes on for taking care of liver disease. We’re doing a good job. We can do better though.
Host: Thank you so much, Dr. Daniel, for coming on, sharing your study with us, and your incredible expertise. Thank you again for joining us. This has been Transformational Pediatrics with Children’s Mercy Kansas City. To refer your patient or for more information, please visit childrensmercy.org/giconnect to get connected with one of our providers. Please remember to subscribe, rate, and review this podcast and all the other Children’s Mercy podcasts. I'm Melanie Cole.
Improved Outcomes for Liver Transplantation with Biliary Atresia
Melanie Cole, MS (Host): Welcome to Transformational Pediatrics with Children’s Mercy Kansas City. I'm Melanie Cole, and today we’re discussing improved outcomes for liver transplantation with biliary atresia. Joining me is Dr. James Daniel. He’s the co-director of the Brendan Tripp Elam Transplant Center and the James F. Daniel endowed chair in liver care with Children’s Mercy. Dr. Daniel, it’s a pleasure to have you join us today. This is a fascinating study. Tell us what prompted the research on improved outcomes for liver transplantation with biliary atresia. Tell us about it.
James Daniel, MD (Guest): Well, I think the main reason we did the study was to make sure we’re doing a good job. We also wanted to see if we could identify risk factors that would effect outcome. We want to do a good job with these kids. So knowing what they have going into transplant that could affect their outcomes is very important.
Host: Certainly is. So tell us about the study itself. What did it examine? What was the design? Give us some details.
Dr. Daniel: We are part of a large registry. There are approximately 40 pediatric liver transplant centers in the United States and a couple outside the United States that share data. This data’s collected, and we can go back at a later time and look at the data and compare. So what we did is we looked at data that went back all the way to 1995. We were able to look at 2,000 patients that had liver transplantation for biliary atresia. The design on this study was to look at and compare prior to 2002 when the allocation system in the United States changed. Now for a lot of people doing liver transplantation in children, we had the feeling that our kids were sicker and sicker and sicker by the time they came to transplant, yet we still felt like we were doing a pretty good job. So we wanted to look back over the last basically 20 years. See what had been going on with these patients. Were we making improvements? What were the things that effected their outcomes? So we had a large data group—2,000 patients, a little bit more than 2,000—and we were able to look back over a couple of decades. So it was a very important study to do.
Host: What were some of those risk factors present that effected the outcomes? What did you see?
Dr. Daniel: The main risk factors that we found that effected outcomes have changed a little bit since 1995. From 1995 to 2005, one of the bigger risk factors was nutrition. The kids weren’t growing well and that put them at a disadvantage when they had the liver transplant. Since that time, we’ve been able to do things to improve their nutrition. We get very aggressive using tube feeds or IV nutrition. In fact, now that when we look at it, that risk factor has dropped out. Still the biggest risk factor that we see is infections after transplantation. There's still the main cause of mentality. We also see that little patients—if you're small or get a small donor organ—that tends to have an effect on you. One of the things that came out from this study was the way we do the donor also effects the outcomes. There's different ways to get donor organs. You can get a donor partial liver from an adult that’s alive—that’s called living donor—or you can get a donated organ from someone’s who has died. Then you can either take the whole organ or you can take part of it depending on the size and what you need. We found that when you take part of it, it does increase the risk of having a little more adverse outcome. So those are the kind of things we learn from the study. That things have improved in some areas. Yet some areas we know there's still work to be done.
Host: Certainly, there is, but that makes a lot of sense Dr. Daniels. So what was the role of the Society of Pediatric Liver Transplantation in this study? Did they play a role?
Dr. Daniel: Oh yes. They're the data holders, I guess would be a good way to say it. They're the ones that have the registry. We started this registry in the mid-1990s, and it was originally funded through a pharmaceutical organization. Then it had an NIH grant. Now it’s just a collaborative where everybody contributes. It enables us to get a tremendous amount o data on liver transplant patients, pediatric patients specifically. So the society’s input is huge. Now, the society has changed over the last 20 years. We’re doing more advocacy. Now we’re trying to make sure that the kids get an ample opportunity to get a liver. We’re making sure parents are involved and there's adequate education. It’s really turned into a very good society. We’ve started off just as a registry, but now we’re broadening out. We’re doing education. We’re doing advocacy, and we’re still collecting the data.
Host: So are there some results you haven’t mentioned that you’d like other providers to know about?
Dr. Daniel: Yeah. We’re doing a good job. If you look at patient mortality, currently about 95% of the patients that we transplant for biliary atresia survive. If you look at how the graft—the donated organ—does, it’s about 90% survive. So those are good numbers. You can pretty much tell your parents you’ve got a nine out of ten chance of having this turn out pretty well. So that’s nice. When we first started doing liver transplantation in the 70s, it was not even close to that. It’s improved and continues to improve. So that’s a nice finding.
Host: Well, it certainly is. As we’re talking about donor livers—And you mentioned that since there's a shortage for the pediatric and adult patients and they're waiting longer for transplantation and they're sicker when they come to you then they were in the past, how have these improvements in medical and surgical management help patients to do better? How is this research, how do you see it translating to patient care? What does this mean to them?
Dr. Daniel: Yeah, that’s a good question. I think we’re better off with many of the things that we do in transplantation. The way we use our medications to prevent rejection has improved over the last couple of decades, so that’s a big factor. The surgical techniques have definitely improved. I think the surgeons understand better how to put the new liver in, how to make sure that the blood vessels and the bile ducts and everything get connected appropriately. When you look at the complications of the blood vessels for example, those complications have gone down. We’re making really good progress I think both surgically and medically. There are sicker patients, they're getting transplanted at about the same age that they have been previously, but they're overall doing better because I think everybody that takes care of these kids are doing a better job.
Host: Certainly, as you say, improvements in the last 20 years have really skyrocketed. When we look to the future, Dr. Daniel, the future of liver transplantation and certainly we think of those ongoing issues such as the shortage of donor organs that’s fueled this search for alternative therapies for liver failure and alternative ways to get liver donations, where do you see this going in the future? Whether you're talking about synthetic or—What do you see happening on the horizon in the next 10 or 20 years?
Dr. Daniel: Well, I think we have to do a better job with our own livers. We need to make sure that we don’t let livers get diseased and damaged. A good example of this is hepatitis C. That was the leading cause of needing a liver transplantation in adults a decade ago. It’s slowly going down the list because we can now treat hepatitis C. We’re currently seeing a lot of research being done in turning the liver around when it gets scarred. That is getting rid of the scar tissue. That’s going to be a major factor. So we need to prevent diseases. When people do get diseased livers, we need to make sure that we can reverse the process. That’s going to have a big impact. We’ll still need more livers. I think advocacy from all sorts of groups and people need to occur so that people are not dying and wasting a liver. There’s a lot of reasons why people don’t donate, but we’ve got to get good education to make sure that we still have a good supply of donated livers. They really can save multiple lives.
Host: Well they certainly can. As we wrap up, what’s the take away for physicians? How will this change the way they practice and what would you like them to know about the importance of improved outcomes for liver transplantation with biliary atresia in pediatrics?
Dr. Daniel: Well, that’s a good question. I think what I would like people to know is that with everything that we’ve been doing over the last couple of decades, things are getting better. When children get liver disease, like biliary atresia, we can pretty much tell the family things are going to be okay. We just have to hang in there. It may be hard, but we’re going to be alright. Everybody needs to advocate for donor livers, and we need to continue to support the research that goes on for taking care of liver disease. We’re doing a good job. We can do better though.
Host: Thank you so much, Dr. Daniel, for coming on, sharing your study with us, and your incredible expertise. Thank you again for joining us. This has been Transformational Pediatrics with Children’s Mercy Kansas City. To refer your patient or for more information, please visit childrensmercy.org/giconnect to get connected with one of our providers. Please remember to subscribe, rate, and review this podcast and all the other Children’s Mercy podcasts. I'm Melanie Cole.