studies

HEPATOLOGY, VOLUME 62, NUMBER 1 (SUPPL) AASLD ABSTRACTS 1055A
1736
Surveillance biopsies in pediatric liver transplant recipients
to guide immunosuppression (IS) reduction
Amanda J. Posner 1 , Kuang-Yu Jen 3 , Linda Ferrell 3 , Anthony J.
Demetris 5 , Sandy Feng 4 , Philip Rosenthal 1,4 , Emily R. Perito 1,2 ;
1 Pediatrics, University of California San Francisco, San Francisco,
CA; 2 Epidemiology and Biostatistics, University of California San
Francisco, San Francisco, CA; 3 Pathology, University of California
San Francisco, San Francisco, CA; 4 Surgery, University of California
San Francisco, San Francisco, CA; 5 Pathology, University of
Pittsburgh, Pittsburgh, PA
Introduction: Recent AASLD guidelines on long-term management
of pediatric liver transplant (LT) recipients recommend considering
IS minimization in children with minimal inflammation
and fibrosis on surveillance biopsy. We instituted surveillance
biopsy and IS minimization protocols, following experience
with Immune Tolerance Network (ITN) IS withdrawal trials.
Methods: Single-center study of surveillance liver biopsies to
assess eligibility for IS reduction (withdrawal in clinical trial,
n=27; or minimization to 50% of baseline calcineurin-inhibitor
[CNI] dose as standard of care [SOC], n=32) in subjects who
underwent LT prior to age 18. At biopsy, all were ≥5 years
post-LT on CNI (n=56) or CNI+mycophenolate (n=3). Biopsies
reviewed by 1 of 2 pathologists using standardized criteria
from Banff recommendations. Results: 59 pediatric LT recipients
were included, at median (range) age 13.1 (5.1-22.1)
years and 9.7 (3.6-20.5) years from LT. LT was whole liver in
42%, split deceased-donor in 24%, and living-donor in 32%.
Of 20 subjects with no fibrosis, 75% qualified for IS reduction.
(FIG) Fibrosis was seen in 39 subjects, but 84% of portal fibrosis
was Ishak stage 1-2 and 78% of perivenular fibrosis was
mild. 38/59 (64%) subjects were eligible for IS withdrawal or
SOC minimization. (FIG) Children eligible vs ineligible were
younger at transplant (median [IQR] 0.8 [0.5-1.6] vs 1.6 [0.8-
4.8] years, p=0.03) with no difference in years since transplant,
whole vs split or living vs deceased donor, AR history,
or AST/ALT/GGT at biopsy. Of 22 children eligible for SOC
IS minimization, 5 completed and 5 are in process; none have
had AR or complications. Conclusion: Surveillance biopsy is
essential tp inform decision-making on IS reduction. Longitudinal
studies are needed to establish benefits vs risks of biopsy-guided
IS reduction.
Surveillance biopsies and IS reduction eligibility in pediatric LT
recipients
Philip Rosenthal - Advisory Committees or Review Panels: Retrophin, Gilead; Consulting:
Roche, Abbvie; Grant/Research Support: Roche, Bristol MyersSquibb,
Gilead, Vertex, Abbvie
The following authors have nothing to disclose: Amanda J. Posner, Kuang-Yu Jen,
Linda Ferrell, Anthony J. Demetris, Emily R. Perito
1737
Epidemiology and outcomes of pediatric liver transplant
recipients with multidrug resistant bacterial and fungal
infections
Gillian Noel, Mark J. Abzug, Donna Curtis, Zhaoxing Pan, Shikha
Sundaram; University of Colorado/Children’s Hospital Colorado,
Denver, CO
Infection is a significant source of morbidity and mortality
following liver transplantation. Adult transplant recipients
experience increased colonization and infection with drug-resistant
organisms including methicillin-resistant staphylococcus
(MRSA), extended-spectrum beta-lactamase producers, vancomycin-resistant
enterococci, and multidrug resistant pseudomonas
aeruginosa. Limited data exist regarding the incidence of
multidrug resistant organisms in the pediatric liver transplant
(LT) population. Objective: To define the incidence and impact
on outcomes of multidrug resistant organisms in pediatric LT
recipients. Methods: A retrospective cohort study of pediatric LT
recipients at Children’s Hospital Colorado between Jan 2006
and Dec 2014 was conducted. Demographic, clinical and
outcome data were collected. Results: Sixty subjects were identified
and followed for one year post-LT (mean age at LT of 4.9
± 6.1 years; 55% female, 67% white, 51% transplanted due
to biliary atresia). Treatment for suspected bacterial infections
occurred in 51% of subjects, but only 44% had a documented
isolate. Major isolates included coagulase negative staphylococci,
enterococci, and gram-negative enterics. Although
MRSA colonization was common (6.5% MRSA positive at LT),
MRSA infections did not occur. Two percent of subjects had
multidrug resistant organisms (extended spectrum beta lactamase
producers) identified. Of subjects treated for bacterial
infections, 68% received 1 course, 18% received 2-3 courses,
and 14% received 4 or more courses of antibiotics. Presumed
cholangitis and bacteremia were the most common reasons for
antibiotic treatment. Treatment for fungal infections occurred in
5% of subjects, although no multidrug resistant fungal infections
were identified. All treated subjects received one course of
antifungal treatment. Of those treated, only 50% had a documented
isolate, primarily candidal species. Fungemia was
the most common reason for antifungal treatment. Subjects
with clinically suspected bacterial or fungal infections post-LT
had more ICU admissions (1-3) versus those without suspected
infection (0) post-LT (p=0.05). There were no differences in
overall numbers of hospitalizations, reoperation rates, rejection,
graft loss, or death in the twelve months post-LT as related
to infection status. Conclusions: While serious bacterial and
fungal infections commonly occur in pediatric liver transplant
recipients, multidrug resistant infections are uncommon in our
institution. Infected subjects have more complicated courses,
characterized by ICU admissions, but their overall outcomes
are similar to those without infections.
Disclosures:
The following authors have nothing to disclose: Gillian Noel, Mark J. Abzug,
Donna Curtis, Zhaoxing Pan, Shikha Sundaram
Disclosures:
Sandy Feng - Consulting: Novartis