title: Risk factors for rejection and infection in pediatric liver transplantation.
abstract: Rejection and infection are important adverse events after pediatric liver transplantation, not previously subject to concurrent risk analysis. Of 2291 children (<18 years), rejection occurred at least once in 46%, serious bacterial/fungal or viral infections in 52%. Infection caused more deaths than rejection (5.5% vs. 0.6% of patients, p < 0.001). Early rejection (<6 month) did not contribute to mortality or graft failure. Recurrent/chronic rejection was a risk in graft failure, but led to retransplant in only 1.6% of first grafts. Multivariate predictors of bacterial/fungal infection included recipient age (highest in infants), race, donor organ variants, bilirubin, anhepatic time, cyclosporin (vs. tacrolimus) and era of transplant (before 2002 vs. after 2002); serious viral infection predictors included donor organ variants, rejection, Epstein-Barr Virus (EBV) naivety and era; for rejection, predictors included age (lowest in infants), primary diagnosis, donor-recipient blood type mismatch, the use of cyclosporin (vs. tacrolimus), no induction and era. In pediatric liver transplantation, infection risk far exceeds that of rejection, which causes limited harm to the patient or graft, particularly in infants. Aggressive infection control, attention to modifiable factors such as pretransplant nutrition and donor organ options and rigorous age-specific review of the risk/benefit of choice and intensity of immunosuppressive regimes is warranted.
authors.affiliation: Washington University School of Medicine and St Louis Children's Hospital, MO, USA. shepherd_r@kids.wustl.edu
authors.forename: R W
authors.initials: RW
authors.lastname: Shepherd
authors.forename: Y
authors.initials: Y
authors.lastname: Turmelle
authors.forename: M
authors.initials: M
authors.lastname: Nadler
authors.forename: J A
authors.initials: JA
authors.lastname: Lowell
authors.forename: M R
authors.initials: MR
authors.lastname: Narkewicz
authors.forename: S V
authors.initials: SV
authors.lastname: McDiarmid
authors.forename: R
authors.initials: R
authors.lastname: Anand
authors.forename: C
authors.initials: C
authors.lastname: Song
mesh_terms: D000293:Adolescent; D002423:Cause of Death; D002648:Child; D006084:Graft Rejection / Q000453:epidemiology* / Q000401:mortality; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D007239:Infections / Q000453:epidemiology* / Q000401:mortality; D016031:Liver Transplantation / Q000009:adverse effects / Q000276:immunology* / Q000401:mortality; D011183:Postoperative Complications / Q000453:epidemiology*; D011336:Probability; D012008:Recurrence; D012086:Reoperation / Q000401:mortality / Q000706:statistics & numerical data; D012307:Risk Factors; D016019:Survival Analysis; D017211:Treatment Failure
chemical_list: D007166:Immunosuppressive Agents