- Xu M.
- Dong C.
- Sun C.
- et al.
- 1.First, we would like to emphasize that the donors in our study were all younger than one year of age, which is very different from the literature [2,
Early hepatic artery thrombosis after pediatric living donor liver transplantation.Transplant Proc. 2019; 51: 1162-1168https://doi.org/10.1016/j.transproceed.2019.01.1043,
- Kutluturk K.
- Sahin T.T.
- Karakas S.
- et al.
Selective revascularization of hepatic artery thromboses after liver transplantation improves patient and graft survival.Transplantation. 1997; 64: 1295-1299https://doi.org/10.1097/00007890-199711150-00011
- Sheiner P.A.
- Varma C.V.
- Guarrera J.V.
- et al.
- 2.We agree that the therapeutic choices, such as surgical intervention, radiological intervention, and conservative anticoagulant therapy are based on the condition of the recipients, including clinical manifestations, liver function tests (LFTs), the findings of hepatic artery by ultrasound (US), timing of hepatic artery thrombosis (HAT), etc. If LFTs show mild elevation and US shows a weak arterial waveform, conservative anticoagulant therapy may be selected, and the patients must be closely followed. In fact, we also choose different treatment options according to the specific condition of the recipients. Re-transplantation should be considered immediately for the recipients with deteriorated liver function without tendency to reverse. For recipients with slight changes in graft function, we choose regular monitoring and anticoagulant therapy. Since we maintained the international normalized ratio (INR) between 2 and 2.5, it was safe for the recipients, and no recipients suffered from bleeding. So, we did not mention bleeding-related complications in the study.
- 3.Surgical thrombectomy and interventional therapy were performed in our center at an early period for pediatric recipients who received young donors, but the success rate was low. Because of the small sample size, statistical analysis could not be used. We tend to think that the prognosis of HAT in recipients who received younger donors was different from those who received older donors. The possibility of graft loss is higher in the latter population once HAT occurs. This may be related to the greater vulnerability of older donors when they are subjected to injury [
- 4.Our article focuses on the analysis of recipients who received liver grafts from donors under one year of age. Because of the high variability of the pediatric population, this result may not be applied to recipients who received older grafts. For patients with early HAT after living donor liver transplantation (LDLT), surgical thrombectomy and re- anastomosis will be the first treatment once thrombosis occurs [], although the incidence of HAT was extremely low for LDLT. From 2014 to 2019, the incidence of HAT in LDLT in our center was 0.47% (3/638). On the other hand, as was mentioned in the literature [
Management and outcome of hepatic artery thrombosis after pediatric liver transplantation.Pediatr Transplant. 2020; (n/a:): e13938https://doi.org/10.1111/petr.13938
- Channaoui A.
- Tambucci R.
- Pire A.
- et al.
- 5.There was no HAT related liver abscess in our follow-up data. This may be because of the formation of arterial collaterals that maintain the blood supply to the graft, thereby avoiding the development of an abscess. However, a small number of patients receiving older grafts developed HAT related liver abscess and needed percutaneous drainage. Despite the higher incidence of biliary complications in this subset of recipients who developed HAT, all achieved satisfactory outcomes with interventional treatment [,
Non-operative management of biliary complications after Liver Transplantation in pediatric patients: a 30-year experience.Pediatr Transplant. 2021; (n/a): e14028https://doi.org/10.1111/petr.14028
- Lee A.Y.
- Lehrman E.D.
- Perito E.R.
- et al.
- 6.The reader mentioned that there is consensus that GRWR was an ideal ratio between 2% and 3%. However, our previous studies have also shown that GRWR less than 2.2% was identified as independent risk factor for HAT [
- 7.Extremely desirable donors are difficult to obtain because of donor shortage []. As expected from all transplant physicians, we are also hoping to reduce the mortality to zero among children on the waiting list [
Global lessons in graft type and pediatric liver allocation: a path toward improving outcomes and eliminating wait-list mortality.Liver Transpl. 2017; 23: 86-95https://doi.org/10.1002/lt.24646]. Although the incidence of HAT in recipients was higher and the occurrence of HAT was more likely to lead to biliary complications in this type of donor, the recipient survival and graft survival under effective treatment was still acceptable, as shown in our study [
- Hsu E.K.
- Mazariegos G.V.
Wait list mortality in pediatric liver transplantation: the goal is zero.Liver Transpl. 2022; https://doi.org/10.1002/lt.26549
- Mazariegos G.V.
- Soltys K.A.
- Perito E.R.
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- Management and outcome of hepatic artery thrombosis with whole-liver transplantation using donors less than one year of age.J Pediatr Surg. 2022; (S0022-3468(22)00344-X)https://doi.org/10.1016/j.jpedsurg.2022.05.009
- Early hepatic artery thrombosis after pediatric living donor liver transplantation.Transplant Proc. 2019; 51: 1162-1168https://doi.org/10.1016/j.transproceed.2019.01.104
- Selective revascularization of hepatic artery thromboses after liver transplantation improves patient and graft survival.Transplantation. 1997; 64: 1295-1299https://doi.org/10.1097/00007890-199711150-00011
- What happened in 133 consecutive hepatic artery reconstruction in liver transplantation in 1 year?.Hepatobiliary Surg Nutr. 2019; 8: 10-18https://doi.org/10.21037/hbsn.2018.11.13
- Expanded criteria donors.Clin Liver Dis. 2014; 18: 633-649https://doi.org/10.1016/j.cld.2014.05.005
- Management and outcome of hepatic artery thrombosis after pediatric liver transplantation.Pediatr Transplant. 2020; (n/a:): e13938https://doi.org/10.1111/petr.13938
- Hepatic artery reconstruction technique in liver transplantation: experience with 3000 cases.Hepatobiliary Surg Nutr. 2021; 10: 281-283https://doi.org/10.21037/hbsn-21-2
- Non-operative management of biliary complications after Liver Transplantation in pediatric patients: a 30-year experience.Pediatr Transplant. 2021; (n/a): e14028https://doi.org/10.1111/petr.14028
- Interventional radiological treatment of paediatric liver transplantation complications.Cardiovasc Inter Rad. 2020; 43: 765-774https://doi.org/10.1007/s00270-020-02430-8
- Risk factors of hepatic artery thrombosis in pediatric deceased donor liver transplantation.Pediatr Surg Int. 2019; 35: 853-859https://doi.org/10.1007/s00383-019-04500-6
- Global lessons in graft type and pediatric liver allocation: a path toward improving outcomes and eliminating wait-list mortality.Liver Transpl. 2017; 23: 86-95https://doi.org/10.1002/lt.24646
- Wait list mortality in pediatric liver transplantation: the goal is zero.Liver Transpl. 2022; https://doi.org/10.1002/lt.26549