AASLD AST NASPGHAN practice guidelines for pediatric liver transplantation candidate evaluation

Guidelines from the American Association for the Study of Liver Diseases (AASLD), the American Society of Transplantation (AST), and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) on the evaluation of pediatric liver transplantation (LT) candidates were published in Hepatology by Martinez et al. A total of 90 guidelines were developed by a multidisciplinary writing group, aiming to provide updated evidence-based recommendations that reflect current best practice and evolving clinical knowledge. 

Key data: Recommendations include urgent referral of all pediatric patients with acute liver failure to a LT center for evaluation, and consideration of LT evaluation for those with chronic liver disease who experience a decompensating event. The evaluation process should be standardized and involve a multidisciplinary team to establish the need and optimal timing for transplantation, identify potential barriers, and address the child’s needs and family readiness. All age-appropriate inactivated and live vaccines should be administered to LT candidates and household contacts before transplantation using an accelerated schedule, when necessary, except in children with acute liver failure. LT candidates should receive measles–mumps–rubella and varicella vaccines starting at 6 months of age. LT should not be performed in patients with uncontrolled sepsis, progressive systemic disease not amenable to treatment with an LT, unresectable extrahepatic malignancy, severe multisystem mitochondrial disease, or irreversible cerebral edema with uncal herniation. Retransplantation should be considered for patients with graft failure that cannot be managed otherwise, with evaluation conducted at an experienced center.  

Key learning: These guidelines provide evidence-based recommendations for the evaluation of pediatric LT candidates, covering indications and contraindications for transplantation, pre-transplantation assessment, and the importance of a coordinated, multidisciplinary approach.