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Background: Children at high risk for prolonged mechanical ventilation (PMV) after liver transplantation (LT) need to be identified early to optimize pulmonary support, allocate resources, and improve surgical outcomes. We aimed to develop and validate a metric that can estimate risk for Prolonged Ventilation After LT (PROVE‐ALT). Methods: We identified preoperative risk factors for PMV by univariable analysis in a retrospective cohort of pediatric LT recipients between 2011 and 2017 (n = 205; derivation cohort). We created the PROVE‐ALT score by mapping multivariable logistic regression coefficients as integers, with cutoff values using the Youden Index. We validated the score by C‐statistic in a retrospectively collected separate cohort of pediatric LT recipients between 2018 and 2021 (n = 133, validation cohort). Results: Among total 338 patients, 21% (n = 72) were infants; 49% (n = 167) had cirrhosis; 8% (n = 27) required continuous renal replacement therapy (CRRT); and 32% (n = 111) required management in hospital (MIH) before LT. Incidence of PMV post‐LT was 20% (n = 69) and 3% (n = 12) required tracheostomy. Independent risk factors (OR [95% CI]) for PMV were cirrhosis (3.8 [1–14], p =.04); age <1‐year (8.2 [2–30], p =.001); need for preoperative CRRT (6.3 [1.2–32], p =.02); and MIH before LT (12.4 [2.1–71], p =.004). PROVE‐ALT score ≥8 [Range = 0–21] accurately predicted PMV in the validation cohort with 73% sensitivity and 80% specificity (AUC: 0.81; 95% CI: 0.71–0.91). Conclusion: PROVE‐ALT can predict PMV after pediatric LT with a high degree of sensitivity and specificity. Once externally validated in other centers, PROVE‐ALT will empower clinicians to plan patient‐specific ventilation strategies, provide parental anticipatory guidance, and optimize hospital resources. [ABSTRACT FROM AUTHOR]

Background: Children with end‐stage liver disease and multi‐organ failure, previously considered as poor surgical candidates, can now benefit from liver transplantation (LT). They often need prolonged mechanical ventilation (MV) post‐LT and may need tracheostomy to advance care. Data on tracheostomy after pediatric LT are lacking. Method: Retrospective chart review of children who required tracheostomy in the peri‐LT period in a large, freestanding quaternary children's hospital from 2014 to 2019. Results: Out of 205 total orthotopic LTs performed in 200 children, 18 (9%) required tracheostomy in the peri‐transplant period: 4 (2%) pre‐LT and 14 (7%) post‐LT. Among those 14 needing tracheostomy post‐LT, median age was 9 months [IQR = 7, 14] at LT and 10 months [9, 17] at tracheostomy. Nine (64%) were infants and 12 (85%) were cirrhotic at the time of LT. Seven (50%) were intubated before LT. Median MV days prior to LT was 23 [7, 36]. Eight (57%) patients received perioperative continuous renal replacement therapy (CRRT). The median MV days from LT to tracheostomy was 46 [33, 56]; total MV days from initial intubation to tracheostomy was 57 [37, 66]. Four (28%) children died, of which 3 (21%) died within 1 year of transplant. Total ICU and hospital length of stay were 92 days [I72, 126] and 177 days [115, 212] respectively. Among survivors, 3/10 (30%) required MV at home and 8/10 (80%) were successfully decannulated at 400 median days [283, 584]. Conclusion: Tracheostomy though rare after LT remains a feasible option to support and rehabilitate critically ill children who need prolonged MV in the peri‐LT period. [ABSTRACT FROM AUTHOR]

We describe the successful pediatric liver transplant for unresectable hepatoblastoma in a 4‐year‐old male with COVID‐19 prior to transplant. The first negative NP swab was documented 1 month after initial diagnosis, when SARS‐CoV‐2 antibodies were also detected. The patient was actively listed for liver transplant after completing four blocks of a SIOPEL‐4 based regimen due to his PRETEXT IV disease which remained unresectable. Following three additional negative NP swabs and resolution of symptoms for 4 weeks, he underwent a whole‐organ pediatric liver transplant. COVID‐19 positivity determined via NP swab SARS‐CoV‐2 real‐time RT‐PCR (Hologic Aptima SARS‐CoV‐2 RT‐PCR assay). IgG and IgM total SARS‐ CoV‐2 antibodies detected by Ortho Clinical Diagnostics VITROS® Immunodiagnostics Products Anti‐SARS‐CoV‐2 Test. Patient received standard prednisone and tacrolimus‐based immunosuppression without induction therapy following transplant. Post‐transplant course was remarkable for neutropenia and thrombocytopenia, with discharge home on post‐transplant day #11. Surveillance tests have remained negative with persistent SARS‐CoV‐2 IgG antibodies at 6 weeks after transplant. We describe one of the earliest, if not the first case of liver transplant following recent recovery from COVID‐19 in a pediatric patient with a lethal malignant liver tumor. A better understanding of how to balance the risk profile of transplant in the setting of COVID‐19 with disease progression if transplant is not performed is needed. We followed existing ASTS guidelines to document clearance of the viral infection and resolution of symptoms before transplant. This case highlights that pediatric liver transplantation can be safely performed upon clearance of COVID‐19. [ABSTRACT FROM AUTHOR]