[68, 69] Risk factors that require careful assessment include patient age and weight, nutritional status, hypoalbuminemia, hepatopulmonary syndrome, and cardiomyopathy associated with cirrhosis.[69,

70] Pediatric conditions and their associated comorbidities that may heighten anesthetic risk include Alagille syndrome (cardiac disease, vascular and renal abnormalities, and moyamoya), biliary atresia with splenic malformation (complex heart disease, interrupted inferior vena cava), and primary hyperoxaluria (renal and cardiac dysfunction).[69] A specialized LT anesthesia team has been associated with more favorable patient outcomes in adults, although pediatric centers were excluded from this study.[71] The United Network for Organ Sharing (UNOS) has recently modified policy to require liver transplant programs to designate a Director of Liver Transplant Anesthesia who has expertise in the area of perioperative care Epigenetics Compound Library datasheet of liver transplant patients and can serve as an advisor to other members of the team. 20. An anesthesiologist familiar with pediatric indications for LT and associated comorbidities should ensure the LT evaluation includes appropriate disease-specific assessments to minimize intraoperative and postoperative anesthetic risk. (2-B) Children with chronic liver disease are often not fully immunized prior to LT.[72, 73] Development of a vaccine

Alectinib preventable disease (VPD) either before or after LT will increase morbidity and mortality and heightened the risk of graft injury or loss.[74, 75] Timing of immunization administration in the LT candidate is important, as vaccines are more immunogenic before the development of endstage liver disease and more immunogenic before than after LT. Humoral immunity to rubella, measles, and varicella vaccines is significantly decreased in children with biliary atresia compared to healthy controls.[76] VPD can develop in immunized children with chronic liver disease

when antibody titers are low.[77] There is a paucity of data related to influenza vaccine in patients with MCE chronic liver disease.[78] Hepatic decompensation has been reported with influenza,[79] and influenza vaccination in adults with cirrhosis significantly reduced the frequency of hepatic decompensation compared to those who did not receive the vaccine.[80] Guidelines for vaccination of liver transplant candidates and recipients are published periodically by the American Society of Transplantation.[81] Clinical practice guidelines for vaccination of the immunocompromised host were recently published by the Infectious Diseases Society of America.[82] Vaccination of household contacts provides additional protection to the child.[83] Paralytic polio has been described in household contacts of oral polio vaccine recipients.[84] Data suggest that administration of live virus vaccines to household contacts, other than oral polio, poses minimal risk to the child.