It’s ESPGHAN Journal Club, and—good heavens—it’s already November! Where did 2025 go? Lovely crisp sunny days, duvet-plus-blanket nights with very clingy cats, and foggy mornings with a fire in the woodstove to warm the kitchen and boil the kettle. After a nice cup of tea, let’s go shuffle-kick through the leaf piles with Dr. Jake Mann.

Jake’s choices for today: From J Pediatr Gastroenterol Nutr, by Anouti A. et al., writing from several USA institutions — Pediatric liver transplant outcomes: A comparative analysis of steatotic donor grafts. To follow, by Chu C. et al., from southern California under the palms of Los Angeles, and published in Hepatol Commun — Ultrasound of the rectus femoris as a novel tool to measure sarcopenia in pediatric chronic liver disease.

Be warned, prospective readers: although in neither selection do the authors squeeze cells and look at the juice — no pesky nucleic acids work! — you may want your hip boots: the statistics are scary deep.

Given that donor livers are growing fatter, the proportion of livers in which steatosis precludes use as an allograft may be increasing, Anouti et al. tell us. Adding to this, donor livers have never been abundant. The question posed: are outcomes substantially worse with fatty allografts than with lean allografts?

In the twenty years between 2004 and 2024, according to a USA liver transplantation database, 595 children and adolescents received liver allografts that were considered steatotic. In 62 (10.4%), steatosis affected >30% of parenchyma. Those recipients — in terms of one-year, five-year, and ten-year survival — fared no worse than did the other 533 with steatosis affecting <30% of parenchyma. This differs from what is observed in adults, who tolerate fatty implants poorly. In children, however, other factors conferred adverse prognosis. If those factors are borne in mind, and measures to address them are taken, the authors propose, fatty donor livers may be more widely usable.

Readers are not given several denominators: how many paediatric liver transplants took place overall? How many donor livers seemed dodgy enough to the surgical team that a histopathologist was called to evaluate a biopsy specimen? How many biopsied livers were discarded rather than implanted? And most importantly — what are survival rates in children who receive non-steatotic livers? To be regretted.

Chu and colleagues offer the results of imaging-study work intended to assess muscle bulk and consistency (fibrosis, fatty infiltration) in paediatric patients with chronic liver disease. Growth failure, they tell us, is not always reflected in paediatric end-stage liver disease scores that are used in selecting children for liver transplantation, and children not listed for transplantation but with growth failure not infrequently die while waiting for an organ.

Frailty and sarcopenia — lack of muscle mass — might, as indicators of growth failure, warrant consideration in juggling children up and down the transplantation list. What measurements, though, should one use in assessing muscle qualitatively and quantitatively? Where should measurements be taken?

Chu et al. subjected the rectus femoris, right and left, to ultrasonography, because that muscle is easy to find and easy to scan. They found that their measurements yielded internally and observer-to-observer consistent results, and that these results correlated well with clinical findings and clinical-laboratory biomarker values. Another arrow in the hepatologic quiver, then, and time will tell how often this new arrow is chosen to be nocked and shot — as well as how often, off the bowstring, it hits the intended target.

Two articles, two précis. But what does Jake think of these contributions to our literature? Why does he recommend that we grapple with them? Don’t click away — he’ll tell us.

Literature

Anouti A. et al. Pediatric liver transplant outcomes: A comparative analysis of steatotic donor grafts. J Pediatr Gastroenterol Nutr. 2025 Sep 22. DOI: 10.1002/jpn3.70213. Online ahead of print. PMID: 40977417

Chu C. et al. Ultrasound of the rectus femoris as a novel tool to measure sarcopenia in pediatric chronic liver disease.Hepatol Commun. 2025 Aug; 159(9): e0799. DOI: 10.1097/HC9.0000000000000799. PMID: 40824275. PMCID: PMC12363444