OBJECTIVE:To investigate the clinical application of continuous renal replacement therapy (CRRT) in infants with acute kidney injury (AKI) after liver transplantation.METHODS:A retrospective study was conducted on infants with AKI after liver transplantation in Tianjin First Center Hospital from January 1, 2019 to June 1, 2021. Infants with AKI within 1 year after liver transplantation were divided into CRRT group and non-CRRT group according to whether CRRT was performed. The preoperative and intraoperative condition, the postoperative complications were compared, the risk factors of CRRT for AKI infants, the clinical characteristics of CRRT were analyzed, and the prognosis between CRRT group and non-CRRT group were compared.RESULTS:(1) A total of 512 cases of pediatric liver transplantation were performed. A total of 189 cases (36.9%) developed AKI within 1 year after surgery, including 18 cases in CRRT group and 171 cases in non-CRRT group. (2) There was no significant difference in preoperative conditions between the two groups. The duration of liver transplantation (hours: 8.8±1.5 vs. 7.5±1.3) and intraoperative blood loss [mL: 370 (220-800) vs. 310 (200-400)] in CRRT group were significantly higher than those in non-CRRT group. CRRT group had significantly higher incidence of postoperative complication [unplanned operation: 8 cases (44.4%) vs. 14 cases (8.2%), primary nonfunction: 1 case (5.6%) vs. 0 case (0%), retransplantation: 3 cases (16.7%) vs. 0 case (0%), hepatic artery thrombosis: 3 cases (16.7%) vs. 4 cases (2.3%), intestinal fistula: 2 cases (11.1%) vs. 2 cases (1.2%)] than non-CRRT group (all P < 0.05). (3) The average start time of CRRT was 10 (1-240) days. The per capita frequency of CRRT treatment was 3.3 (1.0-14.0) times. The average duration of each CRRT treatment was 10.1 (6.0-19.3) hours, the average reduction rate of serum creatinine (SCr) was 25.6% (13.5%-45.0%) after CRRT. (4) In CRRT group, 5 patients died, the 1-year and 2-year survival rates were both 72.22%. In non-CRRT group, 6 patients died, the 1-year and 2-year survival rates were 97.1% and 96.5%, respectively. There were significant differences in 1-year and 2-year survival rates between the two groups (both P < 0.01).CONCLUSIONS:The incidence of AKI after pediatric liver transplantation was high, and most infants treated with CRRT were associated with serious surgical complications. CRRT was a powerful means to remove inflammatory factors and maintain the stability of circulation and internal environment, which could improve the multi-organ dysfunction effectively.

Objective This study aimed to explore the clinical application of continuous renal replacement therapy (CRRT) in pediatric patients with acute kidney injury (AKI) after liver transplantation. Methods Pediatric patients who underwent liver transplantation were retrospectively investigated. Those who developed AKI within 1 year after the surgery were included and divided into a CRRT group and a non-CRRT group. The perioperative conditions and postoperative complications of the two groups were compared along with the prognoses of the groups to analyze the high-risk factors of the postoperative CRRT. Results 189 (36.91%) patients developed AKI within 1 year after the liver transplantation surgery. There were 18 patients in the CRRT group and 171 in the non-CRRT group. The differences in the preoperative conditions were not statistically significant between the two groups. Compared with the non-CRRT group, patients in the CRRT group had significantly longer transplantation times, higher volumes of intraoperative hemorrhage, and increased incidence of postoperative unscheduled surgery, postoperative primary nonfunction of the transplanted liver, secondary liver transplantation, hepatic artery occlusion, and intestinal fistula (P < 0.05). Moreover, the proportion of patients in AKI stage 3 is higher in the CRRT group (83.33%) than that in the non-CRRT group (11.11%), P < 0.001. The median time to initiate CRRT was 10 days postoperatively, the median number of CRRT treatments per patient was 2 times, the average duration of each CRRT treatment was 10.1 h, and the average rate of the decrease in blood creatinine per treatment was 25.6%. Results of multivariate logistic regression analysis showed that AKI stage 3 [OR=40.000, 95%CI (10.598, 150.969), P = 0.016], postoperative unscheduled surgery [OR=6.269, 95%CI (3.051, 26.379), P = 0.007], and hepatic artery occlusion [OR = 17.682, 95%CI (1.707, 40.843), P = 0.001] were recognized as risk factors for postoperative AKI with CRRT therapy. The one- and two-year survival rates were 72.22% and 72.22% in the CRRT group, respectively; and 97.08% and 96.49% in the non-CRRT group, accordingly. There were statistically significant differences in the one- and two-year survival rates between the two groups (P < 0.001). Conclusion The incidence of AKI after liver transplantation in pediatric patients was high. Patients with AKI stage 3, hepatic artery occlusion, and underwent unscheduled surgery postoperatively were with a high likelihood of receiving CRRT, which was related to a lower one- and two-year survival rates. CRRT effectively improved the one- and two-year survival rates.

Objective This study aimed to investigate the colonization and prevalence of carbapenem-resistant Enterobacteriaceae (CRE) in pediatric liver transplant recipients and analyze the high-risk factors and prognosis of CRE infection. Methods A prospective study involving 152 pediatric patients undergoing liver transplantation was carried out. Anal swab bacteria cultures were collected when the patients entered the intensive care unit (ICU) and when they left in order to screen for intestinal CRE colonization. The results were grouped according to the occurrence of CRE infection following surgery, and the patients were divided into two groups: a CRE infection group and a non-CRE infection group. Univariate analysis and multiple logistic regression analysis were conducted to determine the independent risk factors of CRE infection and analyze the survival rate. Results Of the 152 pediatric liver transplant recipients enrolled in the study, there were 13 cases of postoperative CRE infection and 139 cases of non-CRE infection. The incidence of preoperative CRE infection, preoperative cytomegalovirus (CMV) infection, and preoperative sepsis in the CRE infection group was significantly higher than in the non-CRE infection group (P < 0.005). Intraoperative bleeding volume and operation times in the CRE infection group were also significantly higher than in the non-CRE infection group (P < 0.05). Furthermore, postoperative ICU treatment time, postoperative occurrence of unplanned surgery, postoperative mechanical ventilation of more than 24 hours, and the incidence of pre-ICU CRE colonization in the CRE infection group were significantly higher than in the non-CRE infection group (P < 0.05). Finally, the difference between the CRE infection group and the non-CRE infection group in six-month survival rate following surgery was significant (P < 0.001). Conclusion The independent risk factors of CRE infection following pediatric liver transplantation include preoperative CRE infection and pre-ICU CRE colonization. CRE infection progresses quickly, with a poor prognosis and a high mortality rate. The CRE screening of anal swabs is crucial for the early detection of CRE infection.

Objective To explore the clinical efficacy and risk factors of mortality for liver transplantation in patients with acute liver failure. Methods From January 2012 to December 2017, retrospective analysis was performed for 31 patients with acute liver failure undergoing orthotopic liver transplantation. Clinical data and follow-up data were recorded. Univariate survival analysis was performed by Kaplan-Meier and Log-rank tests while multivariate survival analysis conducted by proportional hazards model. Results Age ≥55 years, preoperative hepatorenal syndrome, perioperative infection and preoperative non-molecular adsorbent recirculating system (MARS) support were influencing factors of postoperative survival rate by univariate survival analysis (P<0.05). Preoperative infection was an independent risk factor for survival after liver transplantation by multivariate COX regression analysis (P<0.01). Conclusions Liver transplantation is an effective treatment for acute liver failure. And preoperative infection is an independent risk factor for survival after liver transplantation. Key words: Liver failure; Acute; Liver transplantation; Survival analysis

Objective To summarize the computed tomographic (CT) manifestations of pulmonary aspergillosis after organ transplantation and compare different signs between pulmonary aspergillosis and bacterial pneumonia.Methods CT images of pulmonary aspergillosis (n =62) and bacterial pneumonia (n =68) in post-transplantation patients were reviewed.The signs were categorized with consolidation,mass,large nodule (≥1crn),small nodule and bud-in-tree pattern.Some detailed useful differentiating signs such as halo sign,air bronchogram sign,reversed halo sign,hypodensity sign and cavitation were also analyzed.Results CT patterns of pulmonary aspergillosis included consolidation,mass,large nodule,small nodule and bud-in-tree pattern.The most common was large nodule (75.8％),followed by consolidation (48.4％)and mass (29.0％).And small nodule (16.1 ％) and bud-in-tree (12.9％) patterns were concurrent.For consolidation pattern,the proportion of bacterial pneumonia (69.1％) was the larger;For mass pattern,the proportion of pulmonary aspergillosis (29.0％) was the larger.For large nodule pattern,there was no difference.The detail sign of large nodule in two groups had no difference In detailed signs of consolidation pattern,air bronchogram sign was more often seen in bacterial pneumonia while cavitation was more frequently found in pulmonary aspergillosis.In detailed signs of mass pattern,pulmonary aspergillosis often has single lesion (66.7％),cavitation (83.3％)and air crescent sign (77.8％) is more common.The proportion of halo sign was 30.7％.Conclusions CT manifestations of pulmonary aspergillosis are diverse after organ transplantation.There is some difference and yet overlap with bacterial pneumonia.

Objective To investigate the clinical efficacy and influencing factors in patients with acute-on-chronic liver failure grade 3 after liver transplantation.Methods 33 patients with acute-on-chronic grade 3 liver failure who were treated in Tianjin First Center Hospital from January 2015 to December 2017 was retrospectively analyzed,including 21 patients in liver transplantation group and 12 patients in control group.Among them,28 patients were males and 5 patients were females,aged (43.4± 12.3) years.The data and follow-up information of all patients were collected.The survival condition was analyzed by Kaplan-Meier.Univariate and multivariate Cox regression analysis was used to analyze the risk factors of death in patients after liver transplantation.Results There was no significant difference in Child-Pugh score,total bilirubin,creatinine and infection before operation between liver transplantation group and control group (P＞0.05).The age of patients in liver transplantation group was older than the control group,the difference was statistically significant (P＜0.05).The 1-year and 3-year cumulative survival rates in the liver transplantation group were 61.9％ and 61.9％ respectively and the rates in control group were 8.3％ and 8.3％ respectively by Kaplan-Meier survival analysis.There was significant difference between the two groups (P＜0.05).Twenty-one patients in the liver transplantation group were followed up for a long time,13 patients survived and followed up for 163～ 1 123 days.Except for renal insufficiency complicated with renal anemia in 1 case,the other 12 cases had normal liver function,and 8 cases died in 2～54 days after liver transplantation.Postoperative shock was an independent risk factor for death after liver transplantation by univariate and multivariate Cox regression analysis.Conclusion Acute-on-chronic grade 3 liver failure was indication for liver transplantation,postoperative shock was an independent risk factor for death after liver transplantation.

BACKGROUND The aim of this study was to investigate the correlation between indocyanine green plasma disappearance rate (ICG-PDR) and allograft function as well as postoperative complications after liver transplantation. MATERIAL AND METHODS In this prospective study, 115 cases of adult liver transplantation performed from 1 June 2016 to 1 December 2016 were enrolled. These 115 patients were divided into a group of PDR <18%/min (50 cases) and a group of PDR ≥18%/min (65 cases). The rates of liver recovery, postoperative complications, and survival were compared between these 2 groups. RESULTS Among the total of 115 patients, 111 patients recovered well and were discharged, whereas 4 patients died during the first month after the operation. Between the 2 groups, significant differences were observed in terms of the model for end-stage liver disease (MELD) score, intraoperative bleeding volume, and the level of hemoglobin (Hb), pre-albumin (PA) and total bilirubin (TB) the first week after the operation. Overall, the incidence of hepatic arterial complications and pneumonia was much higher in the PDR<18%/min group (P<0.05). CONCLUSIONS The early postoperative value of ICG-PDR was closely related to graft function and could act as a good predictor for the incidence of postoperative arterial complications.

Objective To summarize the clinical characteristics of collateral circulation after hepatic artery occlusion (HAO) during early postoperative stage in infant recipients undergoing donation-after-cardiac-death (DCD) liver transplantation and further discuss the potential factors associated with collateral formation.Methods A total of 49 infant recipients of DCD liver transplantation from December 2013 to December 20t5 were recruited.Among them,15 cases had HAO at early postoperative stage.Two cases dead within the first postoperative week were excluded.The clinical data of the other 13 cases were retrospectively collected by reviewing medical charts.Clinical features of collaterals after HAO were reviewed and their outcomes analyzed.Results Among 13 infant recipients,9 patients had hepatic arterial branch occlusion (group HABO) while the other 4 patients main hepatic artery occlusion (group MHAO).The mean time of HAO detection was (4.7 ± 1.8) days post-transplantation.Intrahepatic arterial branch flows were restored in all HABO patients at (9.7 ± 5.3) days post-HABO.Additionally,for all of four MHAO patients,intrahepatic artery collaterals developed at (9.8 ± 3.2) days post-MHAO and extrahepatic artery collaterals at (20.0 ± 5.0) days post-MHAO.Two patients in each group had ischemia biliary complications.One patient of graft nonfunction in MHAO group received retransplantation while the remainder had percutaneous transhepatic cholangial drainage and balloon dilation.And nearly normal liver function maintained at the last follow-up.Conclusions Arterial branch occlusion is the major presentation of early postoperative HAO in infant recipients undergoing DCD liver transplantation.Rapid collateral formation appears in all patients with MHAO.However,the incidence of biliary complications remains high and close monitoring is required.And long-term outcomes need further evaluations.

Objective To evaluate the effect of nasal continuous positive airway pressure (nCPAP) in pediatric patients with respiratory failure after liver transplantation.Method A prospective? randomized controlled clinical trial was conducted during June 1st 2013 to June lst2015 in 71 pediatric patients with respiratory failure after liver transplantation.A total of 66 patients completed the trial and 5 patients quitted.Conventional oxygen therapy group included 35 cases and nCPAP group included 31 cases.The vital sign,blood-gas analysis,intra-abdominal pressure and prognosis were compared between the two groups.Result After nCPAP treatment,the heart rate,respiratory rate,and PCO2 decreased at 4 and 24 h (P＜0.05),oxygenation index was improved at 24 and 48 h (P＜0.05),and intra-abdominal pressure decreased at 48 h (P＜0.05).nCPAP showed better outcome than conventional oxygen therapy (P＜0.05).The incidence of refractory atelectasis,intra-abdominal hypertension,and epilepsy was higher in treatment failure population.Conclusion nCPAP is more suitable for pediatric patients with respiratory failure after liver transplantation,especially for those accompanied with intra-abdominal hypertension.

Objective To analyze the impact of graft to recipient weight ratio (GRWR)on pediatric liver transplantation and discuss the diagnostic criteria of small-for-size liver graft in pediatric liver transplantation.Methods A retrospective analysis of 52 cases of pediatric liver transplantion from donation after citizen's death from January 1st 2015 to December 31st 2015.10 patients were divided into GRWR≤2％ group(small-for-size grafts group)and 42 patients were divided into GRWR ＞2％ group (match-for-size grafts group).Liver recovery,complications and survival rate were analyzed.Results 48 out of 52 cases recovered well and discharged,but 4 cases died at the first 3 months postoperation.There is no significant difference in the ALT,TB,INR and portal inflow between the two groups.The incidence of hepatic artery occlusin was 30 ％ in GRWR≤2 ％ group,but was 4.8％ in GRWR＞2％ group(P=0.015).The follow-up time is from 6 months to 17 months,the median survival time was 280 days in GRWR≤2％ group,but was 336 days in GRWR＞2％ group(P=0.726).Conclusion The incidence of hepatic artery occlusin and ischemic biliary complication was much higher in GRWR≤2％ group.The diagnostic criteria of adults small-for-size syndrome can't be applied to pediatric liver transplantation.

Objective To summarize our cxperience on perioperative fluid management of liver transplantation for biliary atresia (BA) in infants.Methods From september 2006 to August 2011,24infants were diagnosed with BA,and underwent liver transplantation.Perioperative hemodynamic parameters including blood gas parameters,lactic acid,serum electrolytes and blood glucose were monitored and retrospectively analyzed.Fluid therapy plan was adjusted according to these parameters.Results Blood pH and base excess decreased immediately at the beginning of anhcpatic phase,and was closed to normal level at the end of operation (7.38 ± 0.09 and - 1.44 ± 0.64).Blood pH and base excess kept increasing after operation,and peaked 12 hours after surgery,then decreased gradually to normal level.Serum lactic acid began to rise immediately at the beginning of anhepatic phase (3.31 ±0.8 mmol/L),peaked at the first 30 minutes of the neohepatic phase,started to drop 6 hours after surgery and reached normal range 12 hours later.Serum potassium concentration decreased significantly since the neohepatic phase (3.21 ± 0.52 mmol/L).Serum calcium concentration decreased significantly since the anhepatic phase ( 1.03 ± 0.12 mmol/L),serum sodium concentration increased gradually since the neohepatic phase ( 141.2 ± 2.9 mmol/L).Blood glucose (BG) after the anhepatic phase was higher than that before the operation (7.4 ± 2.8 nmnol/L).All of the 24 infants received liver transplantation successfully,without dehydration or cardiopulmonary events during the perioperative phases.All infants recovered well from surgery except 4 died.Conclusions During the surgery of liver transplantation for biliary atresia (BA) in infants,colloidal liquid should account for more than 50％ of the total liquid dose.Fluid management after transplantation was sinular to the principles of fluid management of other general surgery.