Objective:To explore the relationship between serum lactate level and early prognosis after liver transplantation (LT) in children.Methods:Between January 1, 2018 and December 31, 2020, 675 pediatric LT recipients were recruited. Clinical data were retrospectively reviewed, early postoperative serum lactate level and clearance rate recorded and receiver operating characteristic (ROC) curve plotted for determining optimal cut-off values. The inter-group differences in early postoperative complications and patient/graft survival rates were compared.Results:According to ROC, blood lactate levels >1.99 mmol/L at 12 h postoperatively were associated with early postoperative graft loss (AUC 0.73, 95% CI: 0.62-0.84, P=0.01). Age and weight of recipients in high-level group were 7.17(5.70-10.40) month and 7.00(6.00-8.60) kg and both were significantly lower than those in low-level group [7.80(6.21-13.58) month and 7.20(6.45-9.00) kg]. The inter-group differences were statistically significant ( P=0.017, P=0.034). Blood plasma transfusion volume, red blood cell transfusion volume, portal vein pressure pre-closure, postoperative intensive care unit (ICU) stay, ventilator use time, early allograft dysfunction rate, early postoperative pulmonary infection rate and recipient mortality rate in high-level group were 400 (200-400) ml, 2.00 (2.00-4.00) U, (15.71±4.44) mmHg, 2.50(2.00-3.00) day, 3.81(2.47-8.50) hour, 22.95%(42/185), 16.76%(31/185) and 6.49%(12/185) respectively. The above values were significantly higher than those in low-level group 200(100-400) ml, 2.00 (2.00-3.00) U, (14.69±4.68) mmHg, 2.00(2.00-3.00) day, 3.53(2.34-6.12) hour, 14.69%(72/490), 11.02%(54/490) and 1.43%(7/490) respectively. The inter-group differences were statistically significant ( P<0.001, P=0.014, P=0.015, P=0.037, P=0.043, P=0.011, P=0.045 & P<0.001). The incidence of early postoperative acute cellular rejection was significantly lower in high-level group than that in low-level group [11.89%(22/185) vs 22.86%(112/490)]. The inter-group difference was statistically significant ( P=0.01). The 1/3-month cumulative survival rates of patient/graft were 94.6%, 94.1% and 92.4%, 91.4% in high-level group versus 99.2%, 98.6% and 99.0%, 98.4% in low-level group. There were significant inter-group differences ( P=0, P<0.000 1). With a rising level of lactate at 12 h postoperatively, risk of early graft loss and early recipient mortality spiked markedly ( P<0.05). Conclusions:Serum lactate level post-operation is a valid predictor of early prognosis after LT in children.

Objective:To study the impact of donor left hepatic vein classification and the reconstruction methods on hepatic venous outflow obstruction (HVOO) after pediatric living-donor liver transplantation using left lateral liver segments.Methods:A retrospective study was performed on the clinical data of 653 children recipients who underwent living-donor liver transplantation with left lateral liver segments from January 2014 to December 2020 at Tianjin First Central Hospital. There were 309 males and 344 females, aged 7.0 (6.0, 10.0) months, with an age range of 3-121 months. Based on the left hepatic vein on preoperative donor enhancement CT as well as the intraoperative reconstruction methods, the recipients were divided into 3 groups: type Ⅰ group ( n=514), anastomosis using a single opening was performed directly between the donor and the recipient; type Ⅱ group ( n=118), angioplasty was performed on two adjacent recipient venous orifices before anastomosis, and type Ⅲ group ( n=21), an interposition vessel was anastomosed to two widely spaced openings or the two veins were anastomosed separately. The preoperative general status of the patient, postoperative HVOO incidences, and graft and recipient survival rates were compared among the three groups. The patients were followed up by outpatient reexamination or telephone. Results:Graft to recipient weight ratio in the type Ⅲ group was smaller than that in the type Ⅰ group and the type Ⅱ group ( P<0.05). For all the 653 patients, the incidence of postoperative HVOO was 4.59% (30/653), with the incidences of HVOO in the 3 groups of patients were 4.1% for the type Ⅰ group (21/514), 5.1% for the type Ⅱ group (6/118), and 14.3% for the type Ⅲ group (3/21), respectively. There was no significant difference among the groups ( P>0.05). The recipient cumulative survival rates at 1 and 3 years after surgery in the type I group were 97.8% and 97.0%, and the corresponding rates in the type Ⅱ group were 96.5% and 94.2%, and in the type Ⅲ group were 94.1% and 86.9%, respectively. There was a significant difference between the type Ⅰ and type Ⅲ groups ( P=0.048). The graft cumulative survival rates at 1 and 3 years in the type Ⅰ group were 97.4% and 96.9%, and the corresponding rates in the type Ⅱ group were 94.9% and 92.5%, and in the type Ⅲ group were 94.1% and 86.9%, respectively. The difference in the postoperative graft cumulative survival rates between the type Ⅰ group and type Ⅱ group was significant ( P=0.044). Conclusions:The anatomy of the left hepatic vein supplying the left lateral liver segment was highly variable, and the majority of the variations could be reconstructed. A reasonable reconstructive method could reduce the incidence of postoperative HVOO and improved the outcomes of the graft.

Objective:To explore the impact of graft recipient weight ratio(GRWR)on pediatric whole liver transplantation in infants aged under 1 year.Methods:From January 2014 to December 2019, clinical data were retrospectively reviewed for 140 children aged under 1 year with whole liver transplantation.They were divided into 3 groups of low GRWR(GRWR<2.5%, 48 cases), middle GRWR(2.5%≤GRWR<5%, 73 cases)and high GRWR(GRWR≥5%, 19 cases). Basic profiles, major postoperative complications and survival rate of graft/recipient were compared.Results:There were 62 males and 78 females with an average age of (7.34±1.81)months and an average weight of(6.81±1.09)kg.The median GRWR was 3.27%(1.33%~8.12%). The higher level of GRWR, the greater age, weight and graft weight of donor in three groups and there was statistical difference ( P<0.05); operative duration, postoperative ICU stay and hospital stay were longer in low GRWR group than those in middle GRWR group and there was statistical difference( P<0.05); The incidence of postoperative hepatic artery thrombosis was higher in low GRWR group than that in middle GRWR group(31.3%vs 8.2%)and there was statistical difference( P<0.05); 4 cases of small-for-size syndrome occurred in low GRWR group, it was significantly different from the other two groups and there was statistical difference( P<0.05); the median follow-up period was(50.7±23.4)months.The survival rates of grafts at 3-month and 1/5-year were 89.6%, 91.8%, 100%; 87.5%, 87.7%, 100%; 87.5%, 87.7%, 100%and there was no inter-group difference( P>0.05). The survival rates of recipients at 3 months, 1 year and 5 years post-operation were 93.8%, 91.8%, 100%; 91.7%, 87.7%, 100%; 91.7%, 87.7%, 100%and there was no inter-group difference( P>0.05). Conclusions:Different from pediatric living donor transplantation, GRWR≥5%does not affect the survival rate of recipient/graft during whole liver transplantation.And GRWR<2.5%may boost the postoperative incidence of hepatic artery thrombosis and small liver syndrome.

Objective:To evaluate the efficacy of basiliximab plus single steroid induced immunotherapy during donor-recipient ABO-compatible pediatric liver transplantation(LT).Methods:From January 1, 2019 to January 19, 2020, a total of 150 children of donor-recipient ABO-compatible LT were randomly divided into basiliximab group(basiliximab plus single steroid induction and postoperative immunosuppression with tacrolimus alone)and steroid group(conventional dose of steroid induction plus postoperative immunosuppression with tacrolimus and steroid). Clinical characteristics, survival rate of recipients and liver allografts, rejection rate and infection rate were observed.Results:The median follow-up time was 9.2(0.7~15.5)months.No significant inter-group differences existed in survival rate of recipients/grafts or the incidence of acute rejection, early postoperative pulmonary infection, cytomegalovirus and Epstein Barr virus infection. However, in 56 living donor LT, acute rejection(6cases, 10.7%)occurred in basiliximab group versus(12cases, 25.5%)in steroid group. During living donor LT, the incidence of acute rejection declined markedly in bsiliximab group as compared with steroid group( P=0.043). Conclusions:Both safe and effective for donor-recipient ABO-compatible pediatric LT, basiliximab plus single steroid induced immunotherapy can significantly lower the occurrences of acute rejection during living donor LT.

Objective:To summarize the clinical characteristics of de novo non-alcoholic fatty liver disease(NAFLD)in pediatric recipients in early stage post liver transplantation(LT)to enhance our understanding of this rare complication.Methods:The clinical data of 8 recipients who underwent liver transplantation in the children's organ transplantation Department of Tianjin first central hospital from January 2014 to December 2019 and developed NAFLD within 3 months after operation were retrospectively analyzed. Taking liver biopsy as the standard for the diagnosis of NAFLD, the clinical and histological characteristics of early NAFLD after transplantation were summarized and analyzed.The median time from LT to NAFLD was 1.55(0.63, 2.93)months and the median follow-up period 23.60(8.74, 32.58)months.Results:NAFLD was all pathologically confirmed by liver biopsy. Seven cases had abnormal liver function and 1 case of steatosis was detected by ultrasound pre-biopsy. There were acute cellular rejection(2 cases)and drug-induced graft injury(1 case). The median period of recovery for graft function was 32.0(12.0, 34.0)days. Macrovesicular graft steatosis predominated.Conclusions:Occurring earlier in children after LT, NAFLD is frequently accompanied by abnormal graft function. Liver biopsy is required for making a definite diagnosis. Abnormal graft function persists a long time. However, prognosis is generally decent.

Objective:To examine the incidence of lymphatic leakage after pediatric liver transplantation and explore the diagnosis and treatment of lymphatic leakage.Methods:From January 1, 2016 to December 31, 2019, clinical data were analyzed retrospectively for 805 pediatric liver transplant recipients. Based upon the diagnosis of lymphatic leakage, they were divided into two groups of lymphatic leakage ( n=271) and lymphatic non-leakage ( n=534). Analyzing the incidence of lymphatic leakage after liver transplantation in children, evaluating the treatment plan, comparing survival rate and the incidence of postoperative complications between two groups. Results:The incidence of lymphatic leakage was 33.7%(271/805); the proportion of partial liver donors was 14.8% in lymphatic leakage group and 25.8% in lymphatic non-leakage group ( P<0.001). Other basic profiles of two groups were not statistically different. The median follow-up period was 32 months in lymphatic leakage group and 30.6 months in lymphatic non-leakage group. No significant inter-group difference existed in cumulative survival rate, vascular complications, bile leakage, acute cell rejection or intestinal obstruction. The area-under-curve (AUC) of ascites to serum triglyceride (TG) ratio for predicting lymphatic leakage was 0.741, optimal cut-off value 0.54, sensitivity 59.2% and specificity 80.1%. Conclusions:Lymphatic leakage is a common complication after liver transplantation in children. With no significant correlation with the morbidity or mortality, it prolongs postoperative hospital stay. The ratio of ascites to serum TG may be utilized as an effective reference index for diagnosing lymphatic leakage. And lymphatic leakage can be improved by taking a low-fat diet.

Objective:To explore the efficacy of reduced left lateral segment graft during pediatric living donor liver transplantation.Methods:From January 2014 to December 2019, 67 children aged under 1 year underwent living donor liver transplantation with reduced left lateral segment graft (RLLS group). Clinical data were analyzed retrospectively and compared with those of left lateral segmentgraft living donor liver transplantation (LLS group). The differences in basic profiles, postoperative complications and postoperative patient/graft survival rate were compared.They were divided into two groups according to whether graft/recipient weight ratio (GRWR) was more than 4%.And major postoperative complications and graft/recipient survival rates were compared.Results:Age, height and weight of recipients were significantly lower in RLLS group than those in control group ( P<0.05). However, donor weight, donor body mass index (BMI), estimated graft volume and proportion of fatty liver from donor were significantly higher than those in control group ( P<0.05). Operative duration, intraoperative blood loss and erythrocyte transfusion were significantly higher than those in control group ( P<0.05). No significant inter-group differences existed in average postoperative hospital stay, intensive care unit (ICU) stay duration or postoperative ventilator use time ( P>0.05); no significant inter-group difference existed in the incidence of such major surgical complications as hepatic artery thrombosis, portal vein stenosis and bile duct complications ( P>0.05). The 1/3-year cumulative survival rates of postoperative patients and grafts were 92.5%, 91.2% and 92.5%, 91.2% in RLLS group and 96.3%, 95.3% and 95.9%, 95.1% in LLS group respectively.There was no significant inter-group difference ( P<0.05). The rate of postoperative hepatic vein stenosis was significantly higher in GRWR>4% group than that in control group ( P<0.05). Conclusions:Due to a rapid progress of technology, living donor liver transplantation has achieved satisfactory outcomes in children with reduced left lateral segment graft.Whether or not performing reduction surgery should be judged comprehensively according to the matching of donors and recipients and blood flow of liver during operations.And GRWR>4% is not an implementation criterion.

Objective:To explore the clinicalfactors related to allograft fibrosis after pediatric liver transplantation.Methods:The clinical data were respectively analyzed for 94 pediatric recipients from January 2013 to December 2016 at Tianjin First Central Hospital.The Patients were assigned into fibrotic and non-fibrotic groups based upon the results of protocol liver biopsies. Univariate and multivariate Logistic regression analyses were performed for examining the risk factors of fibrosis after pediatric livertransplantation. Then Logistic regression model was established to obtain the predicted value of combined predictive factors.Thereceiver operating characteristic curve (ROC) was conducted to evaluate the predictive value of combined predictive factors.Results:A total number of 54(57.5%) patients occurred fibrosis among the 94 patients. There weresignificant differences in cold ischemia time (Z=2.094), warm ischemia time (Z=2.421), biliary stricture( χ2=4.560), drug-induced liver injury ( χ2=7.389), hepatic artery thrombosis and rejection ( χ2=6.955)between two groups ( P<0.05). Logistic regression analysis showed that cold ischemia time (OR=1.003, 95%CI: 1.000~1.007, P=0.044), biliary stricture(OR=6.451, 95%CI: 1.205~33.295), rejection(OR=2.735, 95%CI: 1.057~7.077)and drug-induced liver injury (OR=4.977, 95%CI: 1.207~20.522, P=0.026) were independent risk factors for fibrosis 5 years after liver transplantation. The area under the ROC curve was 0.786(95%CI: 0.691~0.881), for predicting patient outcome.If using 0.311as a cutoff Value, the sensitivity was 90.70%, and the specificity was 60.00%. However, through the ROC curve comparison, there was statistical significance between combined predictive factors and the other independent risk factors ( P>0.05). Conclusions:The incidence of fibrosis 5 years after pediatricliver transplantation is 57.5%. Prolonged cold ischemia time, biliarystricture, rejectionand drug-induced liver injury after liver transplantation are independent risk factors for fibrosis 5 years after pediatric liver transplantation.And the combined predictive factors have a high predictive value forallograftfibrosis.

Objective:To investigate the etiology,clinical features and prognosis of pediatric liver retransplantation.Methods:The data of 1 024 cases of pediatric liver transplantation (<18 years old) from January 2014 to December 2019 operated at Tianjin First Central Hospital were collected,retrospectively. Retransplantation was performed in 26 cases,among which 25 cases received secondary liver transplantation and 1 case received a third liver transplantation. There were 13 male and 12 female patients among the 25 patients. The median age was 12.9(20.5) months(range: 5.8 to 134.8 months), the body weight was 8.0(5.6) kg(range: 5.0 to 30.0 kg) at the time of retransplantation. The pediatric end-stage liver disease(PELD) score was 17.0(21.3) (range: 0 to 45) before retransplantation. The etiology of retransplantation was biliary complications in 7 cases,primary nonfunction of liver graft in 5 cases,antibody-mediated rejection in 4 cases,hepatic artery thrombosis in 3 cases,portal vein thrombosis in 3 cases,concomitant hepatic artery and portal vein thrombosis in 2 cases,thrombogenesis of inferior Vena Cava in 1 case and sinusoidal obstruction syndrome in 1 case. The patients were divided into two groups according to the time interval(30 days) between two liver transplantations,8 patients were classified into early-retransplantation(≤30 days) group and 18 patients were classified into late-retransplantation (>30 days) group. The etiology of liver retransplantation,pre-transplant score,time interval between two transplantations,surgical aspects,major complications and survival rates were compared between the two groups. Continuous variables with normal distribution were compared with t test,while Mann-Whitney U test was applied to compare variables without normal distribution. Categorical variables were compared with chi-square test. The survival curves were created by Kaplan-Meier method and compared by Log Rank test. Results:The median follow-up time was 26.8(30.2) months(range: 1 day to 85.7 months), and the incidence of retransplantation was 1.9%. In the early-retransplantation group,the duration of surgery was (439.8±151.0)minutes,the graft-to-recipient weight ratio was 5.0(1.8)%(range:3.6% to 6.1%),the main cause for retransplantation were primary nonfunction and vascular complications. In the late-retransplantation group,the duration of surgery was (604.4±158.0)minutes,the graft-to-recipient weight ratio was 3.4(2.1)%(range:1.4% to 5.3%),the main cause for retransplantation were biliary complications,antibody mediated rejection and vascular complications.The 3-month,1-year and 2-year recipient survival rates in the early-retransplantation group were all 62.3%,while the recipient survival rates in the late-retransplantation group were 100%,93.8% and 93.8%,respectively. The difference of recipient survival rates was significant between the early-retransplantation group and the late-retransplantation group( P=0.019). The overall 3-month,1-year and 3-year recipient survival rates after the primary liver transplantation were 97.1%,95.4%,94.1%,respectively. Conclusions:The vascular complications,biliary complications,primary nonfunction and antibody-mediated rejection are the main causes of liver retransplantation.The PELD score is higher in patients receiving early retransplantation,while the surgery is relatively more complex in patients receiving late retransplantation,which is reflected by longer duration of surgeries. Patients in the late-retransplantation group showed similar recipient survival rates with primary liver transplantation recipients,and the survival rates are superior to those of patients in the early-retransplantation group. Infection and multiple organ failure are the most common fatal causes after retransplantation.

Objectives:To study the risk factors for massive intraoperative blood loss in children with biliary atresia who underwent liver transplantation for the first time,and to analyze their impacts on graft survival,hospital stay and postoperative complications.Methods:The data of 613 children with biliary atresia who underwent liver transplantation at Department of Pediatric Organ Transplantation,Tianjin First Central Hospital from January 2015 to December 2018 were collected and analyzed. There were 270 males and 343 females, aged 7.4 (3.9) months (range: 3.2 to 148.4 months), the body weight of the recipients were (7.8±3.5) kg (range: 4.0 to 43.3 kg).According to the 85 th quad of estimated blood loss(EBL),they were divided into two groups:massive EBL group(96 cases) and non massive EBL group(517 cases). The age,height,weight and other factors between the two groups were analyzed and compared. Univariate Logistic regression and multiple stepwise regression were used to determine the risk factors of massive EBL. Then,the postoperative complications of the two groups,including portal vein thrombosis and portal vein anastomotic stenosis etc.,were analyzed and compared by chi square test. Kaplan Meier curve and log rank test were used to analyze the recipient and graft survival rate of the two groups. Results:During the study period,713 transplants were performed and 613 patients were enrolled in the study. Ninety-six patients(15.7%) had massive EBL,and the postoperative hospital stay was 21(16) days(range:2 to 116 days),the hospital stay of non-massive EBL group was 22(12)days(range:3 to 138 days)( U=24 224.0, P=0.32). Univariate Logistic regression analysis showed that the recipient′s weight,Kasai portoenterostomy,platelet count,operation time and cold ischemia time were the risk factors of massive EBL during biliary atresia transplantation. Multiple regression analysis showed that cold ischemia time ≥10 hours,prolonged operation time(≥8 hours) and body weight<5.5 kg were important independent risk factors for massive EBL.The incidence of portal vein thrombosis,hepatic vein stenosis,intestinal leakage and pulmonary infection in patients with massive EBL were significantly higher than those without massive EBL(3.1% vs. 0.8%,9.4% vs. 2.1%,6.3% vs. 0.8%,30.2% vs. 20.1%,all P<0.05). The 3-year overall graft and recipient survival rate were significantly lower in patients with massive EBL than those without massive EBL(87.5% vs. 95.7%, P=0.001;84.4% vs. 95.4%, P<0.01,respectively). Conclusions:In children with biliary atresia who underwent liver transplantation for the first time,the effective control of intraoperative bleeding should shorten the operation time and reduce the cold ischemia time as far as possible,on the premise of ensuring the safety of operation. For children without growth disorder,the weight of children should be increased to more than 5.5 kg as far as possible to receive the operation. Reducing intraoperative bleeding is of great significance to the prognosis of children.