The roles of long noncoding RNAs in the regulation of OCT4 expression.

OCT4 is a major transcription factor that maintains the pluripotency of stem cells, including embryonic stem cells, induced pluripotent stem cells and cancer stem cells. An increasing number of long noncoding RNAs have been reported to participate in the regulation of OCT4 expression through various mechanisms, including binding with the OCT4 gene promoter to regulate local methylation; promoting chromosomal spatial folding to form an inner ring, thereby aggregating OCT4 cis-acting elements scattered in discontinuous sites of the chromosome; competitively binding microRNAs with OCT4 to upregulate OCT4 expression at the posttranscriptional level; and sharing a promoter with OCT4. Moreover, the transcription of some long noncoding RNAs is regulated by OCT4, and certain long noncoding RNAs form feedback regulatory loops with OCT4. In this review, we summarized the research progress of the long noncoding RNAs involved in the regulation of OCT4 expression.

Role of selected criteria and preventive chemotherapy in tumor recurrence after liver transplantation.

BACKGROUND: Long-term survival after liver transplantation (LT) for hepatocellular carcinoma (HCC) patients remains poor because of tumor recurrence. To improve the prognosis of HCC patients after LT, we aimed to identify different transplantation criteria and risk factors related to tumor recurrence and evaluate the effect of preventive chemotherapy in a single center. METHODS: In total, data on 20 variables and the survival of 199 patients with primary HCC who underwent LT between 2005 and 2015 were included for analysis. The patients were divided into the following three groups: Group 1, within the Milan and Hangzhou criteria (n = 51); Group 2, beyond the Milan but within the Hangzhou criteria (n = 36); and Group 3, beyond the Milan and Hangzhou criteria (n = 112). Survival probabilities for the three groups were calculated using multivariate Cox regression analysis. The association between preventive therapy and HCC-recurrence after LT was analyzed by multiple logistic regression analysis. RESULTS: Child-Pugh stage C and hepatitis B virus (HBV) infection were independent risk factors for patients with tumor recurrence who did not meet the Milan criteria. The overall survival rates of the 199 patients showed statistically significant differences among the three groups (P < 0.001). Moreover, no significant difference was noted in the survival rate between Group 1 and Group 2 (P > 0.05). Multivariate logistic regression analysis showed that postoperative prophylactic chemotherapy reduced the risk of tumor recurrence in patients who did not meet the Hangzhou and Milan criteria (OR = 0.478; 95% CI: 0.308-0.741; P = 0.001). CONCLUSIONS: Child-Pugh classification and HBV infection were the independent risk factors of tumor recurrence in HCC patients with LT. The Hangzhou criteria were effective and analogous compared with the Milan criteria. Preventive chemotherapy significantly reduced the risk of recurrence and prolonged the survival time for HCC patients beyond the Milan and Hangzhou criteria after LT.

Clinical course and treatment efficacy of COVID-19 near Hubei Province, China: A multicentre, retrospective study.

Currently, COVID-19 has been reported in nearly all countries globally. To date, little is known about the viral shedding duration, clinical course and treatment efficacy of COVID-19 near Hubei Province, China. This multicentre, retrospective study was performed in 12 hospitals in Henan and Shaanxi Provinces from 20 January to 8 February 2020. Clinical outcomes were followed up until 26 March 2020. The viral shedding duration, full clinical course and treatment efficacy were analysed in different subgroups of patients. A total of 149 COVID-19 patients were enrolled. The median age was 42 years, and 61.1% (91) were males. Of them, 133 (89.3%) had fever, 131 of 144 (91%) had pneumonia, 27 (18.1%) required intensive care unit (ICU) management, 3 (2%) were pregnant, and 3 (2%) died. Two premature newborns were negative for SARS-CoV-2. In total, the median SARS-CoV-2 shedding period and clinical course were 12 (IQR: 9-17; mean: 13.4, 95% CI: 12.5, 14.2) and 20 (IQR: 16-24; mean: 21.2, 95% CI: 20.1, 22.3) days, respectively, and ICU patients had longer median viral shedding periods (21 [17-24] versus 11 [9-15]) and clinical courses (30 [22-33] vs. 19 [15.8-22]) than non-ICU patients (both p < .0001). SARS-CoV-2 clearances occurred at least 2 days before fatality in 3 non-survivors. Current treatment with any anti-viral agent or combination did not present the benefit of shortening viral shedding period and clinical course (all p > .05) in real-life settings. In conclusion, the viral shedding duration and clinical course in Henan and Shaanxi Provinces were shorter than those in Hubei Province, and current anti-viral therapies were ineffective for shortening viral shedding duration and clinical course in real-world settings. These findings expand our knowledge of the SARS-CoV-2 infection and may be helpful for management of the epidemic outbreak of COVID-19 worldwide. Further studies concerning effective anti-viral agents and vaccines are urgently needed.

Radiotherapy was associated with the lower incidence of metachronous second primary lung cancer.

Our study aims to estimate the incidence of metachronous second primary lung cancer(SPLC) in initial primary lung cancer(IPLC) survivors and to determine whether radiotherapy affects the risk of metachronous SPLC in the first five years after the diagnosis of lung cancer. Incidence data of IPLC individuals who survived ≥2 years were obtained from SEER-18 database in 2004-2007. Joinpoint regression analysis and competing risk analysis were used to calculate the incidence of metachronous SPLC. Propensity score matching and decision analysis were available to estimate the effect of radiotherapy on metachronous SPLC. 264 of 11657 IPLC survivors with radiotherapy and 1090 of 24499 IPLC survivors without radiotherapy developed metachronous SPLC during 5-year follow-up, respectively. In joinpoint regression analysis, the 5-year incidence of metachronous SPLC in the radiotherapy group was lower than that in the nonradiotherapy group(2385 per 100,000 vs 4748 per 100,000, HR = 0.43,95% CI:0.39-0.47). Competing risk analysis showed that the survivors with radiotherapy were associated with the lower 5 year incidence of metachronous SPLC compared with those without radiotherapy(2.28% vs 4.47%, HR = 0.49,95% CI:0.43-0.57). Through propensity score matching, 4077 pairs of survivors were available to further study that radiotherapy potentially decreased the risk of developing metachronous SPLC with the adjustment of various factors(2.5% vs 3.3%, HR = 0.72, 95% CI:0.55-0.96). Decision analysis suggested that radiotherapy was a negative independent risk factor of metachronous SPLC with clinical net benefit in a range of risk thresholds (2% to 5%). Survivors of IPLC with radiotherapy likely had a low risk of metachronous SPLC during the first five years follow-up, especially non-small cell lung cancer.

Prognostic factors and nomogram for cancer-specific death in non small cell lung cancer with malignant pericardial effusion.

BACKGROUND: The prognosis of lung cancer with malignant pericardial effusion is very terrible owing to the impact of cardiac tamponade. The aim of our study seeks to identify prognostic factors and establish a prognostic nomogram of non small cell lung cancer (NSCLC) with malignant pericardial effusion. METHODS: NSCLC patients with malignant pericardial effusion between 2010 and 2014 are searched from SEER database.Cancer-specific death of these patients are analyzed through the Kaplan-Meier method, Cox proportional hazard model and competing risk model. Prognostic nomogram of cancer-specific death is performed and validated with concordance index (C-index), calibration plots and internal validation population. Propensity score matching is used to evaluate whether chemotherapy affected the survival of study population. RESULTS: 696 eligible NSCLC patients are involved in the study population, with 22.7% of 1-year survival rate and 8.9% of 2-year survival rate. Laterality, AJCC N, AJCC T, and chemotherapy are regarded as independent prognostic factors of cancer-specific death in the Cox proportional hazards model and competing risk model. The C-index of established nomogram is 0.703(95%CI:0.68-0.73) for cancer-specific death in the study population with acceptable calibration, which is significantly higher than classical TNM stage(C-index = 0.56, 95%CI:0.52-0.60). After 1:1 propensity score matching, chemotherapy potentially reduces the risk of cancer-specific death (HR = 0.42 95%CI: 0.31-0.58) of NSCLC with pericardial effusion. CONCLUSIONS: NSCLC with malignant pericardial effusion harbors low overall survival. One prognostic nomogram based on laterality, AJCC N, AJCC T and chemotherapy is developed for cancer-specific death to predict 1-year and 2-year survival rate with good performance.

Statin use and prognosis of lung cancer: a systematic review and meta-analysis of observational studies and randomized controlled trials.

BACKGROUND: Previous clinical studies reported inconsistent results on the associations of statins with the mortality and survival of lung cancer patients. This review and meta-analysis summarized the impact of statins on mortality and survival of lung cancer patients. MATERIALS AND METHODS: Eligible papers of this meta-analysis were searched by using PubMed, EMBASE, and Cochrane until July 2017. Primary end points were the mortality (all-cause mortality and cancer-specific mortality) and survival (progression-free survival and overall survival) of patients with statin use. Secondary end points were overall response rate and safety. The random-effects model was used to calculate pooled HRs and 95% CIs. RESULTS: Seventeen studies involving 98,445 patients were included in the meta-analysis. In observational studies, the pooled HR indicated that statins potentially decreased the cancer-specific mortality and promoted the overall survival of lung cancer patients. Statins showed an association with decreased all-cause mortality in cohort studies (HR =0.77, 95% CI: 0.59-0.99), but not in case-control studies (HR =0.75, 95% CI: 0.50-1.10). However, statin use showed no impact on mortality and overall survival in randomized controlled trials. Meanwhile, this meta-analysis indicated that statin use did not affect the progression-free survival of lung cancer patients in observational studies and randomized controlled trials. In addition, statins potentially enhanced the effects of tyrosine kinase inhibitors (HR=0.86, 95% CI: 0.76-0.98) and chemotherapy (HR=0.86, 95% CI: 0.81-0.91) on the overall survival of patients with non-small-cell lung cancer, but did not increase overall response rate and toxicity. CONCLUSION: Statins were potentially associated with the decreasing risk of mortality and the improvement of overall survival in observational studies but not in randomized controlled trials.

Incidence trends and risk prediction nomogram of metachronous second primary lung cancer in lung cancer survivors.

BACKGROUND: This study was designed to estimate the trends in 5-year incidence of metachronous second primary lung cancer(SPLC) and to establish a risk prediction model to identify candidates who were at high risk of developing metachronous SPLC. METHODS: Incidence data between 2004 and 2007 were obtained from SEER database, including 42453 participants who survived ≥ 2 years after the initial diagnosis of lung cancer. Joinpoint regression analysis was used to calculate the 5-year incidence rates of metachronous SPLC per 100 000 population. Related risk factors of the survivors who developed MSPLC during five years were identified through logistic regression analysis, followed by establishment of risk prediction nomogram. Discrimination (C-index), calibration and decision analysis were further performed to assess the validation and clinical net benefit of risk prediction nomogram. RESULTS: A total of 1412 survivors with lung cancer developed MSPLC during five years, with 3546 per 100 000 population of age-adjusted 5-year incidence. Age, histology, tumor stage, and radiation were recognized as risk factors of metachronous SPLC, as indicated by logistic regression analysis. The risk prediction nomogram of metachronous SPLC harbored moderate discrimination(C-index = 0.67) and good calibration, with the risk of 0.01 to 0.11.The decision curve analysis showed that clinical net benefit of this risk prediction nomogram in a range of risk thresholds (0.01 to 0.06) was higher compared to all-screening or no-screening strategies. CONCLUSIONS: Collectively, the cumulative risk of metachronous SPLC of the survivors increased over time. The risk prediction nomogram was available to select high-risk survivors who should regularly undergo computed tomography screening.

Clinical Profile of Cyclooxygenase-2 Inhibitors in Treating Non-Small Cell Lung Cancer: A Meta-Analysis of Nine Randomized Clinical Trials.

BACKGROUND: Evidence on the benefits of combining cyclooxygenase-2 inhibitor (COX-2) in treating non-small cell lung cancer (NSCLC) is still controversial. We investigated the efficacy and safety profile of cyclooxygenase-2 inhibitors in treating NSCLC. METHODS: The first meta-analysis of eligible studies was performed to assess the effect of COX-2 inhibitors for patients with NSCLC on the overall response rate (ORR), overall survival (OS), progression-free survival (PFS), one-year survival, and toxicities. The fixed-effects model was used to calculate the pooled RR and HR and between-study heterogeneity was assessed. Subgroup analyses were conducted according to the type of COX-2 inhibitors, treatment pattern, and treatment line. RESULTS: Nine randomized clinical trials, comprising 1679 patents with NSCLC, were included in the final meta-analysis. The pooled ORR of patients who have NSCLC with COX-2 inhibitors was significantly higher than that without COX-2 inhibitors. In subgroup analysis, significantly increased ORR results were found on celecoxib (RR = 1.29, 95% CI: 1.09, 1.51), rofecoxib (RR = 1.61, 95% CI: 1.14, 2.28), chemotherapy (RR = 1.40, 95% CI: 1.20, 1.63), and first-line treatment (RR = 1.39, 95% CI: 1.19, 1.63). However, COX-2 inhibitors had no effect on the one-year survival, OS, and PFS. Increased RR of leucopenia (RR = 1.21, 95% CI: 1.01, 1.45) and thrombocytopenia (RR = 1.36, 95% CI: 1.06, 1.76) suggested that COX-2 inhibitors increased hematologic toxicities (grade ≥ 3) of chemotherapy. CONCLUSIONS: COX-2 inhibitors increased ORR of advanced NSCLC and had no impact on survival indices, but it may increase the risk of hematologic toxicities associated with chemotherapy.

Renal function of donors and recipients after living donor kidney transplantation in a Chinese cohort.

BACKGROUND: Living donor kidney transplantation (LKT) has been booming in China. This study aimed to elucidate the renal function of both Chinese donors and recipients after the donation and transplantation. METHODS: One hundred and forty-one pairs of donors and recipients for LKT were randomly selected and followed up for up to seven years. The donors' and recipients' renal function was recorded before and after operation. RESULTS: The donors presented a mean age of (43.9 ± 7.5) years at donation. The female contributed 101/141 (71.6%) in all donors, and no effect was shown between genders on healthy donors' renal function. The donors' glomerular filtration rates (GFR) were (119.5 ± 20.4) ml/min, (85.2 ± 17.6) ml/min, (87.2 ± 15.9) ml/min, (82.1 ± 14.6) ml/min and (83.0 ± 13.7) ml/min preoperatively, and for five days, three months, one year and beyond one year after the operation. The donors for the period of 1 - 3 years, 3 - 5 years and more than 5 years after donation showed GFR as (83.9 ± 12.7) ml/min, (83.0 ± 17.6) ml/min, and (80.9 ± 20.8) ml/min, respectively, no statistically significant difference was found. Moreover, no significant clinical changes in blood pressure and proteinuria were found among the donors. In the recipients, delayed graft function (DGF) rate was 6.4%, acute rejection rate was 11.3%, and GFR were (66.5 ± 16.4) ml/min, (73.2 ± 19.6) ml/min and (63.9 ± 18.6) ml/min respectively at three months, one year and beyond one year post-transplantation respectively. CONCLUSION: The donors/recipients of LKT in Chinese population experience well-functioning remaining/donor kidneys.

[Histopathologic analysis of 1500 renal allograft biopsies].

OBJECTIVE: To summarize the histopathological features of posttransplant complications for renal allografts and evaluate the biopsy values. METHODS: Between January 1997 and May 2010, a total of 1712 percutaneous renal allograft biopsies were performed in 1500 kidney transplants and diagnostic procedures for staining, classification and staging had been performed according to the Banff 1997 and 2005 Schema. RESULTS: There were 213 (14.2%) cases of acute T cell-mediated rejection post transplantation in 1500 kidney transplants. Meanwhile there were 36 (2.4%) cases of acute antibody-mediated rejection. Chronic T cell-mediated rejection and chronic antibody-mediated rejection were 251 (16.7%) cases and 45 (3.0%) cases, respectively. Acute CNI-nephrotoxicity and chronic CNI-nephrotoxicity were 106 (7.1%)cases and 251 (16.7%) cases, respectively. Relapsed or new nephropathy were 6 (0.4%) cases. Chronic CNI-nephrotoxicity is the most common cause of allograft dysfunction in the long survival recipients. CONCLUSION: Percutaneous renal allograft biopsy is valuable for the diagnosis of various posttransplantation complications.

[Histopathological study of 268 hepatic allograft biopsies].

OBJECTIVE: To observe the histopathological features of posttransplant complications for hepatic allografts and evaluate their biopsy values. METHODS: From January 1999 to May 2011, a total of 268 percutaneous hepatic allograft biopsies were conducted in 207 recipients and the diagnostic procedures for staining, classification and staging performed according to the Banff schema and Chinese Schema on hepatic allograft rejection. RESULTS: Among them, there were ischemia/reperfusion injury (n = 26, 9.7%), acute T cell-mediated rejection (n = 83, 31.0%), acute antibody-mediated rejection (n = 12, 4.5%), chronic posttransplantation rejection (n = 31, 11.6%), immunosuppressive-induced liver injury (n = 70, 26.1%) and recurrent diseases (n = 18, 6.7%). Acute T cell-mediated rejection and drug-induced liver injury were two most common causes of allograft dysfunctions. CONCLUSION: Percutaneous hepatic allograft biopsy is valuable for the diagnosis and evaluation of various posttransplantation complications.

Early steroid withdrawal after liver transplantation for hepatocellular carcinoma.

AIM: To evaluate the impact of early steroid withdrawal on the incidence of rejection, tumor recurrence and complications after liver transplantation for advanced-stage hepatocellular carcinoma. METHODS: Fifty-four patients underwent liver transplantation for advanced-stage hepatocellular carcinoma from April 2003 to June 2005. These cases were divided into a steroid-withdrawal group (group A, n = 28) and a steroid-maintenance group (group B, n = 26). In group A, steroid was withdrawn 3 mo after transplantation. In group B, steroid was continuously used postoperatively. The incidence of rejection, 6-mo and 1-year recurrence rate of carcinoma, 1-year survival rate, mean serum tacrolimus trough level, and liver and kidney function were compared between the two groups. RESULTS: In the two groups, no statistical difference was observed in the incidence of rejection (14.3 vs 11.5%, P > 0.05), mean serum tacrolimus trough levels (6.9 +/- 1.4 vs 7.1 +/- 1.1 microg/L, P > 0.05), liver and kidney function after 6 mo [alanine aminotransferase (ALT): 533 +/- 183 vs 617 +/- 217 nka/L, P > 0.05; creatinine: 66 +/- 18 vs 71 +/- 19 micromol/L, P > 0.05], 6-mo recurrence rate of carcinoma (25.0 vs 42.3%, P > 0.05), and 1-year survival rate (64.2 vs 46.1%, P > 0.05). The 1-year tumor recurrence rate (39.2 vs 69.2%, P < 0.05), serum cholesterol level (3.9 +/- 1.8 vs 5.9 +/- 2.6 mmol/L, P < 0.01) and fasting blood sugar (5.1 +/- 2.1 vs 8.9 +/- 3.6 mmol/L, P < 0.01) were significantly different. These were lower in the steroid-withdrawal group than in the steroid-maintenance group. CONCLUSION: Early steroid withdrawal was safe after liver transplantation in patients with advanced-stage hepatocellular carcinoma. When steroids were withdrawn 3 mo post-operation, the incidence of rejection did not increase, and there was no demand to maintain tacrolimus at a high level. In contrast, the tumor recurrence rate and the potential of adverse effects decreased significantly. This may have led to an increase in long-term survival rate.

[Technology and application of simultaneous pancreas-kidney transplantation with modified enteric drainage].

OBJECTIVE: To report the modified technique and the short-term results of simultaneous pancreas-kidney transplantation (SPK) with the enteric drainage (ED) of exocrine secretions. METHODS: From June 2000 to August 2006, thirty-eight patients with diabetes complicated with uremia underwent SPK. The pancreas graft was placed intraperitoneally with exocrine secretions drained into the proximal jejunum without Roux-en-Y procedure. The mean cold ischemic times of pancreas and kidney were (10 +/- 2.0) h and (7 +/- 2.0) h, respectively. Quadruple immunosuppressive therapy with antilymphocyte globulin or anti-CD25 monoclonal antibody, tacrolimus, mycophenolate mofetil and steroids was adopted except one patient. RESULTS: The 6-month survival rates of patients and grafts were both 97.4% after transplantation. All patients achieved insulin-free euglycemia at (7 +/- 6.9) d postoperative except one. For preoperative patients, mean fasting insulin and C-peptide values were (9 +/- 8.1) mU/L and (6 +/- 4.5) mU/L. After operation, fasting insulin and C-peptide values of patients were (12 +/- 5.8) mU/L and (6 +/- 4.7) mU/L, respectively, which peaked to an insulin level of (57 +/- 43.0) mU/L and a C-peptide level of (11 +/- 6.8) mU/L with stimulation. There were eight cases of delayed renal graft function. All other patients achieved immediate renal graft function. No graft losses occurred due to leakage or intra-abdominal infection. The most common surgical complications were wound infection (n = 12), enteric anastomostic hemorrhage (n = 5) and perirenal hemorrhage (n = 2). Three patients (7.9%) had been reoperated for the reasons of intra-abdominal hemorrhage and perirenal hemorrhage. CONCLUSIONS: SPK is an effective treatment option for selected patients with diabetes mellitus and approaching end-stage renal disease. Enteric exocrine drainage by direct side-to-side anastomosis (without Roux-en-Y) seems to be a simple and reliable technique.

Impact of early biliary complications in liver transplantation in the presence or absence of a T-tube: a Chinese transplant centre experience.

BACKGROUND: Biliary complications continue to be an important determinant of the recipient's survival rate after orthotopic liver transplantation (OLT). The objective of this study was to evaluate the incidence of early biliary complications in OLT in the presence or absence of a T-tube. METHODS: This retrospective study, based on inpatient data, focused on the relationship between T-tube placement and early biliary complications of 84 patients after OLT, from November 2002 to June 2005. Patients were divided into two groups based on whether or not a T-tube was used following bile duct reconstruction: T-tube group (group I, n = 33); non-T-tube group (group II, n = 51). RESULTS: 45.2% of OLT recipients had a malignant neoplasm. There were no significant differences in the demographic characteristics or operation data between the two groups. Overall, early biliary tract complications developed in 19.0% (16/84) of patients. The rate of early biliary complications was 30.3% (10/33) and 11.8% (6/51) in groups I II, respectively (p = 0.035). Biliary complications which were directly caused by T-tube placement occurred in 12.1% (4/33) of patients in group I. Overall, the percentage of malignant neoplasms, chronic viral cirrhosis, fulminant liver failure and other primary disease recipients with early biliary complications were 6.2%, 37.5%, 43.8% and 12.5%, respectively. CONCLUSION: This study suggests that the use of a T-tube in Chinese patients undergoing OLT causes a higher incidence of early biliary complications. Most of the early biliary complications occurred in chronic viral cirrhosis and fulminant liver failure recipients.

Simultaneous pancreas-kidney transplantation with modified enteric drainage of exocrine pancreatic secretion.

BACKGROUND: As a valid therapeutic option for patients with type 1 diabetes mellitus (IDDM) and secondary diabetic nephropathy, simultaneous pancreas-kidney transplantation (SPK) remains more undeveloped than other solid organ transplantations due to the restrictions of surgical techniques especially the modes of exocrine pancreatic secretion. The aim of this paper was to summarize our single-center experience in SPK with modified enteric drainage (ED). METHODS: From June 2000 to July 2003, 10 patients with IDDM associated with uremia received SPK. The pancreatic allograft exocrine secretion was drained into the proximal jejunum via a side-to-side duodenojejunostomy without Roux-en-Y anastomosis. Quadruple immunosuppressive regimen consisted of induction of tacrolimus (TAC)/cyclosporine (CsA), mycophenolate mofetil (MMF), steroids and antibodies, which included antilymphocyte globulin (ALG) or anti-CD25 monoclonal antibody. RESULTS: ED-SPK without Roux-en-Y anastomosis was successful in all 10 patients without serious complications such as pancreatitis, graft thrombosis and pancreatic fistula. The patients regained immediate kidney allograft function and euglycemia with insulin-independence. Four patients survived over one year. Episodes of acute rejection were observed in 4 patients, 3 of whom showed reversion after treatment of OKT3 or insulin. Early postoperative complications included peritoneal infection (2 patients), wound infection (2) and renal hematoma (1). CONCLUSION: ED-SPK without Roux-en-Y anastomosis is safe and preferable to the patients with IDDM associated with uremia.

Acute respiratory distress syndrome after liver transplantation: etiology, prevention and management.

OBJECTIVE: To study the etiology, prevention and management of acute respiratory distress syndrome (ARDS) after liver transplantation. METHODS: The clinical data of 104 patients with end-stage liver diseases who had had liver transplantations were retrospectively reviewed. RESULTS: Seventeen patients (16.3%, 17/104) altogether were diagnosed as having ARDS after liver transplantation. Ten of them developed ARDS within 24 hours, of whom 1 died during the operation, and 7 developed ARDS 3 or 4 days after they were extubated and when methylprednisolone was tapered. Fourteen of the 17 ARDS patients (14/17) were found to have overloaded crystalloid infusion, massive transfusion of blood or blood products such as plasma, platelets, in addition to a prolonged surgical time secondary to serious bleeding during the diseased liver removal without evidence of active infection. One was found to have serious systemic infection and operatively disseminated intravascular coagulation. Four of the recipients developed ARDS suddenly when intravenous cyclosporine was given on the 3rd day after operation. One patient of the 4 had all of the aforementioned conditions. Two patients suffered from gastric aspiration. Five (30%, 5/17) of them survived ARDS with the combined treatment consisting of positive end-expiratory pressure mechanical ventilation suctioning as much edema fluid or sputum as possible, administration of diuretics, bolus of corticosteroids, and culture-based antibiotics. Hemeodialysis was indicated for patients with oliguric renal failure. CONCLUSIONS: ARDS is a serious multifactoral complication after liver transplantation with a high mortality and fatality. The most likely cause is fluid overload from crystalloid liquid infusion or massive transfusion. The other predisposing or contributing factors include sepsis, IV use of cyclosporine, fast tapering of corticosteroids, and gastric aspiration. Other factors such as transfusion-related acute lung injury (TRALI), and reperfusion syndrome of the newly implanted liver may also contribute. Though the treatment should primarily be supportive in nature, it is helpful to understand the predisposing and contributing factors and to aid in prevention, management and treatment.