A TCR mechanotransduction signaling loop induces negative selection in the thymus.

The T cell antigen receptor (TCR) expressed on thymocytes interacts with self-peptide major histocompatibility complex (pMHC) ligands to signal apoptosis or survival. Here, we found that negative-selection ligands induced thymocytes to exert forces on the TCR and the co-receptor CD8 and formed cooperative TCR-pMHC-CD8 trimolecular 'catch bonds', whereas positive-selection ligands induced less sustained thymocyte forces on TCR and CD8 and formed shorter-lived, independent TCR-pMHC and pMHC-CD8 bimolecular 'slip bonds'. Catch bonds were not intrinsic to either the TCR-pMHC or the pMHC-CD8 arm of the trans (cross-junctional) heterodimer but resulted from coupling of the extracellular pMHC-CD8 interaction to the intracellular interaction of CD8 with TCR-CD3 via associated kinases to form a cis (lateral) heterodimer capable of inside-out signaling. We suggest that the coupled trans-cis heterodimeric interactions form a mechanotransduction loop that reinforces negative-selection signaling that is distinct from positive-selection signaling in the thymus.

A soft microrobot with highly deformable 3D actuators for climbing and transitioning complex surfaces.

The climbing microrobots have attracted growing attention due to their promising applications in exploration and monitoring of complex, unstructured environments. Soft climbing microrobots based on muscle-like actuators could offer excellent flexibility, adaptability, and mechanical robustness. Despite the remarkable progress in this area, the development of soft microrobots capable of climbing on flat/curved surfaces and transitioning between two different surfaces remains elusive, especially in open spaces. In this study, we address these challenges by developing voltage-driven soft small-scale actuators with customized 3D configurations and active stiffness adjusting. Combination of programmed strain distributions in liquid crystal elastomers (LCEs) and buckling-driven 3D assembly, guided by mechanics modeling, allows for voltage-driven, complex 3D-to-3D shape morphing (bending angle > 200°) at millimeter scales (from 1 to 10 mm), which is unachievable previously. These soft actuators enable development of morphable electroadhesive footpads that can conform to different curved surfaces and stiffness-variable smart joints that allow different locomotion gaits in a single microrobot. By integrating such morphable footpads and smart joints with a deformable body, we report a multigait, soft microrobot (length from 6 to 90 mm, and mass from 0.2 to 3 g) capable of climbing on surfaces with diverse shapes (e.g., flat plane, cylinder, wavy surface, wedge-shaped groove, and sphere) and transitioning between two distinct surfaces. We demonstrate that the microrobot could navigate from one surface to another, recording two corresponding ceilings when carrying an integrated microcamera. The developed soft microrobot can also flip over a barrier, survive extreme compression, and climb bamboo and leaf.

Rapidly deployable and morphable 3D mesostructures with applications in multimodal biomedical devices.

Structures that significantly and rapidly change their shapes and sizes upon external stimuli have widespread applications in a diversity of areas. The ability to miniaturize these deployable and morphable structures is essential for applications in fields that require high-spatial resolution or minimal invasiveness, such as biomechanics sensing, surgery, and biopsy. Despite intensive studies on the actuation mechanisms and material/structure strategies, it remains challenging to realize deployable and morphable structures in high-performance inorganic materials at small scales (e.g., several millimeters, comparable to the feature size of many biological tissues). The difficulty in integrating actuation materials increases as the size scales down, and many types of actuation forces become too small compared to the structure rigidity at millimeter scales. Here, we present schemes of electromagnetic actuation and design strategies to overcome this challenge, by exploiting the mechanics-guided three-dimensional (3D) assembly to enable integration of current-carrying metallic or magnetic films into millimeter-scale structures that generate controlled Lorentz forces or magnetic forces under an external magnetic field. Tailored designs guided by quantitative modeling and developed scaling laws allow formation of low-rigidity 3D architectures that deform significantly, reversibly, and rapidly by remotely controlled electromagnetic actuation. Reconfigurable mesostructures with multiple stable states can be also achieved, in which distinct 3D configurations are maintained after removal of the magnetic field. Demonstration of a functional device that combines the deep and shallow sensing for simultaneous measurements of thermal conductivities in bilayer films suggests the promising potential of the proposed strategy toward multimodal sensing of biomedical signals.

Functional to structural plasticity in unilateral sudden sensorineural hearing loss: neuroimaging evidence.

A cortical plasticity after long-duration single side deafness (SSD) is advocated with neuroimaging evidence while little is known about the short-duration SSDs. In this case-cohort study, we recruited unilateral sudden sensorineural hearing loss (SSNHL) patients and age-, gender-matched health controls (HC), followed by comprehensive neuroimaging analyses. The primary outcome measures were temporal alterations of varied dynamic functional network connectivity (dFNC) states, neurovascular coupling (NVC) and brain region volume at different stages of SSNHL. The secondary outcome measures were pure-tone audiograms of SSNHL patients before and after treatment. A total of 38 SSNHL patients (21 [55%] male; mean [standard deviation] age, 45.05 [15.83] years) and 44 HC (28 [64%] male; mean [standard deviation] age, 43.55 [12.80] years) were enrolled. SSNHL patients were categorized into subgroups based on the time from disease onset to the initial magnetic resonance imaging scan: early- (n = 16; 1-6 days), intermediate- (n = 9; 7-13 days), and late- stage (n = 13; 14-30 days) groups. We first identified slow state transitions between varied dFNC states at early-stage SSNHL, then revealed the decreased NVC restricted to the auditory cortex at the intermediate- and late-stage SSNHL. Finally, a significantly decreased volume of the left medial superior frontal gyrus (SFGmed) was observed only in the late-stage SSNHL cohort. Furthermore, the volume of the left SFGmed is robustly correlated with both disease duration and patient prognosis. Our study offered neuroimaging evidence for the evolvement from functional to structural brain alterations of SSNHL patients with disease duration less than 1 month, which may explain, from a neuroimaging perspective, why early-stage SSNHL patients have better therapeutic responses and hearing recovery.

Determining if T cell antigens are naturally processed and presented on HLA class I molecules.

BACKGROUND: Determining T cell responses to naturally processed and presented antigens is a critical immune correlate to determine efficacy of an investigational immunotherapeutic in clinical trials. In most cases, minimal epitopes and HLA restriction elements are unknown. RESULTS: Here, we detail the experimental use of ex vivo expanded autologous B cells as antigen presenting cells to overcome the limitation of unknown HLA restriction, and the use of electroporated full length mRNA encoding full length parental proteins to ensure that any observed T cell responses are specific for antigens that are naturally processed and presented. CONCLUSIONS: This technique can serve as useful experimental approach to determine the induction or enhancement of specific responses to naturally processed and presented antigens on HLA class I molecules in peripheral blood or tumor infiltrating T cells.

A Cluster-Based Energy Optimization Algorithm in Wireless Sensor Networks with Mobile Sink.

Aiming at high network energy consumption and data delay induced by mobile sink in wireless sensor networks (WSNs), this paper proposes a cluster-based energy optimization algorithm called Cluster-Based Energy Optimization with Mobile Sink (CEOMS). CEOMS algorithm constructs the energy density function of network nodes firstly and then assigns sensor nodes with higher remaining energy as cluster heads according to energy density function. Meanwhile, the directivity motion performance function of mobile sink is constructed to enhance the probability of remote sensor nodes being assigned as cluster heads. Secondly, based on Low Energy Adaptive Clustering Hierarchy Protocol (LEACH) architecture, the energy density function and the motion performance function are introduced into the cluster head selection process to avoid random assignment of cluster head. Finally, an adaptive adjustment function is designed to improve the adaptability of cluster head selection by percentage of network nodes death and the density of all surviving nodes of the entire network. The simulation results show that the proposed CEOMS algorithm improves the cluster head selection self-adaptability, extends the network life, reduces the data delay, and balances the network load.

Relativistic Artificial Molecules Realized by Two Coupled Graphene Quantum Dots.

Coupled quantum dots (QDs), usually referred to as artificial molecules, are important not only in exploring fundamental physics of coupled quantum objects but also in realizing advanced QD devices. However, previous studies have been limited to artificial molecules with nonrelativistic Fermions. Here, we show that relativistic artificial molecules can be realized when two circular graphene QDs are coupled to each other. Using scanning tunneling microscopy (STM) and spectroscopy (STS), we observe the formation of bonding and antibonding states of the relativistic artificial molecule and directly visualize these states of the two coupled graphene QDs. The formation of the relativistic molecular states strongly alters distributions of massless Dirac Fermions confined in the graphene QDs. Moreover, our experiment demonstrates that the degeneracy of different angular-momentum states in the relativistic artificial molecule can be further lifted by external magnetic fields. Then, both the bonding and antibonding states are split into two peaks.

Citrate-Based Self-Circulation Anticoagulation Protocol for Discontinuity of Continuous Renal Replacement Therapy.

BACKGROUND/AIMS: Continuous renal replacement therapy (CRRT) has been used widely in the treatment of critically ill children for its continuity. However, sometimes we have to interrupt the continuity for necessary surgeries or blood transfusions. Our objective was to demonstrate a feasible self-circulation anticoagulation protocol based on citrate (CSAP) to address discontinuity during CRRT. METHODS: We conducted a prospective observational study of 57 pediatric patients undergoing 88 CRRT sessions that were receiving CSAP during the treatment discontinuity period by using an anticoagulation regimen containing 5 mL 4% sodium citrate in 50 mL of saline to maintain the continuity. We documented the reasons for CSAP and the total duration of the treatment. We assessed the in-line pressure recordings, blood routine examination, blood electrolytes, and blood gas analysis before, throughout, and after the period of CSAP. RESULTS: The average duration of CSAP was 118.5 ± 45.3 min. There was no significant increase in arterial pressures, venous pressures, and transmembrane pressures and no significant decreases in blood cell counts observed at the end of the CSAP, compared to the data recorded at the beginning of the CSAP. Compared to before the CSAP, there was no significant change in the ratio of total to ionized calcium, Na+, HCO3-, and pH value after CSAP. CONCLUSIONS: CSAP might be a safe, effective, and easy approach for use during the treatment discontinuity of CRRT in children.

Ecthyma gangrenosum due to Pseudomonas aeruginosa sepsis as initial manifestation of X-linked agammaglobulinemia: a case report.

BACKGROUND: X-linked agammaglobulinemia (XLA, OMIM#300,300), caused by mutations in the Bruton tyrosine kinase (BTK) gene, is a rare monogenic inheritable immunodeficiency disorder. Ecthyma gangrenosum is a cutaneous lesion caused by Pseudomonas aeruginosa that typically occurs in patients with XLA and other immunodeficiencies. CASE PRESENTATION: We report the case of a 20-month-old boy who presented with fever, vomiting, diarrhea, and ecthyma gangrenosum. Blood, stool, and skin lesion culture samples were positive for P. aeruginosa. A diagnosis of XLA was established, and the c.262G > T mutation in exon 4 of BTK was identified with Sanger sequencing. Symptoms improved following treatment with antibiotics and immunoglobulin infusion. CONCLUSIONS: Primary immunodeficiency (i.e., XLA) should be suspected in male infants with P. aeruginosa sepsis, highlighting the importance of genetic and immune testing in these patients.

Morphable 3D mesostructures and microelectronic devices by multistable buckling mechanics.

Three-dimensional (3D) structures capable of reversible transformations in their geometrical layouts have important applications across a broad range of areas. Most morphable 3D systems rely on concepts inspired by origami/kirigami or techniques of 3D printing with responsive materials. The development of schemes that can simultaneously apply across a wide range of size scales and with classes of advanced materials found in state-of-the-art microsystem technologies remains challenging. Here, we introduce a set of concepts for morphable 3D mesostructures in diverse materials and fully formed planar devices spanning length scales from micrometres to millimetres. The approaches rely on elastomer platforms deformed in different time sequences to elastically alter the 3D geometries of supported mesostructures via nonlinear mechanical buckling. Over 20 examples have been experimentally and theoretically investigated, including mesostructures that can be reshaped between different geometries as well as those that can morph into three or more distinct states. An adaptive radiofrequency circuit and a concealable electromagnetic device provide examples of functionally reconfigurable microelectronic devices.

Pre-TCR ligand binding impacts thymocyte development before αßTCR expression.

Adaptive cellular immunity requires accurate self- vs. nonself-discrimination to protect against infections and tumorous transformations while at the same time excluding autoimmunity. This vital capability is programmed in the thymus through selection of αßT-cell receptors (αßTCRs) recognizing peptides bound to MHC molecules (pMHC). Here, we show that the pre-TCR (preTCR), a pTα-ß heterodimer appearing before αßTCR expression, directs a previously unappreciated initial phase of repertoire selection. Contrasting with the ligand-independent model of preTCR function, we reveal through NMR and bioforce-probe analyses that the ß-subunit binds pMHC using Vß complementarity-determining regions as well as an exposed hydrophobic Vß patch characteristic of the preTCR. Force-regulated single bonds akin to those of αßTCRs but with more promiscuous ligand specificity trigger calcium flux. Thus, thymic development involves sequential ß- and then, αß-repertoire tuning, whereby preTCR interactions with self pMHC modulate early thymocyte expansion, with implications for ß-selection, immunodominant peptide recognition, and germ line-encoded MHC interaction.

A Novel Fault Diagnosis Method of Rolling Bearings Based on AFEWT-KDEMI.

According to the dynamic characteristics of the rolling bearing vibration signal and the distribution characteristics of its noise, a fault identification method based on the adaptive filtering empirical wavelet transform (AFEWT) and kernel density estimation mutual information (KDEMI) classifier is proposed. First, we use AFEWT to extract the feature of the rolling bearing vibration signal. The hypothesis test of the Gaussian distribution is carried out for the sub-modes that are obtained by the twice decomposition of EWT, and Gaussian noise is filtered out according to the test results. In this way, we can overcome the noise interference and avoid the mode selection problem when we extract the feature of the signal. Then we combine the advantages of kernel density estimation (KDE) and mutual information (MI) and put forward a KDEMI classifier. The mutual information of the probability density combining the unknown signal feature vector and the probability density of the known type signal is calculated. The type of the unknown signal is determined via the value of the mutual information, so as to achieve the purpose of fault identification of the rolling bearing. In order to verify the effectiveness of AFEWT in feature extraction, we extract signal features using three methods, AFEWT, EWT, and EMD, and then use the same classifier to identify fault signals. Experimental results show that the fault signal has the highest recognition rate by using AFEWT for feature extraction. At the same time, in order to verify the performance of the AFEWT-KDEMI method, we compare two classical fault signal identification methods, SVM and BP neural network, with the AFEWT-KDEMI method. Through experimental analysis, we found that the AFEWT-KDEMI method is more stable and effective.

Pediatric non-diabetic ketoacidosis: a case-series report.

BACKGROUND: This study is to explore the clinical characteristics, laboratory diagnosis, and treatment outcomes in pediatric patients with non-diabetic ketoacidosis. METHODS: Retrospective patient chart review was performed between March 2009 to March 2015. Cases were included if they met the selection criteria for non-diabetic ketoacidosis, which were: 1) Age ≤ 18 years; 2) urine ketone positive ++ or >8.0 mmol/L; 3) blood ketone >3.1 mmol/L; 4) acidosis (pH < 7.3) and/or HCO3 < 15 mmol/L; 5) random blood glucose level < 11.1 mmol/L. Patients who met the criteria 1, 4, 5, plus either 2 or 3, were defined as non-diabetic ketoacidosis and were included in the report. RESULTS: Five patients with 7 episodes of non-diabetic ketoacidosis were identified. They all presented with dehydration, poor appetite, and Kussmaul breathing. Patients treated with insulin plus glucose supplementation had a quicker recovery from acidosis, in comparison to those treated with bicarbonate infusion and continuous renal replacement therapy. Two patients treated with bicarbonate infusion developed transient coma and seizures during the treatment. CONCLUSION: Despite normal or low blood glucose levels, patients with non-diabetic ketoacidosis should receive insulin administration with glucose supplementation to correct ketoacidosis.

Scanning Tunneling Microscopy of the π Magnetism of a Single Carbon Vacancy in Graphene.

Pristine graphene is strongly diamagnetic. However, graphene with single carbon atom defects could exhibit paramagnetism. Theoretically, the π magnetism induced by the monovacancy in graphene is characteristic of two spin-split density-of-states (DOS) peaks close to the Dirac point. Since its prediction, many experiments have attempted to study this π magnetism in graphene, whereas only a notable resonance peak has been observed around the atomic defects, leaving the π magnetism experimentally elusive. Here, we report direct experimental evidence of π magnetism by using a scanning tunneling microscope. We demonstrate that the localized state of the atomic defects is split into two DOS peaks with energy separations of several tens of meV. Strong magnetic fields further increase the energy separations of the two spin-polarized peaks and lead to a Zeeman-like splitting. Unexpectedly, the effective g factor around the atomic defect is measured to be about 40, which is about 20 times larger than the g factor for electron spins.

Creating one-dimensional nanoscale periodic ripples in a continuous mosaic graphene monolayer.

In previous studies, it has proved difficult to realize periodic graphene ripples with wavelengths of a few nanometers. Here we show that one-dimensional (1D) periodic graphene ripples with wavelengths from 2 nm to tens of nanometers can be implemented in the intrinsic areas of a continuous mosaic (locally N-doped) graphene monolayer by simultaneously using both the thermal strain engineering and the anisotropic surface stress of the Cu substrate. Our result indicates that the constraint imposed at the boundaries between the intrinsic and the N-doped regions play a vital role in creating these 1D ripples. We also demonstrate that the observed rippling modes are beyond the descriptions of continuum mechanics due to the decoupling of graphene's bending and tensional deformations. Scanning tunneling spectroscopy measurements indicate that the nanorippling generates a periodic electronic superlattice and opens a zero-energy gap of about 130 meV in graphene. This result may pave a facile way for tailoring the structures and electronic properties of graphene.

Pathogenicity classification of missense mutations based on deep generative model.

Missense mutations affect the function of human proteins and are closely associated with multiple acute and chronic diseases. The identification of disease-associated missense mutations and their classification for pathogenicity can provide insights into the genetic basis of disease and protein function. This paper proposes MLAE (Method based on LSTM-Ladder AutoEncoder), a deep learning classification model for identifying disease-associated missense mutations and classifying their pathogenicity based on the Variational AutoEncoder (VAE) framework. MLAE overcomes the limitations of the VAE framework by introducing the Ladder structure, combined with LSTM networks. This reduces the loss of original information during the transmission process, thereby making the model more effective in learning. In the experiment, MLAE classified all 27572 possible missense variants of the three input proteins with an average classification AUC of 0.941. This result provides evidence that MLAE is effective in predicting pathogenicity. Additionally, MLAE provides results for multi-label classification, with an average Hamming loss of 0.196, supporting the classification of complex variants. The proposed MLAE method provides an insightful approach to effectively capture amino acid sequence information and accurately predict the pathogenicity of mutations, thereby providing an analytical basis for the study and prevention of related diseases.

Quantification and Functional Studies of Neutrophilic Cells Identifies Distinct Papilloma Phenotypes.

OBJECTIVES: To characterize the distribution of immune cell subsets within laryngeal papillomas and to study the function of potentially immunosuppressive neutrophilic and regulatory T cells (Tregs). METHODS: Fresh clinical papilloma specimens were collected at the time of surgery and studied with multiparameter flow cytometry. Papilloma infiltrating neutrophilic cells and Tregs were sorted and studied functionally with ex vivo T cell suppression assays. RESULTS: Flow cytometric analysis of fresh laryngeal papillomas samples from 18 adult patients with recurrent respiratory papillomatosis revealed patterns in immune constituency between patients. Clearly divergent phenotypes based primarily on the degree of neutrophilic and T cell infiltration were identified. Relative neutrophilic cell enrichment and T cell depletion were observed in 50% of samples and neutrophilic cell depletion and T cell enrichment were observed in the others. Greater papilloma neutrophilic cell enrichment was positively associated with the number of clinically indicated interventions required in the 12 months prior to sample collection, linking papilloma neutrophil inflammation to disease severity. Functional assays revealed the ability of both papilloma infiltrating neutrophilic and Tregs to suppress T cell function at roughly equal magnitudes, but substantially increased infiltration of neutrophilic cells compared to Tregs across samples. CONCLUSION: Neutrophilic cells are an important contributor to immunosuppression within the respiratory papilloma microenvironment. Given these data and the association between greater neutrophilic cell infiltration and lack of clinical response to therapeutic vaccination, additional study of strategies aimed at limiting neutrophilic cell infiltration or function within papillomas is warranted. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:3238-3244, 2024.

Saccharide mapping as an extraordinary method on characterization and identification of plant and fungi polysaccharides: A review.

Saccharide mapping was a promising scheme to unveil the mystery of polysaccharide structure by analysis of the fragments generated from polysaccharide decomposition process. However, saccharide mapping was not widely applied in the polysaccharide analysis for lacking of systematic introduction. In this review, a detailed description of the establishment process of saccharide mapping, the pros and cons of downstream technologies, an overview of the application of saccharide mapping, and practical strategies were summarized. With the updating of the available downstream technologies, saccharide mapping had been expanding its scope of application to various kinds of polysaccharides. The process of saccharide mapping analysis included polysaccharides degradation and hydrolysates analysis, and the degradation process was no longer limited to acid hydrolysis. Some downstream technologies were convenient for rapid qualitative analysis, while others could achieve quantitative analysis. For the more detailed structure information could be provided by saccharide mapping, it was possible to improve the quality control of polysaccharides during preparation and application. This review filled the blank of basic information about saccharide mapping and was helpful for the establishment of a professional workflow for the saccharide mapping application to promote the deep study of polysaccharide structure.

Computed tomography radiogenomics: A potential tool for prediction of molecular subtypes in gastric stromal tumor.

BACKGROUND: Preoperative knowledge of mutational status of gastrointestinal stromal tumors (GISTs) is essential to guide the individualized precision therapy. AIM: To develop a combined model that integrates clinical and contrast-enhanced computed tomography (CE-CT) features to predict gastric GISTs with specific genetic mutations, namely KIT exon 11 mutations or KIT exon 11 codons 557-558 deletions. METHODS: A total of 231 GIST patients with definitive genetic phenotypes were divided into a training dataset and a validation dataset in a 7:3 ratio. The models were constructed using selected clinical features, conventional CT features, and radiomics features extracted from abdominal CE-CT images. Three models were developed: ModelCT sign, modelCT sign + rad, and model CTsign + rad + clinic. The diagnostic performance of these models was evaluated using receiver operating characteristic (ROC) curve analysis and the Delong test. RESULTS: The ROC analyses revealed that in the training cohort, the area under the curve (AUC) values for modelCT sign, modelCT sign + rad, and modelCT sign + rad + clinic for predicting KIT exon 11 mutation were 0.743, 0.818, and 0.915, respectively. In the validation cohort, the AUC values for the same models were 0.670, 0.781, and 0.811, respectively. For predicting KIT exon 11 codons 557-558 deletions, the AUC values in the training cohort were 0.667, 0.842, and 0.720 for modelCT sign, modelCT sign + rad, and modelCT sign + rad + clinic, respectively. In the validation cohort, the AUC values for the same models were 0.610, 0.782, and 0.795, respectively. Based on the decision curve analysis, it was determined that the modelCT sign + rad + clinic had clinical significance and utility. CONCLUSION: Our findings demonstrate that the combined modelCT sign + rad + clinic effectively distinguishes GISTs with KIT exon 11 mutation and KIT exon 11 codons 557-558 deletions. This combined model has the potential to be valuable in assessing the genotype of GISTs.

Clinical application of regional citrate anticoagulation for membrane-based therapeutic plasma exchange in children with liver failure.

Background: Regional citrate anticoagulation (RCA) is being used more commonly in children for continuous renal replacement therapy. Few reports describe the application of membrane-based therapeutic plasma exchange (mTPE) with RCA in children with liver failure (LF). Aims: To explore the application of RCA-mTPE in children with LF. Methods: We retrospectively analyzed data from children with LF who underwent RCA-mTPE in the Children's Hospital of Chongqing Medical University's pediatric intensive care unit. We used the total to ionized calcium ratio (T/iCa) > 2.5 as the diagnostic criteria for citrate accumulation (CA). The patients were divided into two groups according to the occureence of CA at the end of RCA-mTPE (CA group: T/iCa > 2.5; NCA group: T/iCa ≤ 2.5). To evaluate the clinical safety and efficacy of RCA-mTPE, the following data from medical records were assessed and compared between groups: clinical characteristics, reasons for LF, RCA-mTPE parameters and duration, laboratory findings, and complications. Results: In total, 92 RCA-mTPE treatments were administered to 21 children with LF over 3.8 ± 0.9 h. The following mean values were determined: blood flow rate (QB) = 2.8 ml/kg/min, 4% sodium citrate dose/blood flow rate ratio (QCi/QB) = 1.1(QCi,ml/kg/h); plasma dose/body weight ratio(QP/BW) = 18.5 (QP, ml/kg/h); 10% calcium gluconate dose/blood flow rate ratio (QCa/QB) = 0.2(QCa, ml/kg/h). The mean concentration of iCa in vitro was 0.38 ± 0.07 mmol/L. Citrate accumulation was recorded after 34 (37%) treatments. Hypocalcemia occurred in 11 (12%) and 7 (7.6%) treatments, during and after mTPE, respectively. Three hypotensive and one convulsive events, related to hypocalcemia, and two clotting events occurred during RCA-mTPE. After RCA-mTPE, the patients' pH, HCO3- and Na+ levels, and T/iCa were significantly increased and the total bilirubin (TB), conjugated bilirubin (DB), prothrombin time (PT), activated partial thromboplastin time (APTT), alanine aminotransferase (ALT), aspartate aminotransferase (AST),and ammonia levels were significantly decreased. The TB, DB, and lactic acid levels, before RCA-mTPE, were significantly higher in the CA group than in the NCA group, but there were no significance between the two groups in QB/BW, QCi/QB, and QP/BW, mTPE duration, and estimated amount of citrate metabolized. Conclusions: Children with LF undergoing RCA-mTPE are at risk of hypocalcemia. With proper protocol adjustment, however, RCA-mTPE can be used safely and effectively in these patients.