Epidemiology and Risk Factors of Early Bacterial Infections After Pediatric Living Donor Liver Transplantation.

BACKGROUND: Advancements in surgical techniques, immunosuppression regimens, and peri-operative and postoperative care have resulted in marked improvement in outcomes after pediatric living donor liver transplantation (PLDLT). Despite these developments, infectious complications remain a major cause of morbidity and mortality. METHODS: This is a retrospective cohort analysis of pediatric recipients from January 2004 to December 2018. Patients were classified into infected and non-infected groups based on the occurrence of bacterial infection during the first 3 months after transplant. Perioperative risk factors for early post-transplant bacterial infections and postoperative outcomes were investigated. RESULTS: Seventy-two out of 221 children developed early bacterial infection (32.6%). The first episodes of bacterial infection most frequently occurred in the second week after LDLT (37.5%). In multivariate analysis, active infection before transplant and complications with Clavien-Dindo grading >3 were the only independent risk factors. Early bacterial infections were independently associated with longer intensive care unit stays, longer hospital stays, and a higher incidence of readmission for bacterial infection during the first year after transplant. Additionally, the overall patient survival rate was significantly higher in the non-infected group (P = .001). Risk factors for infection, such as age, weight, disease severity, ABO-incompatible, and other operative factors, were not identified as independent risk factors. CONCLUSION: We have demonstrated that there are similarities and disparities in the epidemiology and risk factors for early bacterial infection after transplant between centers. Identification and better characterization of these predisposing factors are essential in the modification of current preventive strategies and treatment protocols to improve outcomes for this highly vulnerable group.

Peri-operative extracorporeal membrane oxygenation in adult and pediatric living donor liver transplantation: a single-center experience.

Background: Extracorporeal membrane oxygenation (ECMO) is a potential rescue therapy for patients with acute cardiopulmonary dysfunction refractory to conventional treatment. In this study, we described the clinical profiles and outcomes of adult and pediatric living donor liver transplantation (LDLT) patients who received ECMO support during the peri-operative period. Methods: From June 1994 to December 2020, eleven out of the 1,812 LDLTs performed at Kaohsiung Chang Gung Memorial Hospital required ECMO support: six for respiratory failure, three for cardiogenic shock, and two for refractory septic shock. Comparison between the survivor and non-survivor groups was made. Results: The survival rate for liver transplantation (LT) patients on ECMO support is 36.4%-40% in adults and 33.3% in pediatrics, while the survival rate per indication is as follows: acute respiratory distress syndrome (ARDS) (50%), cardiogenic shock (33.3%), and sepsis (0%). Shorter durations of LT-to-ECMO and pre-ECMO mechanical ventilation were observed in the survivor group. On the other hand, we observed persistently elevated total bilirubin levels in non-survivors, while none of the survivors had aspartate aminotransferase (AST)/alanine aminotransferase (ALT) levels >1,000 U/L. A higher proportion of non-survivors were on concurrent continuous renal replacement therapy (CRRT). Conclusions: Our experience has proven ECMO's utility during the peri-operative period for both adult and pediatric LDLT patients, more specifically for indications other than septic shock. Further studies are needed to better understand the factors leading to poor outcomes in order to identify patients who will more likely benefit from ECMO.

Hydrops fetalis and neonatal abdominal compartment syndrome continuum from immature gastric teratoma: a case report.

BACKGROUND: Hydrops fetalis as well as abdominal compartment syndrome (ACS) are conditions that are associated with high mortality rates. A rare case of immature gastric teratoma causing fetal hydrops and subsequent ACS is presented. The related pathophysiologic mechanisms are discussed, and the importance of timely recognition and appropriate interventions are highlighted. CASE PRESENTATION: The male patient was born preterm, weighing 3.9 kg., by Cesarean section. Prior prenatal ultrasounds were normal, but a scan done just before delivery had findings indicating polyhydramnios, fetal ascites, and meconium peritonitis. Upon delivery, the patient had respiratory distress, anasarca and a massively distended abdomen. Resuscitation measures, including ventilatory support, were instituted. Imaging studies showed ascites as well as a large, complex intra-abdominal lesion with calcifications. In the succeeding hours, anuria persisted, anasarca worsened, the abdomen became more distended, and inotrope requirements increased. The occurrence of ACS, from what was presumed to be a retroperitoneal teratoma, was therefore considered. Laparotomy was done on the 28th hour of life, with en bloc excision of a massive tumor and attached section of the greater curvature of the stomach. Passage of urine occurred intra-operatively, and the patient was soon after weaned off inotropes and ventilator support. The histopathologic result was immature gastric teratoma. No chemotherapy was given, and the patient's serum AFP is at normal levels 15 months following surgery. CONCLUSION: The presence of a massive intra-abdominal lesion can result in the pathophysiologic continuum of hydrops fetalis and neonatal ACS. The early recognition of such an association can enable appropriate expectant management of similarly affected neonates, including emergent decompression laparotomy.