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research letter

Indian Pediatr 2017;54:244-246

Respiratory Morbidity Following Pediatric Orthotopic Liver Transplantation

*Shahzad Alam, Anilkumar Sapare, #Sanjay Rao, Rajiv Aggarwal and #Ashley L D’Cruz

Department of Pediatrics and #Pediatric Surgery, Narayana Hrudayalaya, N H Health City, Bangalore, Karnataka, India.

Email: *[email protected]

Published online: February 02, 2017. PII:S097475591600048

 


We evaluated the pulmonary complications following orthotopic liver transplantation in 45 children (age <18 y). 22 patients (49%) developed respiratory complications. Pediatric end-stage liver disease (PELD) score >25 and positive fluid balance were independent risk factors. Patients with respiratory complication had significantly higher mortality and intensive care unit stay.

Keywords: ARDS, Complications, Pneumonia.



O
rthotopic liver transplantation (OLT) is the treatment of choice for children with end stage liver disease. Despite advances in intensive care and surgical techniques, respiratory complications are frequently associated with pediatric OLT [1,2]. We retrospectively analyzed medical records of children (age <18 y) who underwent OLT during 2009-14 in a tertiary-care referral hospital in Bangalore, India.

Respiratory complications were assessed from clinical and radiological features. Pediatric end-stage liver disease (PELD) score was calculated using online calculators. Fluid balance was calculated as percentage of body weight using formulae: (total fluid in [L] – total fluid out [L] / (admission weight [kg]) × 100%. Patients were dichotomized as those with pulmonary complications and those without. Chi-square test was used to evaluate categorical data and Mann-Whitney U test for continuous data. Statistical significance was defined as P<0.05. Univariate analysis was performed and variables with P<0.05 were entered into a multivariate logistic regression analysis to determine independent predictors. Odds ratio was calculated for significant factors. Outcome compared included mortality and duration of intensive care unit (ICU) stay.

Forty-five children (28 boys) with median (range) age of 27 (7,143) months were included. Commonest indication of OLT was biliary atresia (n=23) followed by cryptogenic cirrhosis (n=4). Twenty-two patients (48.9%) developed significant pulmonary complications. Commonest of them was pulmonary edema (n=11; 24.4%) followed by pneumonia (n=10; 22.2%). Although 22 (48.9%) patients had pleural effusion, 8 (17.8%) were significant enough to required thoracocentesis or intercoastal drainage tube. Five (11.1%) patients developed acute respiratory distress syndrome (ARDS). Seven (15.5%) patients died during the post-operative period; all had pulmonary complications. Operative mortality (7 vs 0; P=0.003) and mean (SD) length of ICU stay [22.9 (11.8) vs 12.7 (52); P=0.014] were significantly higher in patients with pulmonary complications. PELD score >25 (P=0.001) and positive fluid balance in first 3 post-operative days (P=0.001) were independent risk factors (Table I) associated with complications with odds ratio (95% CI) of 11.4 (1.8, 71.6) and 5.7 (1.2, 26.8), respectively.

TABLE I	Variables in Patients with Postoperative Pulmonary and Non-pulmonary Complications After Transplant (n=45)
Variable Pulmonary  Non pulmonary
complication complication 
(n=22) (n=23)
Age (mo)* 48.7  (45.9) 36.9  (29.8)
Female gender 11 6
Weight-for-age Z score <-3SD 11 12
Height-for-age Z score <-3SD 12 11
Preoperative massive ascites 10 8
Preoperative INR* 2.35  (1.1) 2.02  (0.6)
#Preoperative PELD score >25 20 8
Preoperative respiratory problem 4 3
Preoperative sepsis 6 2
Preoperative ventilation requirement 3 1
Intraoperative transfusion >40ml/kg 16 14
Intraoperative positive fluid balance 18 17
  >10% body weight
Positive fluid balance in first 17 6
 3 post- operative days
Oliguria in first 7 post- operative day 3 1
Acute kidney injury in first 12 10
 7 post- operative day
Acute graft rejection 5 2
Re-laparotomy 8 3
Values in numbers or *mean (SD); #P<0.001; P=0.001.

The rate of pulmonary complications in the early post-operative period is in broad agreement to the range of 13-70% in recent published reports [1-5]. Although all the patients who died had pulmonary complications; not all deaths could be directly attributed to them. Major complication associated with mortality was ARDS which could be a part of severe sepsis. Thus, respiratory complication was the major mode of death rather than cause. Association of different complications with mortality could not be determined because of the small sample size. In our series, patients with pulmonary complications had significantly longer length of ICU stay and mortality. Earlier studies [6,7] also reported higher mortality, and higher ICU and hospital stay in patients with pulmonary complications. Severity of the disease [8,9] and excessive fluid and transfusion requirement [6,8] have also been reported previously as significant risk factors.

We conclude that respiratory morbidity is common in children who undergo OLT. Optimal timing to allow OLT at lower PELD score, and meticulous attention to prevent fluid overload may reduce risk of pulmonary complications and improve outcome. /p>

Contributors: SA and AKS: concept, data collection, statistics, data analysis, drafting of article and critical review; SR and RA: data analysis, drafting of article, and critical review; ALD: drafting of article and critical review. All authors approved the manuscript.

Funding: None; Competing interest: None stated.

RReferences

1. Siniscalchi A, Cucchetti A, Toccaceli L, Spiritoso R, Tommasoni E, Spedicato S, et al. Pretransplant model for end-stage liver disease score as a predictor of postoperative complications after liver transplantation. Transplant Proc. 2009;41:1240-2.

2. Xia D, Yan LN, Xu L, Li B, Zeng Y, Wen TF, et al. Postoperative severe pneumonia in adult liver transplant recipients. Transplant Proc. 2006;38:2974-8. 

3. Bozbas SS, Eyuboglu FO, Ozturk Ergur F, Gullu Arslan N, Sevmis S, Karakayali H, et al. Pulmonary complications and mortality after liver transplant. Exp Clin Transplant. 2008;6:264-70. 

4. Hong SK, Hwang S, Lee SG, Lee LS, Ahn CS, Kim KH, et al/i>. Pulmonary complications following adult liver transplantation. Transplant Proc. 2006;38:2979-81.

55. Pirat A, Ozgur S, Torgay A, Candan S, Zeynelođlu P, Arslan G. Risk factors for postoperative respiratory complications in adult liver transplant recipients. Transplant Proc. 2004;36:218-20.

6. Huang CT, Lin HC, Chang SC, Lee WC. Pre-operative risk factors predict post-operative respiratory failure after liver transplantation. PLoS One. 2011;6:e22689.

7. Feltracco P, Barbieri S, Galligioni H, Michieletto E, Carollo C, Ori C. Intensive care management of liver transplanted patients. World J Hepatol. 2011;3:61-71. 

8. Levesque E, Hoti E, Azoulay D, Honore I, Guignard B, Vibert E, et al. Pulmonary complications after elective liver transplantation-incidence, risk factors, and outcome. Transplantation. 2012;94:532-8.

9. Bourdeaux C, Tri TT, Gras J, Sokal E, Otte JB, de Ville de Goyet J, et al. PELD score and posttransplant outcome in pediatric liver transplantation: A retrospective study of 100 recipients. Transplantation. 2005;79:1273-6.


 

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