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.
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