Acute interstitial pneumonitis associated pediatric acute respiratory distress syndrome in 8 recipients after liver transplantation

Abstract

Objective To summarize the clinical course of acute interstitial pneumonitis (AIP) associated pediatric acute respiratory distress syndrome (PARDS) in 8 recipients after liver transplantation, and further discuss the potential risk factors and therapeutic highlights. Methods A total of 476 pediatric patients received liver transplantation in Tianjin First Center Hospital from January 2012 to September 2016. Among them, 8 cases of AIP associated PARDS in ICU were recruited in this study. Medical data including clinical presentation, ICU management and outcomes were analyzed retrospectively. Results The onset time-window of AIP associated PARDS was (2.67±0.77) months after liver transplantation, and the time interval between initial symptom and ICU administration was (6.75±5.82) days. Five cases had the history of acute rejection therapy, and 5 cases had CMV and/or EBV viremia history. All 8 cases received mechanical ventilation, 2 cases given nasal non-invasive ventilation and the rest 6 cases given invasive ventilation, 3 of which were switched to high frequency oscillatory ventilation (HFOV) combined with inhaled nitric oxide. At the stage of hypoxic climax, the fraction of inspired oxygen (FiO2) was up-regulated to 1.0 to maintain the oxygenation index (OI) of (25.24±5.94). Temporary replacement of immunosuppressants with intravenous glucocorticoids was implemented in all 8 cases without acute rejection episode. Of 8 cases, 2 cases died from PARDS, 1 case died from portal thrombosis associated hepatic failure, and the rest 5 cases survived. Conclusion AIP associated PARDS is a critical complication with high mortality in pediatric patients after liver transplantation. Excessively strong immunosuppression therapy at early post-transplant stage shows a risk factor for AIP. Lung protective ventilation strategy and HFOV are recommended to reduce ventilator induced lung injury in pediatric patients. Temporary intravenous glucocorticoids may reduce acute inflammatory reaction in PARDS patients without increasing the risk of acute rejection. Key words: Acute interstitial pneumonitis; Pediatric acute respiratory distress syndrome; Pediatric liver transplantation; Lung protective ventilation strategy; Glucocorticoids