Chinsu Liu

Background.: This study aimed to identify serum microRNAs (miRNA) as a predictive tool for operational tolerance in pediatric liver transplantation (LT). Methods.: Pediatric LT recipients were included in an immunosuppressant (IS) minimization protocol in our institution. Blood samples were collected at 2 stages: pre-protocol and post-completion. Ninety miRNAs expression was analyzed from blood samples using the NextAmp Analysis System and mirSCAN PanelChip (Quark Biosciences, Inc.). Participants were categorized into 3 groups: IS-free (complete withdrawal), IS-high (serum tacrolimus level > 2 ng/mL), and IS-low (serum tacrolimus level ≤ 2 ng/mL). Results.: Between 2011 and 2019, 37 patients were enrolled in the IS minimization protocol at Taipei Veterans General Hospital. Of these, 13 patients (35.1%) successfully achieved IS-free status, whereas 24 (64.8%) remained non-IS-free. Eighteen patients with blood samples at pre-protocol and post-completion stage were included in the analysis. A total of 27 miRNAs exhibited significant differences in expression between the IS-free and IS-high groups at the pre-protocol stage. Additionally, 13 miRNAs showed significant changes in expression between the pre-protocol and post-completion stages in the IS-free group. miRNAs associated with immune suppression were expressed at higher levels in the IS-high group and at lower levels in the IS-free group at the pre-protocol stage. Conclusions.: In this study, we identified 6 miRNAs—hsa-miR-21-5p, hsa-miR-22-3p, hsa-miR-30c-5p, hsa-miR-181b-5p, hsa-miR-20a-5p, and hsa-miR-125b-5p—that predict operational tolerance in pediatric LT at both the pre-protocol stage and during the minimization period. Notably, hsa-miR-125b-5p demonstrated perfect discriminative performance at the pre-protocol stage (area under the curve 1.00; sensitivity 100%; and specificity 100%) and showed significant changes in ΔCq between the pre-protocol and post-completion stages in the IS-free group. To our knowledge, this is the first report of miRNA biomarkers exhibiting such high accuracy for identifying operational tolerance in pediatric LT.

Background: Noninfectious complications of peritoneal dialysis (PD) are common in infants. Mechanical dysfunctions with abdominal compartment syndrome, hydrothorax with respiratory failure, and medication-induced chyloperitoneum are rare during PD. In this case report, we aim to present several life-threatening events and the timely management of a PD infant. Case Presentation: This male infant is a case of infantile nephronophthisis, NPHP3/renal-hepatic–pancreatic dysplasia type 1, with end-stage kidney disease, and he received PD therapy at 4 months of age. Because of the young age with low body weight and hepatosplenomegaly with a limited abdominal cavity, intra-abdominal pressure-associated noninfectious complications frequently occurred. Acute respiratory failure with abdominal dullness was detected at 5 months of age. Abdominal compartment syndrome caused by PD catheter outflow obstruction from omental wrapping was diagnosed via laparoscopic revision surgery. Hyperkalemia, decreased PD drainage volume, and sudden respiratory distress occurred at 10 months old. Hydrothorax due to pleuroperitoneal communication was confirmed by scintigraphy. After thoracoscopic diaphragmatic bleb repair and plication surgery were performed, no recurrence of hydrothorax was observed. Calcium channel blocker-induced chyloperitoneum was observed at 13 months of age. Chylous ascites disappeared after tapering off the calcium channel blocker in 3 days. After the patient grew up with a larger peritoneal cavity, no more pressure-associated complications of PD occurred. Conclusions: The key to successful treatment of rare and life-threatening noninfectious complications of PD in young infants lies in early detection and timely intervention. A limited abdominal cavity is not a contraindication for PD therapy, especially in very young infants with low body weight, because hemodialysis is not a choice of long-term dialysis modality.

Purpose To investigate the interaction between graft-to-recipient weight ratio (GRWR) and portal venous hemodynamics (PVH), with a net impact on the perioperative outcomes of living donor liver transplantation (LDLT). Methods We analyzed, retrospectively, adult LDLT recipients divided into three groups according to their GRWR: Group 1, > 1.0% (n = 124); Group 2, 0.8 ~ 1.0% (n = 70); and Group 3, < 0.8% (n = 31). Results The intraoperative PVH parameters did not differ significantly among the groups, but Group 3 had the highest number of patients needing portal inflow modulation to achieve optimal final portal pressure. Group 3 was also more prone to delayed recovery of liver function, a higher incidence of posttransplant kidney injury necessitating dialysis (16.1% vs. 3.2% for Group 1 and 4.3% for Group 2, p = 0.015) and a higher incidence of liver graft loss within 3 months post-LDLT (22.6% vs. 7.3% for Group 1 and 4.3% for Group 2, p = 0.007). Logistic regression analysis revealed that extremely small liver grafts (GRWR < 0.7%) were the most significant risk factor for early graft loss (HR: 16.951, 95% CI: 3.961 ~ 72.535). Survival analysis revealed comparable outcomes between patients who received liver grafts with a GRWR of 0.7 ~ 0.8% and those who received liver grafts with a GRWR > 0.8%. Patients with extremely small liver grafts had significantly lower graft survival rates (1-month, 3-months, and 1-year post-LDLT, of 66.7%, 50.0%, and 50.0%, respectively (p < 0.01). Conclusion Under intraoperative PVH monitoring, the accepted GRWR in LDLT could be extended to 0.7%, but a GRWR < 0.7% remains a risk factor for early graft loss.

Introduction: Peritoneal dialysis (PD) is a well-established treatment choice for end-stage kidney disease (ESKD). While there are several methods for PD catheter insertion, they each have limitations. In this study, we present a new hybrid method for PD catheter insertion and compare it to the conventional laparoscopic method. Methods: This retrospective study included 171 patients who were undergoing their first PD catheter insertion, and a total of 20% of the enrolled patients had a past medical history of abdominal surgery. Out of these, 101 patients underwent the laparoscopic method and 70 underwent a new invented hybrid method. The study aimed to compare the surgical outcomes, incidence of early and late complications, hospital stay, and medical expenses between the two groups. Results: There were no notable differences in basic demographic features and comorbid conditions between the two groups. The results of our data revealed that the hybrid group had a significantly shorter break-in period and did not require temporary hemodialysis. Additionally, length of hospital stay and medical costs were significantly lower in the hybrid group (all p < 0.05). The incidence of early complications was lower in the hybrid group, while the incidence of late complications was comparable between the two groups. Conclusion: Our study demonstrates that the hybrid method of PD catheter insertion provides a safe and efficient alternative to the traditional laparoscopic method, enabling urgent-start PD and reducing hospital stays and medical expenses. Our findings support the use of the hybrid method as a new standard of care for ESKD patients undergoing PD catheter insertion.

Background: In the era of the coronavirus disease 2019 (COVID-19) pandemic, surgeons and medical staff are often at a high risk of infection in the operating room, especially when the patient is spontaneously breathing. In this study, we examined the minimum requirements for personal protective equipment with double surgical masks to potentially reduce unnecessary waste of supplies. Methods: Two mannequins were each connected to a test lung machine simulating a surgeon and patient with spontaneous breathing. An aerosol generator containing severe acute respiratory syndrome coronavirus 2 virion particle substitutes was connected to the patient mannequin. The sampling points for the target molecules were set at different distances from the patient mannequin and sent for multiplex quantitative polymerase chain reaction analysis. Three clinical scenarios were designed, which differed in terms of the operating room pressure and whether a fabric curtain barrier was installed between the mannequins. Results: Analysis of the multiplex quantitative polymerase chain reaction results showed that the cycle threshold (Ct) value of the target molecule increased as the distance from the aerosol source increased. In the negative-pressure operating room, the Ct values were significantly increased at all sample points compared with the normal pressure room setting. The Ct value sampled at the surgeon mannequin wearing double face masks was significantly increased when a cloth curtain barrier was set up between the two mannequins. Conclusion: Double surgical masks provide elementary surgeon protection against COVID-19 in a negative pressure operating room, with a physical barrier in place between the surgeon and patient who is spontaneously breathing during local anesthesia or sedated surgery.

Introduction: Persistent lymphatic leakage from the surgical drain is a troubling complication occasionally encountered postoperatively. This study investigated lymphatic leaks after renal or liver transplantation, comparing the treatment efficacy of traditional catheter drainage vs. minimally invasive lymphatic interventions. We also discuss access and treatment targets considering the physiology of lymphatic flow.Methods: Between September 2018 and September 2020, 13 patients with lymphatic leakage were treated with minimally invasive lymphatic interventions; 11 had received a renal transplant, and two received a liver transplant. The control group included 10 patients with postrenal transplant lymphatic leakage treated with catheter drainage. The treatment efficacy of catheter drainage, lymphatic interventions, and different targets of embolization were compared.Results: The technical success rate for lymphatic intervention was 100%, and the clinical success rate was 92%, with an 82.9% reduction in drain volume on the first day after treatment. The duration to reach clinical success was 5.9 days with lymphatic intervention, and 33.9 days with conservative catheter drainage.Conclusion: Lymphangiography and embolization are minimally invasive and efficient procedures for treating persistent lymphatic leaks after renal or liver transplantation. We suggest prompt diagnosis and embolization at upstream lymphatics to reduce the duration of drain retention, days of hospitalization, and associated comorbidities.

Background: LT is a treatment option for MMA patients, but renal function impairment is one of the long‐term concerns. The aim of this study was to evaluate the outcomes of early LT in these patients.Methods: A total of 11 MMA mut‐type patients (including 10 mut0 cases and 1 mut‐case) who received LT in our institute were reviewed. Their metabolic profiles were compared between the pre/post‐transplant periods. Their immunosuppressant and renal function changes after transplantation were assessed.Results: After a mean follow‐up of 97.5 ± 38.4 months, there were two deaths, and the actual survival rate was 81.8%. Their metabolic profiles had improved (mean blood ammonia level 366.8 ± 105.5 vs. 53.1 ± 17.4 μg/dl, p < .001; C3/C2 ratio 2.68 ± 0.87 vs. 0.73 ± 0.22, p = .003; mean urine MMA level 920.5 ± 376.6 vs. 196.2 ± 85.4, p = .067), and hospital stays were decreased (78.8 ± 74.5 vs. 7.4 ± 7.0 days/year, p = .009) after transplantation. The mean age at transplant was 1.81 ± 2.02 years old, and nine of these patients received LT before the age of 1.5 years old (early LT). Under prospective immunosuppressant dose reduction, three of these early LT patients discontinued the drug and were sustained for more than 5 years. Most of the patients had a preserved renal function, and no patient is currently on dialysis.Conclusions: In addition to the improvement in the metabolic parameters, early LT in MMA patients may allow for a dose reduction of the immunosuppressant, and the patient's renal function could be preserved in the long term.