Zhi-Jun Zhu

Hepatic ischemia–reperfusion injury (HIRI) is not only a common complication of liver transplantation and major hepatic surgery but also a critical determinant of postoperative prognosis. Lactate metabolic reprogramming has been observed in HIRI, yet the role of lactate and its related lactylation in the pathogenesis of HIRI remains unclear. To address this, we integrated single-cell and bulk RNA-seq data with multiple bioinformatic approaches. Five single-cell gene set activity scoring methods (AUCell, UCell, singscore, ssGSEA, and AddModuleScore) were applied to evaluate lactylation activity across cell types, followed by differentially expressed gene (DEG) analysis and high-dimensional Weighted Correlation Network Analysis (hdWGCNA) to identify lactylation-associated genes. Five machine learning algorithms (Random Forest, Boruta, LASSO, GBM, and Decision Tree) were used to screen optimal feature genes, with SHAP analysis further explaining their importance. Bulk RNA sequencing data from the Gene Expression Omnibus (GEO) database were used for validation. Furthermore, NR4A3-related inhibitors were screened using the ChEMBL online tool and assessed by docking and molecular dynamic simulation. We observed significant heterogeneity in lactate metabolism activity across cell types in hepatic ischemia–reperfusion injury (HIRI), with higher activity levels observed for hepatocytes and mononuclear phagocytes. The integration of SHAP and machine learning identified PFKFB3, ZYX, and NR4A3 as closely associated with high lactylation after HIRI, and cross-analysis with bulk RNA data confirmed their consistent upregulation. Candidate gene expression was experimentally validated in a murine liver IRI model through Western blotting and RT-qPCR. Although lactylation has been previously reported in HIRI, this study’s unique contribution is to reveal the cell-type heterogeneity of lactylation-related gene expression at the single-cell level through multi-omics integration and machine learning. The identification of NR4A3, PFKFB3, and ZYX as lactylation-associated regulators proposes novel therapeutic targets for improving graft survival in liver transplantation.

Background: Portal vein thrombosis (PVT) increases operative complexity and complication risks in liver transplantation (LT), but whether it compromises long-term survival with proper inflow reconstruction remains debated. This study aimed to evaluate the impact of preoperative PVT on perioperative and long-term outcomes after LT and to assess outcomes following individualized portal inflow reconstruction in patients with complex PVT. Methods: Adult orthotopic LT recipients between 2016 and 2024 were retrospectively recruited and stratified into PVT (n=144) and non-PVT (n=373) groups. Baseline, operative, and survival data were compared. Results: PVT patients had higher rates of Child-Pugh B/C (86.2% vs. 74.8%), hepatic encephalopathy (30.6% vs. 20.6%), upper gastrointestinal bleeding (UGIB; 57.6% vs. 35.9%), and prior splenectomy (16.7% vs. 2.4%; all Pvs. 75.1%), longer operative time (453 vs. 405 min), greater blood loss (1,200 vs. 800 mL), and more red cell transfusions (800 vs. 600 mL; all Pvs. 3.5%) and 1-year renal dysfunction (52.5% vs. 39.4%) were more frequent in the PVT group (PConclusions: Preoperative PVT did not compromise long-term survival after LT but increased operative complexity, PV-related complications, and renal dysfunction. When appropriately designed, a non-anatomical portal reconstruction strategy could achieve favorable outcomes in complex PVT cases.

Background: The use of laparoscopic procedures for liver transplantation (LT) remains controversial. This study aimed to present our preliminary experience with a minimally invasive pediatric living donor liver transplantation (LDLT). Methods: The medical records of pediatric patients who underwent laparoscopy‐assisted LDLT, namely laparoscopic mobilization of the diseased liver followed by open explant hepatectomy and graft implantation using an upper midline incision at Beijing Friendship Hospital between November 2019 and March 2023, were retrospectively reviewed, focusing on demographics and pre‐, intra‐, and postoperative outcomes. Results: Laparoscopy‐assisted LDLT was successfully performed in all 13 pediatric patients. The mean total operative time was 478 min (range, 315–615 min), the median portal vein clamping time was 47 min (range, 33–107 min), the average time required to remove the liver was 229 min (range, 115–357 min), and the median cold ischemia time was 85 min (range, 29–214 min). The intraoperative course for all the recipients was uneventful. All patients recovered well without any significant acute postoperative problems, with only one patient presenting with hepatic artery thrombosis on postoperative day 1 who made a good recovery after immediate thrombectomy and re‐anastomosis. During a median follow‐up of 41.8 (range, 24.3–64.3 months), all recipients survived with 100% graft survival. Conclusion: This is the world's largest single‐center cohort study of pediatric laparoscopy‐assisted LDLT using an upper midline incision. Our results provide preliminary evidence for the safety and feasibility of minimally invasive LDLT in selected pediatric patients, which may be a reasonably compromised strategy before attempting pure laparoscopic LT. Trial Registration: Chinese Clinical Trial Registry Identifier: ChiCTR2400086319

Hepatic encephalopathy (HE) is a frequent and life-threatening neurological complication of acute liver failure (ALF) encountered in the intensive care unit and remains a major determinant of short-term mortality and long-term neurological outcomes. Increasing evidence indicates that HE in ALF is primarily driven by hyperammonemia, with synergistic contributions from systemic inflammation, cerebral hemodynamic dysregulation, metabolic failure, and osmotic imbalance. These interacting mechanisms promote astrocytic swelling, disruption of the blood–brain barrier, cerebral edema, and intracranial hypertension. In patients with ALF, early recognition of cerebral involvement and systematic exclusion of alternative causes of altered mental status are essential. Given the dynamic and heterogeneous neurological manifestations of HE, reliance on isolated clinical, biochemical, or radiological parameters is insufficient. Multimodal neuromonitoring—integrating neurological examination, ammonia kinetics, cerebral hemodynamic assessment, and neuroimaging—allows more accurate assessment of cerebral injury and supports timely, targeted intervention. This review summarizes current evidence on the pathophysiology of HE in ALF with a focus on mechanisms relevant to intensive care practice. We highlight evidence-based strategies for cerebral protection, including early and sustained control of hyperammonemia with continuous renal replacement therapy, optimization of cerebral perfusion and osmotic balance, selective use of plasma exchange, and structured neurocritical care. An integrated management framework is proposed to guide prognostication and inform timely decisions regarding advanced liver support and liver transplantation in the ICU setting.

Reply to: A mono-organ POLG1-related mitochondrial DNA depletion syndrome must be confirmed by quantitative real-time polymerase chain reaction (PCR) or droplet digital PCR

Background: Mitochondrial DNA depletion syndrome (mtDDS) is a rare genetic disorder caused by mutations in nuclear genes responsible for mitochondrial DNA maintenance, most notably POLG1. The disease is characterized by diverse clinical manifestations, including myopathy, hepatopathy, and neurological deficits. Due to its phenotypic heterogeneity, diagnosing mtDDS in pediatric populations remains a significant clinical challenge, often leading to delays in life-saving interventions. Case Description: We report the case of an 11-month-old male infant presenting with acute liver failure and recurrent hypoglycemia. Laboratory findings revealed elevated liver enzymes, jaundice, and persistent metabolic distress. Notably, the patient lacked the neurological symptoms typically associated with POLG1 mutations, complicating the initial clinical picture. Genetic analysis via whole exome sequencing (WES) identified two novel compound heterozygous mutations in the POLG1 gene (695G>A and 1735C>T), confirming the diagnosis of mtDDS. Following the diagnosis, the patient underwent a successful liver transplantation, which resulted in significant clinical stabilization and improved quality of life. Conclusions: This case expands the known mutational spectrum of the POLG1 gene and highlights an atypical presentation of mtDDS isolated to hepatic dysfunction. Our findings underscore the critical importance of early genetic testing, such as WES, in infants with unexplained liver failure or metabolic crises. Timely diagnosis is essential to guide surgical interventions like liver transplantation, which can effectively improve outcomes. Clinicians should maintain a high index of suspicion for underlying mitochondrial genetic defects in pediatric hepatopathy to facilitate early intervention and long-term management.

Background: This study aims to evaluate the safety and feasibility of performing portoenterostomy in rabbits under immunosuppressive therapy. Methods: 49 New Zealand rabbits were randomly divided into two groups: the experimental group ( n = 24) underwent portoenterostomy, while the control group ( n = 25) received traditional choledochojejunostomy. Postoperatively, all rabbits were administered oral methylprednisolone and cyclosporine A. Four rabbits from each group were sacrificed on postoperative days 30, 60, and 90. Primary outcomes included postoperative mortality, morbidity, and pathological changes at the anastomotic site. Secondary outcomes encompassed biochemical indicators such as ALT, AST, ALB, ALP, GGT, DBIL, TBIL, TBA, BUN, and Scr. Results: In a study comparing portoenterostomy and choledochojejunostomy, 49 rabbits underwent surgery (24 in the portoenterostomy group and 25 in the choledochojejunostomy group). The postoperative mortality rates were 4/24 in the portoenterostomy group and 6/25 in the choledochojejunostomy group. Changes in serum bilirubin and creatinine levels suggested the occurrence of anastomotic stricture, cholangitis, and renal dysfunction in some rabbits. The portoenterostomy group showed less severe anastomotic stricture compared to the choledochojejunostomy group, and the use of immunosuppressive agents did not negatively affect the healing process. Pathological observations indicated good healing outcomes within 1 to 3 months postoperatively, despite the presence of inflammation and scar formation. Conclusions: The study demonstrates that small portoenterostomy performed under immunosuppressive therapy is a safe, simple, and technically feasible surgical approach.

BACKGROUND Advancements in transplant immunology and pharmacotherapy have led to improved outcomes in pediatric ABO-incompatible liver transplantation. However, the long-term dynamics of donor-specific versus non-donor-specific blood group antibodies (BGAs) in this population remain unclear. This study aimed to determine whether incomplete immune tolerance to donor-specific BGAs persists after ABO-incompatible liver transplantation. MATERIAL AND METHODS This retrospective study included 29 pediatric patients who underwent ABO-incompatible living donor liver transplantation with extended follow-up. Five of these patients exhibited persistent donor-specific BGA titers greater than 1: 64 (IgG or IgM) and received standardized preoperative immunosuppression; all 29 patients received intraoperative and postoperative immunosuppression. Demographic data, pre- and post-transplant BGA titers, and histopathological findings from liver biopsies were collected and analyzed. RESULTS All recipients were blood type O; 10 received grafts from blood type A donors, whereas 19 received grafts from blood type B donors. Donor-specific BGA titers (both IgG and IgM) remained persistently low and were significantly lower than non-donor-specific BGAs (P<0.001). Liver biopsy findings revealed mild to moderate antibody-mediated rejection in 5 patients. All patients achieved long-term survival. CONCLUSIONS The persistently low titers of donor-specific BGAs in pediatric ABO-incompatible living donor liver transplantation recipients may indicate a state of incomplete immune tolerance, possibly influenced by the developmental characteristics of the pediatric immune system and preconditioning with monoclonal antibodies. Further studies are warranted to confirm these findings and clarify the mechanisms underlying immune tolerance in this setting.