Intraoperative Continuous Kidney Replacement Therapy With Regional Epoprostenol Anticoagulation During Liver Transplantation in a Child With Severe Gastrointestinal Bleeding.

Abstract

Background: Acute kidney injury (AKI) is a significant complication in pediatric liver transplant (LT) patients. This is often exacerbated by liver dysfunction, fluid overload, and metabolic disturbances. Intraoperative continuous kidney replacement therapy (IO-CKRT) is an emerging strategy to manage these complex patients, aiming to stabilize fluid, electrolyte, and acid-base imbalances. Epoprostenol is utilized as an anticoagulant during CKRT to maintain circuit patency, particularly in patients at high risk of bleeding by inhibiting platelet aggregation. However, the use of IO-CKRT with epoprostenol specifically in pediatric LT recipients is poorly documented.

Methods: We present a case of a 12 year-old girl with biliary atresia and cirrhosis who underwent urgent LT from a deceased donor. She developed hemorrhagic shock and multi-organ failure, necessitating pre-transplant plasmapheresis and subsequent CKRT with epoprostenol. IO-CKRT was maintained during the 12 h LT to manage acid-base balance, electrolyte levels, and volume status.

Results: Despite epoprostenol anticoagulation for hemofiltration, no abnormal bleeding occurred in the gastrointestinal or surgical areas during transplantation. Post-transplantation, the patient's inotropic support requirements decreased within 24 h.

Conclusions: IO-CKRT effectively achieves fluid and metabolic balance during LT in pediatric patients with AKI, fluid overload, and metabolic issues. Epoprostenol proves to be a safe and effective regional anticoagulation option for CKRT in bleeding patients undergoing LT, preventing site bleeding without systemic complications. This case highlights a unique and important application that warrants further investigation into its broader effectiveness and potential complications in this vulnerable patient population.