Acute respiratory distress syndrome after liver transplantation: etiology, prevention and management.

Objective: To study the etiology, prevention and management of acute respiratory distress syndrome (ARDS) after liver transplantation.

Methods: The clinical data of 104 patients with end-stage liver diseases who had had liver transplantations were retrospectively reviewed.

Results: Seventeen patients (16.3%, 17/104) altogether were diagnosed as having ARDS after liver transplantation. Ten of them developed ARDS within 24 hours, of whom 1 died during the operation, and 7 developed ARDS 3 or 4 days after they were extubated and when methylprednisolone was tapered. Fourteen of the 17 ARDS patients (14/17) were found to have overloaded crystalloid infusion, massive transfusion of blood or blood products such as plasma, platelets, in addition to a prolonged surgical time secondary to serious bleeding during the diseased liver removal without evidence of active infection. One was found to have serious systemic infection and operatively disseminated intravascular coagulation. Four of the recipients developed ARDS suddenly when intravenous cyclosporine was given on the 3rd day after operation. One patient of the 4 had all of the aforementioned conditions. Two patients suffered from gastric aspiration. Five (30%, 5/17) of them survived ARDS with the combined treatment consisting of positive end-expiratory pressure mechanical ventilation suctioning as much edema fluid or sputum as possible, administration of diuretics, bolus of corticosteroids, and culture-based antibiotics. Hemeodialysis was indicated for patients with oliguric renal failure.

Conclusions: ARDS is a serious multifactoral complication after liver transplantation with a high mortality and fatality. The most likely cause is fluid overload from crystalloid liquid infusion or massive transfusion. The other predisposing or contributing factors include sepsis, IV use of cyclosporine, fast tapering of corticosteroids, and gastric aspiration. Other factors such as transfusion-related acute lung injury (TRALI), and reperfusion syndrome of the newly implanted liver may also contribute. Though the treatment should primarily be supportive in nature, it is helpful to understand the predisposing and contributing factors and to aid in prevention, management and treatment.