[Management and prognosis of pediatric acute liver failure in pediatric intensive care unit]

Objective: To understand the management of children with pediatric acute liver failure (PALF) in pediatric intensive care unit (PICU). Methods: A retrospective case-control study was conducted. A total of 101 children with PALF hospitalized in PICU of Beijing Children's Hospital from July 2017 to October 2022 were included. Demographic, clinical management and prognosis data were collected. According to whether PALF was the main diagnosis, the patients were divided into primary diagnosis group and complication group. The primary diagnosis group was subdivided into effective group and ineffective group with routine treatment (except liver transplantation). The intergroup comparisons were performed using independent samples t-test, Mann-Whitney U test, χ² test or Fisher exact test. Multivariate Logistic regression analysis was employed to identify risk factors associated with prognosis. Results: Among the 101 children with PALF, 58 were male and 43 were female, with an age of 30 (10, 103) months, 60 cases in primary diagnosis group and 41 cases in complication group. There were no significant differences in prothrombin time (PT) and international normalized ratio (INR) between the two groups (both P>0.05), while the total bilirubin, direct bilirubin and blood ammonia were all significantly higher in the primary diagnosis group (all P<0.05). Unoriginal liver failure (25 cases (42%)) and poisoning (13 cases (22%)) were the most common causes of PALF in the primary diagnosis group, while shock (17 cases, 43%) and hemophagocytic syndrome (14 cases (34%)) in the complication group. The mortality rate of the main diagnosis group was significantly lower than that of the complication group (25% (15/60) vs. 61% (25/41), χ²=13.18, P<0.001), as well as the incidence of combined organ function injury, while the amount of plasma used and the ratio of plasma exchange times to PICU hospitalization days were significantly higher (all P<0.05). In the primary diagnosis group, there were 32 cases (53%) in the effective group and 28 cases (47%) in the ineffective group. In the ineffective group, 15 cases (54%) died and 13 cases (46%) were transferred to another site for liver transplantation assessment. The hospitalization time of PICU in the effective group was significantly longer than that in the ineffective group, while the ratio of plasma exchange times to PICU hospitalization days, the average daily hours of continuous renal replacement therapy (CRRT), the rate of CRRT and the average daily plasma dosage in the effective group were all significantly lower than those in the ineffective group (all P<0.05). The worst PT, INR and blood ammonia, and the stage 4 hepatic encephalopathy morbidity and significant bleeding rate in the effective group were all significantly lower than those in the ineffective group (all P<0.05). Multivariate Logistic regression analysis showed that after adjusting for age, sex, total bilirubin, INR and blood ammonia, stage 4 hepatic encephalopathy was the independent risk factor for the failure of routine treatment of PALF (OR=84.16,95%CI 4.04-1752.37, P=0.004). Conclusions: PT and INR could not specifically represent liver synthetic function in some PICU patients, so current PALF diagnostic criteria for PICU children has limitations. Complicated with stage 4 hepatic encephalopathy was an independent risk factor of the failure of conventional treatment in patients with PALF.