Living Donor Liver Transplantation

Liver transplantation was first proposed by Tack Cannon in 1956. In 1960, Moore et al completed an experimental study on animal liver transplantation. In 1963, Starzl completed the world's first human orthotopic liver transplantation for a congenital biliary atresia. At that time, due to the lack of clinical experience and the lack of effective anti-rejection drugs, the 1-year survival rate of the initial liver transplantation was less than 20%. After the 1980s, due to the advancement of transplantation technology, the use of shunting technology and the introduction of cyclosporine (CsA) in the liver-free period have increased the 1-year survival rate after liver transplantation to 60% to 75%. In particular, the effect of liver transplantation in children is better than that of adults, and the 2-year survival rate reaches 80%. In addition to the age factor, the difference in primary disease is a more important reason. The main target of liver transplantation in children is biliary atresia, followed by metabolic diseases and sclerosing diseases. Liver malignant tumors are rare in children, with survival rate. The improvement of liver transplantation technology has truly become an acceptable treatment for end-stage liver disease. In 1987, Wisconsin University developed an organ preservation solution, UW solution, to extend the cold ischemia time of the liver to 24 hours. This research result greatly improved the quality of donor liver preservation and significantly reduced the primary graft without function. Complications caused by liver preservation. The emergence of UW fluid has prolonged the preservation of donor liver, and some new techniques such as reduced volume liver transplantation, cleft palate liver transplantation and living donor liver transplantation have emerged. In 1989, Japan introduced a new immunosuppressant FK506 for clinical use. It has a high reversal rate of refractory acute and chronic rejection. It can be used alone or in combination with hormones, especially for CsA and hormone refractory rejection. reaction. As new powerful immunosuppressants continue to be pushed to the clinic, the success rate of liver transplantation has been greatly improved. In 1989, Tzakis first reported the piggyback technique, which was later praised by many scholars, especially in children with orthotopic liver transplantation. Because no hepatic phase does not use the flow-through technology, the various pathophysiological disturbances caused by the bypass process are avoided, and the incidence of postoperative complications is greatly reduced. The current data show that the clinical effect of orthotopic liver transplantation in children is better than that of adults, which may be related to the short onset time of children and the difference in immune status between adults. Due to the improvement of surgical operation techniques and the application of new immunosuppressive agents in recent years, the clinical application of orthotopic liver transplantation in children has been rapidly developed and the therapeutic effect has been improved year by year. The world's first living donor liver transplant was successfully performed by Australian physician Strong in 1989. Despite the technical difficulty and high risk of surgery in living donor liver transplantation, people still bravely accepted this procedure based on the serious lack of cadaveric liver and the fact that some children with advanced liver disease died before waiting for the liver to arrive. In particular, due to differences in cultural backgrounds, some Asian countries and regions have not yet established a brain death law, which makes it difficult to obtain cadaveric donor liver. Therefore, this technology has developed rapidly in Japan, Hong Kong, and Taiwan, Asia. In the late genital stage, it has become a routine operation in some liver transplant centers. Domestic Wang Xuehao et al reported 13 cases of live liver transplantation in 2002, 10 of which were Wilson's disease, donors were from the mother of the sick child, all donors did not have any complications after surgery, and 9 recipients had long-term healthy survival. This procedure is more promising in children's liver transplantation. Surgical indications, contraindications, and perioperative management are the same as described in the Allogeneic Orthotopic Liver Transplantation section. The most important issue for living donor liver transplantation is how to ensure the safety of the donor. The donor is carefully evaluated before surgery. The fine anatomy during surgery is the most important part. The former includes the psychological and past health status of the donor, cardiopulmonary and liver and kidney functions. Blood routine, blood type, blood sugar, electrolyte and coagulation function, a series of serum virological tests (hepatitis B patients can not be selected as donors), imaging examination (including CT or MRI), if necessary, MRCP, transhepatic artery or Superior mesenteric artery angiography to understand the movement and anatomy of the hepatic vein, hepatic artery, portal vein and biliary tract, paying special attention to the presence or absence of hepatic artery variation. If MRCP is not performed before surgery, it is best to perform cholangiography during the operation to show the biliary structure and the presence or absence of biliary tract variation. For example, some image data before surgery are still unclear about the direction or variation of blood vessels. B-ultrasound should be prepared for further confirmation during surgery. Only after clearly understanding the direction of the portal vein, hepatic vein and its branches can the liver parenchyma be Cutting is judged accurately. All examinations must be carried out on a voluntary basis. Live liver transplantation involves the life of two living organisms and all legal procedures must be completed before surgery. The donor blood type must match. Treatment of diseases: pediatric hepatoblastoma fulminant hepatic failure Indication Parental living donor liver transplantation is applicable to: End stage liver disease In theory, all liver diseases in children can not be cured by all the treatments used in conventional internal surgery, and it is expected that the death can not be avoided in a short period of time, that is, some end-stage liver diseases can be considered for liver transplantation. Specifically, serum bilirubin >256.5mol/L; prothrombin time longer than 5s and can not be corrected with vitamin K; serum albumin is less than 25g / L or hepatic encephalopathy can not be maintained by drug treatment, All are indications for liver transplantation. In children, mainly biliary atresia and congenital metabolic disorders, such as 1 anti-trypsin deficiency deficiency, glycogenosis, hepatolenticular degeneration syndrome, etc., this type of disease accounts for about 18% of pediatric liver transplantation Second, primary or secondary biliary cirrhosis, Buka syndrome, sclerosing cholangitis, hepatic cystic fibrosis with liver cancer. 2. Liver malignancy Hepatoblastoma is more common in children, and it is usually appropriate that the tumor cannot be treated by conventional hepatectomy and there is no distant metastasis outside the liver. This type of sick child generally has no severe liver function damage, and has a high success rate and a short-term survival rate after surgery, but it is easy to relapse after transplantation. 3. fulminant hepatic failure The prognosis of this disease is extremely poor. Liver transplantation may save the lives of some sick children. Because of the difficulty in obtaining an ideal donor liver for emergency liver transplantation, parental liver transplantation is currently available. Regardless of the cause of liver disease end-stage changes, liver transplantation should be performed before extreme liver failure to reduce the surgical mortality and postoperative complications. Data show that the main targets for liver transplantation under 15 years of age are biliary atresia (50%), metabolic disease (16%) and multiple sclerosing diseases (12%), while malignant tumors account for only 7%. Due to the lack of donor liver, in recent years, the use of parental liver transplantation, that is, the removal of a part of the adult liver (usually taking the left outer lobe of the liver), orthotopic transplantation has been successful in pediatric receptors. This method has opened up new prospects for pediatric liver transplantation. Contraindications 1. A malignant neoplasm other than the liver. 2. Severe infection of important organs other than the hepatobiliary system. 3. Systemic diseases, such as congenital cardiovascular disease, renal insufficiency, etc. 4. Portal vein thrombosis. 5. Fulminant hepatic failure Hepatitis B antigen (HBsAg and HBeAg) is positive, and the postoperative hepatitis recurrence rate is almost 100%, but it can still survive long-term through effective medical treatment. Preoperative preparation 1. A comprehensive understanding of the general condition of sick children Measuring the body weight and height of the recipient, performing B-ultrasound and CT examinations to understand the size of the liver is necessary to select a donor of the right size. Compared with heart and kidney transplantation, the incidence of rejection after liver transplantation is low, so tissue matching is generally based on A, B, O blood group matching. Serum cytomegalovirus (CMV)-negative receptors are best received from CMV-negative donor livers. If CMV-positive donor livers are received, the chance of CMV infection after liver transplantation will increase significantly. If the small recipient of the disease needs to be implanted into the adult donor liver after hepatectomy, depending on the space, it may be considered to reduce the volume of the liver transplant or to have the indications to remove the spleen at the same time. The author's hospital used to implant an adult donor liver for a 14-year-old child. The spleen was removed at the same time as the diseased liver. It has been healthy for 3 years and 4 months. 2. Preoperative assessment of the hepatobiliary system A variety of imaging methods and various experimental methods (B-ultrasound, CT, MRI, or MRCP) must be used to clarify the diagnosis of primary disease. The following blood tests should be routine, 1 hepatitis B serological markers, HBsAg, HBsAb, HBeAg, HBeAb, HBc-Ab and HBV-DNA; 2 hepatitis C virus markers, HCV-Ab and HCV-RNA; 3 anti-nuclear antibodies (ANA); 4 anti-mitochondrial antibody (AMA); 5EB virus antibody; 6 cytomegalovirus (CMV); 7 alpha fetoprotein (AFP); 8 carcinoembryonic antigen (CEA); 9 HIV antibody; 10 liver function, renal function, Blood glucose, blood coagulation, blood K+, Na+, Cl- determination. For children with suspected portal vein or mesenteric venous thrombosis, color Doppler ultrasonography is necessary to examine the above veins, including the vena cava. 3. Preoperative complete organ function check on the recipient Check heart, kidney, lung, blood system, gastrointestinal system, etc. 4. Psychological and sociological assessment of sick children and their families before surgery Ensure that they have a thorough understanding and cooperation on the complexity, risk and related issues of the surgery. 5. In the process of waiting for the donor liver, it is necessary to actively and effectively treat various complications caused by the primary disease of the recipient. 6. Organization of the liver transplant team Liver transplantation is a very complicated and delicate work. The organization of preoperative liver transplantation team is very important. It usually consists of donor liver, liver and anesthesia. The departments involved in collaboration should include at least pediatric surgery, hepatobiliary surgery, and heart. Surgery, laboratory, hematology, microbiology and immunization, blood bank, pathology, radiology, pharmacy, etc., the cooperation between all these departments should be run through animal experiments before clinical liver transplantation. Surgical procedure 1. Acquisition of donor liver In adult liver transplantation, taking the left lobe of the liver as a donor liver is usually not sufficient, but it is feasible in children, adults with left or right hepatic liver transplantation. At present, there is no recognized standard for the minimum donor liver volume required for receptor survival at home and abroad. According to Professor Fan Shangda's experience, the minimum donor liver volume is 40% of the estimated liver volume of the recipient. At present, donor surgery has routinely eliminated autologous blood transfusion or no blood transfusion. The operation time has been greatly shortened compared with the initial stage of development. The recipient does not need to be transferred. The time of no liver and inferior vena cava can be controlled within 1 hour. After the abdomen, the liver should be freed according to the conventional hepatectomy method, and the first and second hepatic hilums should be dissected separately. If the right hepatic liver is prepared, the right hepatic vein, the middle hepatic vein, the right portal vein, the right hepatic artery and the right hepatic duct should be dissected. Be careful to free. When determining the tangential line of hepatectomy, the right hepatic hilum can be temporarily blocked, and the liver color change is used as a boundary, and it is cut with an ultrasonic knife. There is no uniform identification of whether the middle hepatic vein remains in the right hepatic liver transplantation. Normally, the middle hepatic vein should be included. Because of the drainage of the middle venous V and VIII segments, if the middle hepatic vein is not preserved, the right hepatic congestion may be caused. Affect its liver function. Cutting the liver parenchyma with an ultrasonic scalpel is a time-consuming task, but its greatest benefit is that it does not block the blood flow into the liver during surgery and avoid liver damage caused by ischemia and reperfusion. After the liver parenchyma was cut and separated, the right portal vein was infused (Lactate Ringer's solution), placed in a pot containing ice crumbs, and the UW solution was used to perfuse the right portal vein and biliary tract. The full perfusion of the biliary tract is beneficial to avoid or reduce. Postoperative biliary stricture occurred. In order to reduce the damage to the intima of the hepatic artery to reduce the possibility of thrombosis after surgery, the hepatic artery can be irrigated. Before the donor is placed, the small bile duct of the liver section should be carefully examined (can be observed through the gallbladder injection), and the corresponding suture treatment. The remaining left hepatic section must be carefully stopped to stop and open all open bile ducts. 2. Liver implantation If the parental donor liver retains the hepatic vein, the right hepatic vein is first anastomosed to the recipient inferior vena cava or right hepatic vein, and then the hepatic vein is anastomosed to the left hepatic vein of the recipient. Before the completion of the anastomosis, albumin is perfused through the portal vein to eliminate the accumulation of gas in the lumen and the remaining preservation solution, to prevent possible air embolism and hyperkalemia, followed by anastomosis of the portal vein and hepatic artery. After the above three venous anastomosis is completed, the expansion factor technique should be used in the knotting to facilitate the expansion of the anastomosis after the blood flow is opened, and to prevent the anastomotic stenosis. The anastomosis of the hepatic vein should be appropriate for the length. If the right hepatic vein is too long, the blood flow may be distorted after recovery. Due to the small hepatic artery in children, microsurgical techniques can be applied during anastomosis. After all the vascular anastomosis is completed and the blood flow is restored, the blood flow is checked by ultrasound Doppler during the operation. The reconstruction of the bile duct can be performed by end-to-end anastomosis or biliary anastomosis. Regarding the intraoperative venous bypass problem, it has been shown that no transfusion technique is applied, and the circulation can be effectively maintained for 2 hours. As for renal dysfunction, it can gradually recover after surgery, and hemodialysis is feasible once renal failure occurs. complication The most common complications after liver transplantation are pulmonary complications, intra-abdominal hemorrhage and vascular complications, biliary complications, rejection, and non-functioning liver transplantation. 1. Prevention of pulmonary complications After returning to the ICU ward after surgery, the tracheal intubation could not be removed. The setting of the ventilator should set the number of assisted ventilation according to the spontaneous breathing frequency of the sick child, the continuous detection of blood oxygen saturation saturation, and the blood gas analysis result. In adults, it is usually necessary to assist ventilation 2 times every 3 times for spontaneous breathing. Children can refer to it. The oxygen saturation should be maintained above 95%, and the oxygen concentration should be 40% to 70%. In order to wake up the sick child as soon as possible, heat preservation measures should be taken. The tracheal intubation is generally removed within 24 hours. At the initial stage after the operation, the results of the blood gas analysis should be obtained as soon as possible in order to adjust the ventilator settings immediately. After each setting of the ventilator, the blood gas analysis is periodically reviewed and the ventilator is accordingly Setting for fine-tuning, minimum ventilation and maximum airway pressure testing help to judge the lungs. Atelectasis is the most likely to occur after surgery, mostly due to weak self-breathing and the inability of tracheal secretions to be effectively discharged. Therefore, routine chest X-ray examination should be performed every day after surgery. Once the atelectasis occurs, it is necessary to strengthen the cough for the sick child, turn over the back regularly, and let the sick child blow a balloon to make the lungs expand better. The best way to prevent atelectasis is to avoid premature extubation. The timing of extubation should be maintained to maintain airway patency until the lungs function enough to allow the lungs to fully expand. Of course, it is also necessary to refer to the blood oxygen analysis parameters after the shutdown. After the completion of the liver transplantation, the reopening of the blood flow significantly increased the blood flow into the inferior vena cava through the hepatic vein, resulting in a significant increase in cardiac preload. In the stage of right heart function compensability, only pulmonary hypertension and pulmonary congestion were observed. Once decompensated, heart failure occurs. The drug treatment for dilating the vein to reduce the preload should be taken for this purpose. At this time, the participation of specialists in cardiology is indispensable. In the unextracted stage of tracheal intubation, the management of tracheal intubation is very important. Once the chest radiograph shows a change in lung inflammation, effective antibiotics should be selected in a targeted manner. In the case of a large amount of postoperative immunosuppressive agents and a long-term application of broad-spectrum antibiotics, fungal or viral pneumonia may occur. To avoid the above problems, the best way is to find the immunosuppressant as soon as possible after the operation. The most suitable amount and avoid long-term use of broad-spectrum antibiotics. Antifungal and antiviral agents should be used in the event of an occurrence. 2. Evaluation of liver function Functional evaluation of transplanted liver is an important part of postoperative management. Generally, comprehensive judgment can be made by the amount of bile, the color, the mental state of the sick child, the presence or absence of acidosis, and the recovery of liver and kidney function and coagulation function. The amount and color of bile is an important index for judging the function of new liver. The transplanted liver with better function should have more than 100ml of bile in 24h, and the bile is golden yellow and thick, the amount of bile is very small, and the color is pale green or watery. It indicates that liver function is very poor. The levels of serum aminotransferase (ALT and AST) were positively correlated with the degree of hepatic ischemia damage. After 2 to 3 days, the transaminase peaked and then decreased rapidly, indicating that liver function was good. If the transaminase does not fall and continues to rise, more than 500 U / L, or even deeper jaundice, it indicates poor liver function. Children with renal insufficiency before surgery have good liver function after transplantation, and renal function can be restored immediately or gradually. Immediate renal insufficiency after surgery often indicates early liver failure. For the water, electrolyte and acid-base imbalance that may occur in the early stage of transplantation, liver function is good, and it can be corrected within 24 to 48 hours, and the appearance of refractory acidosis indicates early liver dysfunction. Coagulation function is normal before surgery. If the transplanted new liver function is good, the coagulation function can be normal on the second day after surgery. The early liver transplant function is mainly characterized by different degrees of coma, renal failure and acidosis. Sustained abnormalities in coagulation function, little or no bile, and progressive elevation of serum transaminase. The main reasons for the non-function of liver implantation can be summarized as follows: 1 the warm ischemia time is too long when the donor liver is taken; 2 the cold perfusion and preservation injury of the donor liver; 3 the large blood vessel embolization after transplantation, mainly the hepatic artery embolization. A second liver transplant should be performed as soon as possible. 3. Treatment of intra-abdominal bleeding Intra-abdominal hemorrhage is a common problem after liver transplantation. The reason may be the lack of certain technical links in the operation or the inability of the new liver to synthesize clotting factors in the early stage after transplantation. The diagnosis of intra-abdominal hemorrhage mainly depends on the life of the sick child. Signs, hemodynamics, hematocrit, and peritoneal drainage were observed carefully and continuously. If there is a large amount of bleeding in a short period of time, it may be judged that there may be active bleeding. It should be disconnected from the abdomen to stop bleeding. The bleeding points found are sutured or clamped to stop bleeding. If the wound is extensively oozing and there is no active bleeding point, heat should be used. The saline gauze is packed for 20 to 30 minutes, and then the argon knife is used to spray the wound or spray the fibrin gel. After the above treatment, the blood can be stopped. The combined use of fresh frozen plasma, platelets, fresh blood and various hemostatic drugs is also very important. The most important thing to prevent postoperative bleeding is the strict hemostasis at every stage of the operation. The anastomosis of each blood vessel must be foolproof. 4. Prevention of vascular occlusion Hepatic artery thrombosis in children with liver transplantation is more likely than adult liver transplantation because the child's hepatic artery is finer. Due to improper technique of anastomosis or arterial spasm, the anastomotic stenosis can lead to thrombosis and complete obstruction of the hepatic artery. It can cause liver necrosis, elevated serum transaminase, sudden decrease in bile secretion, and severe acute liver failure. Hepatic artery thrombosis may also be a recessive process, with repeated fever and progressive increase in transaminases. Because the nutrient vessels of the common bile duct are mainly from the hepatic artery, once the hepatic artery thrombosis occurs, it can lead to arrhythmia of the common bile duct and cause complications such as bile leakage and the final bile duct stricture. The most effective method for clinical confirmation of hepatic artery embolization is color Doppler ultrasonography. If the hepatic artery has pulsatile blood flow, it indicates that the hepatic artery is not smooth, and celiac angiography can make a definitive diagnosis. Prevention of hepatic artery thrombosis usually followed by intravenous infusion of dextran-40 (10ml / h, continuous intravenous infusion for 1 to 2 weeks), or subcutaneous injection of heparin, while oral aspirin (150mg, 3 / d), oral dipyridamole ( Pan Shengding) (75mg, 3/d), maintained for 4 weeks. Once hepatic artery embolization occurs, emergency diagnosis and treatment, feasible hepatic artery reconstruction, that is, the hepatic artery of the donor liver and the recipient's abdominal aorta end-to-side anastomosis, and secondary liver transplantation is performed under conditions. Portal vein thrombosis is less likely to occur than hepatic artery thrombosis, mostly due to improper operation of the operation, such as damage to the portal wall, anastomotic stenosis or distortion after anastomosis. The main clinical manifestations are hepatic ischemia and portal hypertension, liver dysfunction, and rapid formation of ventral ascites. B-ultrasound can be used to confirm the diagnosis, and it is feasible to take the operation to take the plug. When there is liver failure, the second liver transplantation is performed. 5. Deal with bile leakage The causes of bile leakage after transplantation are: 1 when the common end of the common bile duct is anastomosed, the anastomotic operation error or the anastomotic tension is too high; 2 the ischemic necrosis of the bile duct wall, often due to the donor liver trimming or the recipient disease liver resection when the common bile duct Excessive dissociation damages blood supply. Once bile leakage occurs, the child may have signs of peritonitis, fever, and peritoneal effusion. The leaking site is most common in the anastomosis or other parts of the bile duct away from the anastomosis, or it may be the T-tube outlet. Small bile leakage can be cured by effective abdominal drainage, severe bile leakage such as biliary peritonitis, B-ultrasound indicates a large amount of effusion in the abdominal cavity, surgery should be performed immediately, re-synchronization or diversion of the common bile duct jejunum Roux-Y anastomosis. If the biliary branch stump of the liver section of the liver transplantation is not ligated and causes bile leakage, it must be treated surgically. 6. Control rejection reaction The key to the success of liver transplantation is the effective control of immune rejection. Acute rejection usually occurs 6 to 10 days after surgery or at any time within 3 months after surgery. It is clinically non-specific, mainly characterized by fever, apathy, upper abdominal pain, jaundice, serum aminotransferase, alkaline phosphatase, -glutamate transpeptidase and bilirubin. B-ultrasound can prompt the liver volume to increase rapidly, the amount of bile drainage in the T-tube is sharply reduced, and the color is light and thin. Fine needle aspiration biopsy should be performed in clinically suspected acute rejection. The typical histological changes are a large number of activated lymphocytes infiltrating around the portal area and extending to the liver parenchyma. The central vein is surrounded by bile duct epithelium and vascular endothelium. There are interstitial edema and cholestatic around the liver lobules. Once diagnosed, methylprednisolone 1000mg was immediately treated with shock treatment for 2 to 3 days, and then decreased to maintenance. For hormone-resistant refractory rejection, anti-thymocyte immunoglobulin (ATG) shock therapy can be used for 4 to 5 days, and OKT3 can also be applied. Conventional anti-rejection treatment after surgery mostly uses "triple" therapy, namely methylprednisolone + cyclosporine A + azathioprine. Methylprednisolone started to take 200mg intravenously every time, 4/d, and then decreased by 40mg to 20mg daily, and then reduced after 1 month. Cyclosporine A 3 ~ 5mg / (kg · d) intravenously, azathioprine 1 ~ 1.5mg / (kg · d). The above drugs are used for 2 to 4 weeks. Blood levels should be monitored during medication. 7. Control infection In general, bacterial and fungal infections occur mostly 2 to 4 weeks after liver transplantation, while viral infections are mainly cytomegalovirus (CMV) infections, which occur more than 3 months after transplantation. The main reasons are as follows: 1 The use of immunosuppressive agents, especially large doses of hormones, reduces the body's immunity and is prone to infection; 2 intraoperative portal vein blockage leads to intestinal congestion, hypoxia, and intestinal defense barrier damage. Intestinal bacterial translocation into the abdominal cavity; 3 into the liver blood flow reconstruction and opening, a large number of bacteria and endotoxin into the portal vein; 4 bile duct jejunal anastomosis process contamination; 5 long-term use of broad-spectrum antibiotics lead to fungal infection. Among the bacterial infections, the most common bacteria are Escherichia coli, Proteus, Enterococcus, Pneumococci and Staphylococcus aureus. However, most of them are mixed infections, and their clinical manifestations may include pulmonary infection, incision and intra-abdominal infection, liver abscess, biliary tract infection, and severe systemic bacteremia and sepsis. For the infection of different parts mentioned above, according to the bacterial culture and drug sensitivity test, rational use of antibiotics. Drainage occurs immediately in the abdominal cavity or in the liver with a localized abscess. Fungal infections occur mostly in children with early liver transplantation with liver dysfunction or early postoperative bacterial infection. Common fungi are Candida and Aspergillus. The clinical manifestations are high fever, generally anti-infective treatment is ineffective, the lungs are shaded on the chest radiograph, and fungi are found in the incision, drainage tube bile, and ascites. In order to prevent fungal infections, intestinal decontamination treatment is feasible during the perioperative period, and fluconazole can be administered orally. When a fungal infection occurs, you can use Dafukang. The drug has liver and kidney toxicity and should not be used for a long time. It should not exceed 2 weeks at most. Cytomegalovirus infection is more common in children after liver transplantation. The reason is that 2/3 of the natural population is asymptomatic CMV carriers, due to low immunity of the body after transplantation, viral activation or brought in due to blood transfusion. The probability of morbidity is higher when the donor CMV antibody is positive and the receptor CMV antibody is negative. The main clinical manifestations are fever, leukopenia, thrombocytopenia, abnormal liver function, diarrhea may occur in sick children, that is, CMV enteritis, and focal pneumonia may also occur. The diagnosis uses the monoclonal antibody and the virus early antigen binding method, and the CMV positive can be detected by indirect immunofluorescence test, and the clinical manifestation can be confirmed. At present, intravenous infusion of ganciclovir is commonly used in the treatment, and CMV immunoglobulin is also applied. 8. Prevention and treatment of renal insufficiency Most occur within 1 week after surgery, about half of the children are caused by the application of chondroitin A (CSA), other causes are severe trauma, hemorrhagic shock, donor liver function and nephrotoxic antibiotics. The clinical manifestations are oliguria or anuria, and blood urea nitrogen and creatinine are progressively elevated. The first application of diuretics in treatment, if not corrected, consider hemodialysis.