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Hosaagrahara Ramakrishna S, Hassan A, Kasala MB, Perumal K, Venkategowda C, Malleeswaran S, Periasamy M, Kaliyaperumal M, Patcha RV, Varghese J, Reddy MS. Pediatric combined living donor liver and kidney transplantation for primary hyperoxaluria type 2. Am J Transplant 2023; 23:1622-1625. [PMID: 37187295 DOI: 10.1016/j.ajt.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 05/03/2023] [Accepted: 05/11/2023] [Indexed: 05/17/2023]
Abstract
We report the case of a 12-year-old boy with primary hyperoxaluria type 2 (PH2) presenting with end-stage renal disease and systemic oxalosis who underwent a combined living donor liver and kidney transplant from 3 donors, 1 of whom was a heterozygous carrier of the mutation. Plasma oxalate and creatinine levels normalized immediately following the transplant and remain normal after 18 months. We recommend combined liver and kidney transplantation as the preferred therapeutic option for children with primary hyperoxaluria type 2 with early-onset end-stage renal disease.
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Affiliation(s)
| | - Akhila Hassan
- Department of Pediatrics Mazumdar Shaw Medical Centre, Narayana Health City, Bommasandra, Bangalore, India
| | - Mohan Babu Kasala
- Department of Pediatric Intensive Care, Gleneagles Global Health City, Perumbakkam, Chennai, India
| | - Karnan Perumal
- Department of Pediatric Intensive Care, Gleneagles Global Health City, Perumbakkam, Chennai, India
| | - Chaitra Venkategowda
- Department of Liver Anesthesia and Critical Care, Gleneagles Global Health City, Perumbakkam, Chennai, India
| | - Selvakumar Malleeswaran
- Department of Liver Anesthesia and Critical Care, Gleneagles Global Health City, Perumbakkam, Chennai, India
| | - Muthukumar Periasamy
- Department of Nephrology, Gleneagles Global Health City, Perumbakkam, Chennai, India
| | | | - Rajanikanth V Patcha
- Department of Liver Transplant and Hepatopancreaticobiliary Surgery, Gleneagles Global Health City, Perumbakkam, Chennai, India
| | - Joy Varghese
- Department of Hepatology and Liver Transplant, Gleneagles Global Health City, Perumbakkam, Chennai, India
| | - Mettu Srinivas Reddy
- Department of Liver Transplant and Hepatopancreaticobiliary Surgery, Gleneagles Global Health City, Perumbakkam, Chennai, India
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Malleeswaran S, Sivajothi S, Reddy MS. Viscoelastic Monitoring in Liver Transplantation. Liver Transpl 2022; 28:1090-1102. [PMID: 34724319 DOI: 10.1002/lt.26352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 10/21/2021] [Accepted: 10/27/2021] [Indexed: 12/13/2022]
Abstract
Cirrhosis and liver transplantation (LT) surgery are associated with substantial alterations to the patient's coagulation status. Accurate monitoring of these changes during LT can help manage bleeding proactively and potentially reduce transfusion requirements. Unlike conventional coagulation tests (CCTs), viscoelastic monitoring (VEM) can provide an accurate, real-time, point-of-care assessment of coagulation status during LT and hence has become an invaluable tool for anesthetists and intensive care physicians. However, it remains an enigmatic subject for transplantation surgeons who are more conversant with CCTs. This review discusses the principles of VEM, provides a primer to understanding and interpreting its output, and explains how it can be used to make real-world clinical decisions during LT.
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Affiliation(s)
- Selvakumar Malleeswaran
- Department of Liver Anesthesia and Critical Care, Institute of Liver Diseases and Transplantation, Gleneagles Global Health City, Chennai, India
| | - Sivanesan Sivajothi
- Department of Liver Anesthesia and Critical Care, Institute of Liver Diseases and Transplantation, Gleneagles Global Health City, Chennai, India
| | - Mettu Srinivas Reddy
- Department of Hepatobiliary Surgery and Liver Transplantation, Institute of Liver Diseases and Transplantation, Gleneagles Global Health City, Chennai, India
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Krishnan SK, Mouleeswaran KS, Gopal P, Patcha R, Ramakrishna SH, Karnan P, Malleeswaran S, Varghese J, Reddy MS. First Report of a Paediatric Collision Tumour in the Liver Recognised After Liver Transplantation: Blissful Ignorance Has Benefits! J Clin Exp Hepatol 2022; 12:696-700. [PMID: 35535070 PMCID: PMC9077198 DOI: 10.1016/j.jceh.2021.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 05/19/2021] [Indexed: 12/12/2022] Open
Abstract
Liver tumours are uncommon in the paediatric population, constituting 1-2 % of all paediatric tumours and 4% of all paediatric liver tumours. Hepatoblastoma followed by hepatocellular carcinoma is the most common tumours in this age group. Simultaneous development of two discrete liver tumours of distinct histologies (collision tumour) has been occasionally reported in adults but never in children. We hereby present the first reported case of hepatic collision tumours (hepatocellular carcinoma and cholangiocarcinoma) in the explant liver of a child who underwent living donor liver transplantation for end-stage liver disease and severe hepatopulmonary syndrome. The manuscript describes the clinical, radiological and histopathological findings of this case and also highlights the dilemma associated with management of this case had the diagnosis been made in the preoperative setting and also about the proposed management plan for this case in the postoperative period.
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Key Words
- AFP, alpha fetoprotein
- CA 19-9, carbohydrate antigen
- CC, cholangiocarcinoma
- CECT, contrast-enhanced computed tomography
- CPAP, continuous positive airway pressure
- Ck, cytokeratin
- HCC, hepatocellular carcinoma
- HPS, hepatopulmonary syndrome
- LDLT, living donor liver transplantation
- LT, liver transplant
- MAA scan, macro albumin aggregate scan
- PELD, pediataric end-stage liver disease score
- POD, postoperative day
- UCSF, University of California San Francisco
- UGI, upper gastrointestinal
- cholangiocarcinoma
- collision tumour
- hepatocellular carcinoma
- liver transplant
- paediatric liver transplant
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Affiliation(s)
- Sathish K. Krishnan
- Department of Liver Transplant and Hepatopancreatico Biliary Surgery, Gleneagles Global Health City, Chennai, India
| | | | - Prasanna Gopal
- Department of Liver Transplant and Hepatopancreatico Biliary Surgery, Gleneagles Global Health City, Chennai, India
| | - Rajanikanth Patcha
- Department of Liver Transplant and Hepatopancreatico Biliary Surgery, Gleneagles Global Health City, Chennai, India
| | - Somashekara H. Ramakrishna
- Department of Peadiatric Hepatology and Pediatric Intensive Care, Gleneagles Global Health City, Chennai, India
| | - Perumal Karnan
- Department of Peadiatric Hepatology and Pediatric Intensive Care, Gleneagles Global Health City, Chennai, India
| | - Selvakumar Malleeswaran
- Department of Liver Anaesthesia and Critical Care, Gleneagles Global Health City, Chennai, India
| | - Joy Varghese
- Department of Hepatology and Liver Transplant, Gleneagles Global Health City, Chennai, India
| | - Mettu S. Reddy
- Department of Liver Transplant and Hepatopancreatico Biliary Surgery, Gleneagles Global Health City, Chennai, India
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Hosaagrahara Ramakrishna S, Kasala MB, Perumal K, Malleeswaran S, Patcha RV, Varghese J, Sathiyasekaran M, Reddy MS. When Push Comes to Shove! Emergency ABO-Incompatible Pediatric Living Donor Liver Transplant for Acute Wilson's Disease. J Clin Exp Hepatol 2022; 12:658-663. [PMID: 35535085 PMCID: PMC9077158 DOI: 10.1016/j.jceh.2021.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 08/09/2021] [Indexed: 12/12/2022] Open
Abstract
ABO-incompatible living donor liver transplantation (ABOi-LDLT) is on the rise as a viable option in countries with limited access to deceased donor grafts. While reported outcomes of ABOi-LT in children are similar to ABO- Compatible liver transplant (ABOc-LT), most children beyond 1-2 years of age will need desensitization to overcome the immunological barrier of incompatible blood groups. The current standard protocol for desensitization is Rituximab that targets B lymphocytes and is given 2-3 weeks prior to LT. However, this timeline may not be feasible in children requiring emergency LT for acute liver failure (ALF) or acute-on-chronic liver failure (ACLF). In this emergency situation of ABOi-LT, a safe multipronged approach may be an acceptable alternative solution. We report a child with acute Wilson's disease with rapidly deteriorating liver function who underwent a successful ABOi-LDLT using a rapid desensitization protocol.
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Key Words
- ABOc-LT, ABO-compatible liver transplantation (ABOi-LDLT)
- ABOi-LDLT, ABO-incompatible living donor liver transplantation
- ACLF, Acute-on-chronic liver failure
- ALF, Acute liver failure
- AMR, Antibody-mediated rejection
- CMV, Cytomegalovirus
- CSF, Cerebrospinal fluid
- GRWR, Graft-to-recipient weight ratio
- LDLT, Living donor liver transplantation
- LT, Liver transplant
- MMF, Mycophenolate mofetil
- PVT, Portal vein thrombosis
- Rituximab
- acute Wilson’s disease
- acute-on-chronic liver disease
- emergency ABOi-LDLT
- living donor liver transplantation
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Affiliation(s)
| | - Mohan Babu Kasala
- Department of Pediatric Intensive Care, Gleneagles Global Health City, Perumbakkam, Chennai, India
| | - Karnan Perumal
- Department of Pediatric Intensive Care, Gleneagles Global Health City, Perumbakkam, Chennai, India
| | - Selvakumar Malleeswaran
- Liver Anesthesia and Critical Care, Gleneagles Global Health City, Perumbakkam, Chennai, India
| | - Rajanikanth V Patcha
- Department of Liver Transplant and Hepatopancreaticobiliary Surgery, Gleneagles Global Health City, Perumbakkam, Chennai, India
| | - Joy Varghese
- Department of Hepatology and Liver Transplant, Gleneagles Global Health City, Perumbakkam, Chennai, India
| | - Malathy Sathiyasekaran
- Senior Pediatric Gastroenterologist, MGM, Rainbow and Kanchi Kamakoti CHILDs Trust Hospitals, Chennai, India
| | - Mettu Srinivas Reddy
- Department of Liver Transplant and Hepatopancreaticobiliary Surgery, Gleneagles Global Health City, Perumbakkam, Chennai, India
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Ramakrishna SH, Kasala MB, Perumal K, Malleeswaran S, Patcha RV, Varghese J. Living-Donor Liver Transplantation for Late-Onset Lysosomal Acid Lipase Deficiency. J Clin Exp Hepatol 2022; 12:672-676. [PMID: 35535100 PMCID: PMC9077196 DOI: 10.1016/j.jceh.2021.06.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 06/28/2021] [Indexed: 12/12/2022] Open
Abstract
Late-onset liposomal acid lipase deficiency (LAL deficiency), previously known as Cholesteryl ester storage disease (CESD) is a rare genetic lysosomal storage disorder caused by deficiency of lysosomal acid lipase (LAL) due to mutations in the LIPA gene. LAL deficiency is a systemic disease that leads to the accumulation of fat and inflammation in the liver, premature atherosclerosis and gastrointestinal disease. Most of the patients require liver transplantation due to decompensated cirrhosis. Enzyme replacement therapy has been approved and is available in many countries. Here we describe a 16-year-old patient who was diagnosed to have late-onset LAL deficiency when he presented to us with ESLD. Subsequently, he underwent a living-donor liver transplant (LDLT) successfully. We discuss the ethical dilemmas in considering LDLT for LAL deficiency.
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Key Words
- CE, Cholesteryl ester
- CESD
- CESD, Cholesteryl ester storage disease
- CT, Computerized tomography
- ESLD, End-stage liver disease
- GRWR, Graft to recipient weight
- HDL, High-density lipoprotein
- LAL, Lysosomal acid lipase
- LAL-D, Lysosomal acid lipase deficiency
- LDL, Low-density lipoprotein
- LDLT
- LDLT, Living-donor liver
- LT, Liver transplant
- NGS, Next-generation sequencing
- PAS-D, Periodic acid-Schiff-diastase
- WD, Wolman disease
- late-onset LAL deficiency
- liver transplantation
- sebelipase alfa
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Affiliation(s)
| | - Mohan B. Kasala
- Department of Pediatric Intensive Care, Gleneagles Global Health City, Perumbakkam, Chennai, India
| | - Karnan Perumal
- Department of Pediatric Intensive Care, Gleneagles Global Health City, Perumbakkam, Chennai, India
| | - Selvakumar Malleeswaran
- Liver Anesthesia and Critical Care, Gleneagles Global Health City, Perumbakkam, Chennai, India
| | - Rajanikanth V. Patcha
- Department of Liver Transplant and Hepatopancreaticobiliary Surgery, Gleneagles Global Health City, Perumbakkam, Chennai, India
| | - Joy Varghese
- Department of Hepatology and Liver Transplant, Gleneagles Global Health City, Perumbakkam, Chennai, India
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Varghese J, Malleeswaran S, Patcha RV, Appusamy E, Karnan P, Kapoor D, Venugopal K, Kedarisetty CK, Singh B, Rao PS, Yalakanti RB, Mohanka R, Shrimal A, Nikam V, Kumar K, Shenvi SD, Venugopal BP, Heaton ND. A Multicentric Experience on Living Donor Liver Transplantation in Coronavirus Disease 2019 Hotspots in India. Liver Transpl 2021; 27:1334-1338. [PMID: 33253477 PMCID: PMC7753810 DOI: 10.1002/lt.25957] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 10/21/2020] [Accepted: 11/16/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Joy Varghese
- Institute of Liver Disease & TransplantationGleneagles Global Health CityChennaiIndia
| | | | - Rajanikanth V. Patcha
- Institute of Liver Disease & TransplantationGleneagles Global Health CityChennaiIndia
| | - Ellango Appusamy
- Institute of Liver Disease & TransplantationGleneagles Global Health CityChennaiIndia
| | - Perumal Karnan
- Institute of Liver Disease & TransplantationGleneagles Global Health CityChennaiIndia
| | - Dharmesh Kapoor
- Department of Hepatology & TransplantationGleneagles Global Health CityHyderabadIndia
| | - Kota Venugopal
- Department of Hepatology & TransplantationGleneagles Global Health CityHyderabadIndia
| | | | - Balbir Singh
- Department of Hepatology & TransplantationGleneagles Global Health CityHyderabadIndia
| | - Prashantha S. Rao
- Department of Hepatology & TransplantationGleneagles Global Health CityHyderabadIndia
| | | | - Ravi Mohanka
- Department of Liver Transplant & Hepatobiliary SurgeryGleneagles Global Health CityMumbaiIndia
| | - Anurag Shrimal
- Department of Liver Transplant & Hepatobiliary SurgeryGleneagles Global Health CityMumbaiIndia
| | - Vinayak Nikam
- Department of Liver Transplant & Hepatobiliary SurgeryGleneagles Global Health CityMumbaiIndia
| | - Karan Kumar
- Department of Hepato‐pancreato‐biliary & Transplant SurgeryBGS Gleneagles Global HospitalBengaluruIndia
| | - Sunil D. Shenvi
- Department of Hepato‐pancreato‐biliary & Transplant SurgeryBGS Gleneagles Global HospitalBengaluruIndia
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Varghese J, Joshi V, Bollipalli MK, Malleeswaran S, Patcha R, Nair H, Vij V, Sachan D, Subramanian P, Jain M, Venkataraman J. Role of therapeutic plasma exchange in acute liver failure due to yellow phosphorus poisoning. Indian J Gastroenterol 2020; 39:544-549. [PMID: 33409946 PMCID: PMC7787244 DOI: 10.1007/s12664-020-01095-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 09/14/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Therapeutic plasma exchange (TPE) has been utilized in various liver disorders. There is limited data on the efficacy of TPE in patients with acute liver failure (ALF). METHODS Study group consisted of patients who underwent TPE for ALF due to yellow phosphorous poisoning (YPP) between 2015 and 2019. Demographic data and biochemical parameters were recorded before and after TPE. Overall survival and transplant-free survival (based on King's College Hospital Criteria [KCHC]) were analyzed. RESULTS Forty-three patients underwent TPE for ALF due to YPP. Most of them were young males. Overall survival was 34 (79.06%). In our study population, 20 patients fulfilled KCHC (Group A) and 23 did not fulfill KCHC (Group B). Both the groups showed significant improvement in alanine aminotransferase, aspartate aminotransferase, and international normalized ratio (INR) after TPE (p < 0.05). In Group B, there was significant improvement in ammonia after TPE (p < 0.05) and all 23 patients (100%) survived after TPE. In Group A, 4 underwent liver transplantation (LT), 7 survived without LT, and the remaining 9 died without LT. Mean survival after completing TPE was 41.2 ± 44.5 days in Group A and 90 days in Group B. This difference was statistically significant (p = 0.001). There was statistically significant difference in post-TPE values of INR (p = 0.012) and ammonia (p = 0.011) between non-survivors and survivors. Adverse events such as hypotension (11.62%) and minor allergic reaction (4.65%) were managed conservatively. CONCLUSION TPE is an effective procedure in ALF due to YPP, not fulfilling KCHC for LT. In KCHC fulfilled group, though it shows LT-free survival benefit, there is requirement of prospective, large volume, multi-center study to assess its efficacy.
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Affiliation(s)
- Joy Varghese
- Department of Hepatology and Transplant Hepatology, Institute of Liver Diseases and Transplantation, Gleneagles Global Health City, Chennai 600 100, India
| | - Vivek Joshi
- Department of Hepatology and Transplant Hepatology, Institute of Liver Diseases and Transplantation, Gleneagles Global Health City, Chennai 600 100, India
| | | | - Selvakumar Malleeswaran
- Department of Liver Anesthesia and ICU, Gleneagles Global Health City, Chennai 600 100, India
| | - Rajinikanth Patcha
- Department of HPB and Transplantation, Gleneagles Global Health City, Chennai 600 100, India
| | - Harikumar Nair
- Department of Hepatology and Transplant Hepatology, Institute of Liver Diseases and Transplantation, Gleneagles Global Health City, Chennai 600 100, India
| | - Vivek Vij
- Department of HPB and Transplantation, Gleneagles Global Health City, Chennai 600 100, India
| | - Deepti Sachan
- Department of Transfusion Medicine, Dr. Rela Institute and Medical Centre, Chennai 600 044, India
| | - Pushkala Subramanian
- Department of Immunology, The Tamil Nadu Dr. MGR University, Chennai 600 032, India
| | - Mayank Jain
- Department of Hepatology and Transplant Hepatology, Institute of Liver Diseases and Transplantation, Gleneagles Global Health City, Chennai 600 100, India
| | - Jayanthi Venkataraman
- Department of Hepatology, Sri Ramachandra Institute for Higher Education and Research, Chennai 600 116, India
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Rajakumar A, Gupta S, Malleeswaran S, Varghese J, Kaliamoorthy I, Rela M. Anaesthesia and intensive care for simultaneous liver-kidney transplantation: A single-centre experience with 12 recipients. Indian J Anaesth 2016; 60:476-83. [PMID: 27512163 PMCID: PMC4966351 DOI: 10.4103/0019-5049.186025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background and Aims: The perioperative management of patients presenting for simultaneous liver and kidney transplantation (SLKT) is a complex process. We analysed SLKTs performed in our institution to identify preoperative, intraoperative and post-operative challenges encountered in the management. Methods: We retrospectively studied the case records of 12 patients who underwent SLKT between 2009 and 2014 and analysed details of pre-operative evaluation and optimisation, intraoperative anaesthetic management and the implications of use of perioperative continuous renal replacement therapy (CRRT) and the post-operative course of these patients. Results: Of the total 12 cases, 4 were under 16 years of age. The indications for SLKT were primary hyperoxaluria (5), congenital hepatic fibrosis with polycystic kidney disease (2), ethanol-related end-stage liver disease (ESLD) with hepatorenal syndrome type 1 (1). Four patients had ESLD with end-stage renal disease due to other causes. Six recipients received live donor grafts and 6 patients received cadaveric grafts. Seven patients received intraoperative CRRT. Mean duration of surgery was 12.5 h. Cardiac output monitors used were trans-oesophageal echocardiogram (2), pulmonary artery catheter (1) and pulse contour cardiac output monitor (3). There was 1 sepsis-related mortality on 7th post-operative day. Conclusion: A thorough pre-operative evaluation and optimisation, knowledge and anticipation of potential problems, and meticulous intraoperative fluid management guided by appropriate monitoring and use of CRRT when needed can help in achieving successful outcomes.
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Affiliation(s)
- Akila Rajakumar
- Department of Liver Transplant Anaesthesia and Intensive Care, Institute of Liver Disease and Transplantation, Global Health City, Chennai, Tamil Nadu, India
| | - Shiwalika Gupta
- Department of Liver Transplant Anaesthesia and Intensive Care, Institute of Liver Disease and Transplantation, Global Health City, Chennai, Tamil Nadu, India
| | - Selvakumar Malleeswaran
- Department of Liver Transplant Anaesthesia and Intensive Care, Institute of Liver Disease and Transplantation, Global Health City, Chennai, Tamil Nadu, India
| | - Joy Varghese
- Department of Hepatology, Institute of Liver Disease and Transplantation, Global Health City, Chennai, Tamil Nadu, India
| | - Ilankumaran Kaliamoorthy
- Department of Liver Transplant Anaesthesia and Intensive Care, Institute of Liver Disease and Transplantation, Global Health City, Chennai, Tamil Nadu, India
| | - Mohamed Rela
- Department of Hepatobiliary and Liver Transplant Surgery, Institute of Liver Disease and Transplantation, Global Health City, Chennai, Tamil Nadu, India; Department of Hepatobiliary and Liver Transplant Surgery, Institute of Liver Studies, King's College, London
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