Acta Med. Okayama, 2024
Vol. 78, No. 4, pp. 323‑330
CopyrightⒸ 2024 by Okayama University Medical School.

Original Article

http://escholarship.lib.okayama-u.ac.jp/amo/

Effect of Recipient Age on Perioperative Complications after Pediatric Liver
Transplantation: A Single-Center Retrospective Study
Akira Katayamaa, Satoshi Kimurab, Takashi Matsusakic, and Hiroshi Morimatsua＊aDepartment of Anesthesiology and Resuscitology, Okayama University Graduate School of Medicine,
Dentistry and Pharmaceutical Sciences, Okayama 700-8558, Japan,b
Department of Anesthesia, Kyoto University Hospital, Kyoto 606-8507, Japan,c
Department of Anesthesiology, Mie University Hospital, Tsu 514-8507, Japan

It has not been clear how recipient age affects the incidence of serious complications after pediatric living donorliver transplantation (LDLT). We investigated the records of 42 pediatric patients receiving LDLT, dividing oursample into two groups: the infant group (aged < 1 year) and the non-infant group (aged ≥ 1 year and ≤ 15
years). The primary outcome was postoperative complications assessed using the Clavien-Dindo classification.
Multivariate analysis using the Cox regression model was applied to adjust for confounding factors in assessing
the incidence of Clavien-Dindo grade ≥ III (C-D ≥ III) complications. The incidence of C-D ≥ III complications
was higher in the non-infant group (46.2%) than in the infant group (12.5%) (odds ratio 6.00, 95% confidence
interval [CI] 1.13-31.88, p = 0.03). In multivariate analysis using the Cox regression model, the Graft-toRecipient Weight Ratio (GRWR) was independently associated with the incidence of C-D ≥ III complications(hazard ratio [HR] 0.62, 95%CI 0.40-0.95, p = 0.03), but being an infant was not (HR 0.84, 95%CI 0.35-1.98,
p = 0.68). In conclusion, the incidence of C-D ≥ III complications was higher in the non-infant group than in
the infant group, but this was largely a function of GRWR: multivariate analysis revealed that GRWR was
independently associated with complications.
Key words: pediatric liver transplantation, postoperative severe complications, Graft-to-Recipient Weight Ratio

Liver transplantation is the treatment of choice forboth adults and children with end-stage liver disease. Liver transplantation outcomes have gradually
improved owing to developments in surgical techniques, perioperative management, and immunosuppressive agents [1]. Survival rates after living donorliver transplantation are higher in children than in
adults [2]. However, young age and/or low body weight
are risk factors for high mortality and graft loss, especially in pediatric liver transplantation [3]. Therefore,
the Pediatric End-stage Liver Disease (PELD) score was
Received January 18, 2024 ; accepted May 7, 2024.
Corresponding author. Phone : +81-86-235-7778; Fax : +81-86-235-6984
E-mail : pb9b45wr@s.okayama-u.ac.jp (H. Morimatsu)＊

developed, using the 3-month pre-liver transplantationmortality risk as the endpoint. The PELD score contains the component ‘age’, with patients under 1 year ofage being assigned an extra point in the PELD score[4 , 5]. Graft-to-Recipient Weight Ratio (GRWR) is
another important factor associated with graft function
after liver transplantation. The ideal range of GRWR is0.8-4% [6 , 7], and the use of small-for-size-grafts (< 1%)leads to lower graft survival, probably throughenhanced parenchymal cell injury and reduced metabolic and synthetic capacity [6]. This implies that asmaller recipient body weight is beneficial for graft surConflict of Interest Disclosures: No potential conflict of interest relevantto this article was reported.

324

Katayama et al.

vival because of a greater GRWR, essentially the reverse
assumption of the PELD score.
Therefore, we conducted a retrospective cohort
study to determine the incidence of serious postoperative complications after pediatric liver transplantation.
We hypothesized that a younger recipient age would not
be associated with a greater incidence of serious postoperative complications. In addition, we investigatedfactors associated with postoperative complications.

Materials and Methods
Study design.
In this single-center retrospective
observational study, we selected patients who underwent liver transplantation at Okayama University
Hospital between September 1, 2009 and November
30, 2020. This study was approved by the Institutional
Review Board of our hospital (approval number:
2301-009). The Committee waived the need for obtaining informed consent for studies involving the use of thehospital database. All regulations and measures of ethics and confidentiality were in accordance with the
Declaration of Helsinki.
Patient information and data collection.
We
included patients who were aged ≤ 15 years and had
undergone living donor liver transplantation at
Okayama University Hospital. Patients who had undergone multiple liver transplantations were excluded fromthe study. Data were extracted from the electronic
medical record system. We collected data on basic
patient characteristics (age, sex, height, weight, etiology, GRWR, and length of intensive care unit [ICU]
and hospital stays), preoperative pathological test
results, surgical information (operation time, cold
ischemic time, warm ischemic time, and anhepatictime), and anesthesia information (amount of red
blood cells [RBCs], fresh frozen plasma [FFP], plateletconcentrate [PC], and albumin administered, blood
loss, and urinary output). The incidence of ClavienDindo (C-D) classification grade ≥ III (C-D ≥ III) complications within 30 days was obtained through theelectronic medical records. The body weight used to
calculate the amount per kg body weight of RBCs, FFP,
PC, and albumin administered was derived from anesthetic records. Drainage volumes are routinely measured by ICU nurses every 2 h at each of four drains at
the foramen of Winslow, left and right subdiaphragm,
and bile duct, and were documented in the medical

Acta Med. Okayama Vol. 78, No. 4

record.
Anesthetic management.
All patients wereadministered general anesthesia with endotracheal
intubation. General anesthesia was induced using
50-100 mg thiopental and 4-5 μg/kg fentanyl with
0.6 mg/kg rocuronium to facilitate endotracheal intubation. Anesthesia was maintained with 1.5-2% sevoflurane and intermittent injections of fentanyl, andmuscle relaxation was achieved with intermittent injections of rocuronium. During the surgery, RBCs, FFP,
and PC were administered to maintain a hemoglobin
level of 8.0 g/dL, prothrombin activity % (PT%) of50%, and platelet count of 30,000/μL, respectively. All
patients were transferred to the ICU after surgery andintubated.
Immunosuppressive management.
Immuno­suppression was achieved according to the institutional
protocol. The basic immunosuppressive regimen comprised a calcineurin inhibitor (tacrolimus or cyclosporine) and corticosteroid (2 mg/kg/day). Additionally,
recipients of incompatible-blood-type grafts received
preoperative anti-CD20 antibody (rituximab, 375 mg/m2) and mycophenolate mofetil (20 mg/kg/day) withpreoperative blood exchange.
Definitions. We divided the study population
into two groups: infants and non-infants. The infantgroup included patients aged < 1 year, and the noninfant group included patients aged ≥ 1 year and ≤ 15
years.
We used the C-D classification to assess the severityof postoperative complications. Based on the type oftherapy needed for treatment [8], it consists of 7 grades(I, II, IIIa, IIIb, IVa, IVb, and V) with grade III complications requiring surgical, endoscopic, or radiological interventions (either with or without general anesthesia) [9]. In this study, we defined the C-D III or
more (C-D ≥ III) as the criterion for severe postoperative complications.
Travis et al. [10] validated the Sequential Organ
Failure Assessment (SOFA) score for critically ill pediatric patients using age-adjusted criteria. The pediatricSOFA (p-SOFA) score was used to quantify organ dysfunction.
Outcomes. The primary outcome was the incidence of C-D ≥ III complications within 30 days after
liver transplantation.
Secondary outcomes were the comparisons of theparameters associated with graft function, such as total

Perioperative Complications in Pediatric Liver Transplantation

August 2024

bilirubin level (T-Bil), aspartate aminotransferase(AST) level, alanine aminotransferase (ALT) level,
PT%, and drainage volume of ascites, between theinfant and non-infant groups from postoperative day(POD) 1 to POD7. We also compared the p-SOFA
scores between the infant and non-infant groups from
POD1 to POD7.
Statistical analysis.
Preoperative and operative
data exhibited an abnormal distribution; therefore,
they were expressed as medians and interquartile ranges
and compared using the Wilcoxon signed-rank test.
Categorical variables were expressed as number (proportion) and compared using Pearson’s chi-square test.
Multivariate Cox regression analyses were used to
explore factors independently associated with the incidence of C-D ≥ III complications within 30 days after
liver transplantation. GRWR, PELD score, and infant
age were included in the multivariate analysis. We
selected GRWR and the PELD score because they are
well known as predictors of liver transplantation outcomes. The occurrence of C-D ≥ III complications
within 30 days was assessed using the Kaplan-Meier
Table 1

method and compared using Cox regression analysis.
The postoperative liver function and p-SOFA score wereanalyzed using repeated measures analysis of variance.
Statistical analyses were performed using STATA/SE(version 17.0; Stata Corp., College Station, TX, USA)and JMP Pro (version 14.0; SAS Institute Inc., Tokyo).

Results
Patient characteristics.
Forty-three pediatricliver transplantations were performed during the study
period. Of these, 42 were analyzed after excluding one
patient who had undergone a second liver transplantation. The patient characteristics are shown in Table 1.
The median age of patients in the infant and noninfant groups was 6 (interquartile range, 3.5-8) and76.5 (22.8-109) months, respectively; no neonate waspart of the study. The patients were predominantly
male (62.5%) in the infant group while only 42.3%
patients in the non-infant group were male. The mostcommon disease requiring liver transplantation in bothinfant and non-infant groups was biliary atresia.

Perioperative clinical characteristics of pediatric liver transplantation recipientsAge (months), median [IQR]
Sex: Male, n (%)
Height (cm), median [IQR]
Weight (kg), median [IQR]
Disease, n (%)
Biliary atresia
Hepatoblastoma
Alagille syndrome
Others
ABO incompatibility, n (%)
History of surgery
Child-Pugh score, median [IQR]PELD score, median [IQR]
T-Bil (mg/dL), median [IQR]
D-Bil (mg/dL), median [IQR]
PT% (%), median [IQR]
PLT (104/μL), median [IQR]
Hb (g/dL), median [IQR]
AST level (U/L), median [IQR]
ALT level (U/L), median [IQR]
Alb level (g/dL), median [IQR]
Cr level (mg/dL), median [IQR]

325

Infant (n = 16)

Non-infant (n = 26)

P-value

6 [3.5, 8]
10 (62.5%)
63.2 [60.4, 65.9]
6.4 [5.9, 7.5]

76.5 [22.8, 109]
11 (42.3%)
111.6 [76.7, 129.6]
18.1 [9.8, 25.3]< 0.010.20< 0.01< 0.01

12 (75%)0 (0%)
0 (0%)
4 (25%)
4 (25%)
10 (62.5%)
10.5 [8.3, 11.8]
16.3 [11.2, 21.4]
11.7 [7.0, 20.0]
7.5 [4.0, 13.9]
56.5 [42.3, 84]
18.5 [11.6, 25.1]
8.9 [7.9, 10.3]
209.5 [122.5, 450.3]
88.5 [69.8, 236.5]
2.6 [2.2, 3.0]
0.15 [0.087, 0.17]

17 (65.4%)
3 (11.5%)
3 (11.5%)
3 (11.5%)
2 (7.7%)20 (76.9%)
7.5 [6.8, 8.3]
5.4 [1.4, 9.5]
3.1 [1.0, 8.8]
2.1 [0.34, 6.2]
88.0 [70.8, 98.5]
12.9 [7.3, 22.0]
9.6 [8.7, 11.1]
139.5 [72.0, 207.3]
85.5 [47.5, 159.5]
3.1 [2.8, 3.6]
0.26 [0.19, 0.31]

0.51
0.16
0.16
0.26
0.12
0.26
< 0.01< 0.01< 0.01< 0.01< 0.01
0.28
0.24
0.06
0.47
< 0.01<0.01

IQR, interquartile range; PELD, Pediatric End-stage Liver Disease; T-Bil, total bilirubin; D-Bil,direct bilirubin; PT, prothrombin time; PLT, platelets; Hb, hemoglobin; AST, aspartate aminotransferase; ALT, alanine aminotransferase; Alb, albumin; Cr, creatinine.

326

Katayama et al.

Acta Med. Okayama Vol. 78, No. 4

Preoperative severity of liver disease was significantly
worse in the infant group, including quantifying variables such as Child-Pugh score, PELD score, T-Billevel, direct bilirubin (D-Bil) level, PT%, and albumin
level.
Perioperative data.
Comparisons of perioperative data in the infant and non-infant groups are shownin Table 2. There were significant differences between
infant and non-infant groups in terms of intraoperative
data such as RBC transfusion (33.0 mL/kg vs. 21.3mL/kg; p = 0.02), operation time (401.0 min vs. 480.0 min;p = 0.02), and GRWR (3.5% vs. 2.3%; p < 0.01). Other
intraoperative parameters, such as FFP transfusion(30.0 mL/kg vs. 15.8 mL/kg; p = 0.11), urinary output(2.8 mL/kg/h vs. 2 mL/kg/h; p = 0.07), and blood loss
(37.4 mL/kg vs. 31.1 mL/kg; p = 0.25) showed nonsignificant trends or no significant difference. Post­
operative outcomes including length of ICU stay (22.5
days vs. 23.5 days; p = 0.69) and length of hospital stay
(47.5 days vs. 58.0 days; p = 0.46) showed no significant
difference between the infant and non-infant groups.
Main outcomes. The incidence of C-D ≥ III complications was significantly higher in the non-infantgroup (46.2%) than in the infant group (12.5%): odds
ratio 6.00; 95% confidence interval (95%CI) 1.1331.88; p = 0.03 (Fig. 1). When we analyzed only
patients with biliary atresia (29, 69.1%), the pattern
was the same: non-infant group 64.7%, infant group16.7% (p = 0.01). Seven patients had vascular complica-

Table 2

tions, four had intestinal complications, and three had
postoperative bleeding. Vascular complications
included hepatic vein stenosis in three patients, thrombosis of the portal vein in two patients, and hepatic
artery thrombosis and portal vein anastomotic stenosis
in one patient each. Intestinal complications included
perforation of the intestine in two patients, and ileus
and peritonitis in one patient each. Eight patients(30.8%) in the non-infant group underwent reoperation, but only two (12.5%) in the infant group. Threepatients (11.5%) in the non-infant group underwent
70%
60%

P = 0.03

50%
40%
30%
20%
10%
0%

Infant12.5%

Non-infant

46.2%
Odds Ratio: 6.00 (95%CI 1.13-31.88)

Fig. 1
The incidence of C-D ≥ III complications.
C-D ≥ III, Clavien-Dindo classiﬁcation grade ≥ III; 95%CI, 95%
conﬁdence interval.

Intraoperative characteristics of pediatric liver transplantation recipients

Crystalloids (mL/kg), median [IQR]
5% Alb (mL/kg), median [IQR]
RBC (mL/kg), median [IQR]
FFP (mL/kg), median [IQR]
PC (mL/kg), median [IQR]
Blood loss (mL/kg), median [IQR]
Urine (mL/kg/h), median [IQR]
Operation duration (min), median [IQR]
Cold ischemic time (min), median [IQR]
Warm ischemic time (min), median [IQR]
Anhepatic time (min), median [IQR]
GRWR, median [IQR]
ICU stay (days), median [IQR]
Hospital stay (days), median [IQR]Infant (n = 16)

Non-infant (n = 26)

P-value

56.1 [31.4, 81.7]
44.3 [12.1, 59.4]
33.0 [22.2, 56.4]
30.0 [14.1, 54.9]
0.0 [0.0, 0.0]
37.4 [26.8, 77.4]
2.8 [2, 3.9]
401.0 [354.8, 510.0]
32.0 [20.5, 70.0]
40.0 [32.0, 57.0]
152.0 [129.0, 167.0]
3.5 [2.9, 3.8]
22.5 [21.0, 29.8]
47.5 [40.8, 66.8]

80.3 [61.8, 109.6]
40.0 [6, 73.6]
21.3 [8.2, 41.5]
15.8 [2.3, 40.4]
0.0 [0.0, 5.5]
31.1 [18.5, 64.7]
2 [1.2, 3.5]
480.0 [439.0, 541.0]
39.0 [23.0, 58.0]
46.0 [37.0, 55.0]
152.0 [91.0, 181.0]
2.3 [1.5, 3.2]
23.5 [16.8, 30.3]
58.0 [42.8, 70.3]

0.07
0.79
0.02
0.11
0.48
0.25
0.07
0.02
0.64
0.48
0.99
< 0.01
0.69
0.46

IQR, interquartile range; RBC, red blood cell; FFP, fresh frozen plasma; PC, platelet concentrate; GRBW,
Graft-to-Recipient-Weight Ratio; ICU, intensive care unit.

Perioperative Complications in Pediatric Liver Transplantation

Table 3

Details of C-D ≥ III complications

Re-operation, n (%)
Ballooning, n (%)

InfantNon-infant

P-value

2 (12.5%)
0 (0%)

8 (30.8%)
3 (11.5%)

0.18
0.16

C-D ≥ III, Clavien-Dindo classiﬁcation grade ≥ III.

Table 4
Results of multivariate Cox regression
analysis for the incidence of C-D ≥ III complications

GRWR
PELD score
InfantHR

95%CI

P-value

0.62
1.02
0.84

0.40-0.95
0.98-1.06
0.35-1.98

0.03
0.26
0.68

C-D ≥ III, Clavien-Dindo classiﬁcation grade ≥ III;
GRWR, Graft-to-Recipient Weight Ratio; PELD,
Pediatric End-stage Liver Disease; HR, hazard ratio;
95%CI, 95% conﬁdence interval.

327

1.00

Kaplan-Meier Analysis

Event free days of C-D III
0.25
0.50
0.75

percutaneous ballooning for stenosis of the hepatic vein
(Table 3). The median follow-up period was 54.8
months (32.5, 91.8 months, IQR) for the infant group,and 65.7 months (45.6, 105.4 months, IQR) for the
non-infant group. No patients died within 30 days after
liver transplantation.
GRWR, PELD score, and infant age were includedin the multivariate analysis. We selected GRWR and
PELD score because they are well known prognostic
factors for liver transplantation. The results of multivariate Cox regression analysis for the incidence of C-D≥ III complications showed that GRWR was independently associated with the incidence of C-D ≥ III
complications (hazard ratio [HR] 0.62; 95%CI 0.400.95, p = 0.03), but other variables such as PELD score(HR 1.02; 95%CI 0.98-1.06, p = 0.26) and infant age(HR 0.84, 95%CI 0.35-1.98, p = 0.68) were not (Table4). Kaplan-Meier analysis of the incidence of C-D ≥ III
complications showed no significant differences between
the infant and non-infant groups (p = 0.44) (Fig. 2).
Postoperative course of parameters for liver function. While PT% and AST and ALT levels were similar between the infant and non-infant groups, T-Bil,drainage volume of ascites, and p-SOFA scores werehigher in the infant group than in the non-infant group.
However, repeated measures analysis of varianceshowed no statistically significant difference between
any parameter (PT% p = 0.54; AST level p = 0.98; ALT

0.00

August 2024

P = 0.44

010

Postoperative days

2030

Non-infant
InfantFig. 2Kaplan-Meier analysis of the incidence of C-D ≥ III complications.
C-D ≥ III: Clavien-Dindo classiﬁcation grade ≥ III.

level p = 0.94; T-Bil level p = 0.11; occurrence of ascites
p = 0.35; and p-SOFA score p = 0.38) (Fig. 3).

Discussion
In this retrospective study, we assessed the incidence of C-D ≥ III complications in 42 patients aged 2
months to 15 years who underwent living-donor livertransplantation. We found that the incidence of C-D≥ III complications was higher in the non-infant group(46.2%) than in the infant group (12.5%). We performed subgroup analysis of cases with biliary atresia
because different etiologies may lead to different prognosis. We confirmed similar findings even in this subgroup. Multivariate analysis revealed that only GRWR
was independently associated with the incidence of C-D≥ III complications (HR: 0.62, 95%CI: 0.40-0.95,
p = 0.03). Furthermore, the T-Bil level, Child-Pughscore, PELD score, and PT% were significantly worsein the infant group than in the non-infant group. These
results indicate that the incidence of postoperative complications was lower in the infant group despite preoperative laboratory findings being worse in this group.
Because few studies have employed the ClavienDindo classification to quantify serious postoperativecomplications after pediatric liver transplantation, we
cannot compare our results with those of previous
reports. However, with regard to other parameterssuch as 1-year or 5-year survival, Kasahara et al. [2]reported 1-year survival as 88.3% and 5-year survival as328

Katayama et al.

A (mg/dL)

Acta Med. Okayama Vol. 78, No. 4

B (U/L)T.Bil

C (U/L)AST

POD (day)

F

Group

InfantNon-Infant

POD (day)

InfantNon-Infant

p-SOFA

Group

Mean

InfantNon-InfantGroup

POD (day)

AscitesMean

E (mL/kg)Group

POD (day)

InfantNon-Infant

1,000

POD (day)

PT%

Mean

D (%)

Group

Mean

InfantNon-Infant

1,000
Mean

Mean

Group

ALT

1,500

1,500

InfantNon-Infant

POD (day)Fig. 3
Postoperative course of parameters for liver function. A, T-Bil; B, AST; C, ALT; D, PT%; E, Ascites; F, p-SOFA.
POD, postoperative day; T-Bil, total bilirubin; PT, prothrombin time; AST, aspartate aminotransferase; ALT, alanine aminotransferase;
p-SOFA, Pediatric-Sequential Organ Failure Assessment.

85.4% after pediatric liver transplantation, whereas ourstudy results indicated 97.6% and 85.2%, respectively,
which is not inferior. We set the outcome as occurrenceof C-D ≥ III complications because we believe that
perioperative management affects short-term outcomes.
The incidence of C-D ≥ III was lower in the infantgroup, but multivariate Cox regression analysis
revealed that while GRWR was independently associated with the incidence of C-D ≥ III, being an infant
was not. It has been demonstrated that younger age
and/or low body weight are risk factors for high mortality and graft loss, especially in pediatric liver transplantation [11-13]. However, a recent study by Neto etal. [14], which included 1,078 patients aged under 18
years, indicated that body weight is not significantly
associated with patient and graft survival after adjustingfor other risk factors. This finding is consistent with our
results. Moreover, our study showed that the infantgroup had a lower incidence of C-D ≥ III complications
than the non-infant group. Furthermore, the Cox
regression analysis in our study suggested that GRWR
may play a more significant role than age in terms ofshort-term postoperative complications of living-donorliver transplantation in children. However, althoughpast history of abdominal surgery was not different
among the infant group and the non-infant group(n = 10 [62.5%] vs. n = 20 [76.9%], p = 0.26), thenon-infant group had a longer length of surgery. This
fact might have affected the incidence of C-D ≥ III complications.
The postoperative bilirubin levels were higher in theinfant group than in the non-infant group.
Hyperbilirubinemia can be caused by preoperative liver
failure, massive transfusion, or cholestasis [15 , 16].
The infant group had higher preoperative bilirubin levels, which may have influenced the higher postoperative bilirubin levels. Furthermore, the infant group wastransfused with more RBCs intraoperatively, and thehigher bilirubin levels could be attributed to increased
heme breakdown resulting from bulk transfusions [17].
Additionally, the hepatic artery is the only blood supply
to the biliary system, and hepatic artery complications
may lead to elevated bilirubin levels [18]. Gu et al. [19]reported that the incidence of hepatic artery thrombosis was high in younger recipients, especially those agedAugust 2024

Perioperative Complications in Pediatric Liver Transplantation

less than one year, and this may be attributed to thehigher bilirubin levels in the infant group. Although
there are many possible causes, it is unclear exactly why
the bilirubin levels were higher in the infant group in
this study.
With regard to the drainage volume of ascites, it was
higher in the infant group than in the non-infant group.
Herzog et al. [20] reported the overall incidence of ascites after pediatric liver transplantation as 31.2%.
Another report by Antonio et al. [21] showed an inverse
relationship between patient weight and severity of ascites. These results are similar to those of this study,
which suggest that the volume of ascitic fluid depends
on the fluid status of the patient. Our findings showedthat although the infant group had higher bilirubin levels and larger amounts of ascitic fluid, their incidence of
C-D ≥ III complications was lower than that of the
non-infant group. In clinical practice, we use data
mainly associated with liver function, such as AST,
ALT, and platelet counts, PT%, bilirubin level, andoccurrence of ascites, to predict graft function.
However, higher bilirubin levels and larger amounts ofascitic fluid may not necessarily lead to serious postoperative complications as defined by C-D ≥ III.
The limitations of this study were as follows. First,
Kaplan-Meier analysis of the incidence of C-D ≥ III
complications showed no significant difference between
the infant and non-infant groups. One possible reason
for this may be the small number of patients included inthis study and consequent low statistical power. Further
study with larger enrollment numbers is called for.
Nonetheless, we found a significant difference in theincidence of C-D ≥ III based on GRWR, and we believethat this result has important implications for clinicaldecision making. Second, this was a single-center retrospective study, which may have affected the generalizability of the results. Third, the study period was solong that the standard perioperative management protocols, including surgical techniques, anesthetic agents,
and immunosuppressant agents, may have changed.
These changes may have influenced the results of thepresent study. Fourth, all patients in this study underwent living-donor liver transplantation. We cannot
confirm whether our findings can be applied to patients
undergoing deceased-donor liver transplantation. Fifth,
we did not have information on the preoperative status
such as acute-on-chronic liver failure, acute liver failure, hepatopulmonary syndrome, portopulmonary329

hypertension, or hepatic encephalopathy. These conditions may have affected the outcome of liver transplantation.
In conclusion, the incidence of C-D ≥ III complications was higher in the non-infant group (46.2%) thanin the infant group (12.5%). However, this was largelya function of the GRWR, as the incidence of C-D ≥ III
complications after pediatric liver transplantation was
independently associated with GRWR.

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