Background: Hypertension requiring pharmacologic intervention is common in the immediate postoperative period for pediatric liver transplantation (LT) recipients, although the number of patients who require continuous antihypertensive infusions as compared to oral antihypertensive agents alone is not well characterized. The need for continuously infused antihypertensive agents may correlate with patients’ length of PICU stay and risk of short- and long-term cardiovascular morbidity. Aims: The primary aim is to determine the incidence of antihypertensive infusion use in the 48-hour postoperative period in pediatric subjects who underwent isolated LT. Secondary aims include correlation of need for continuous antihypertensive infusions correlates with  PICU length of stay and a need for oral antihypertensive medications at 12 months post-LT.
Methods: This retrospective cohort study included pediatric patients at Lucile Packard Children’s Hospital  who underwent isolated LT between 2019 and 2023. We excluded patients with the distinct ICU-prolonging interventions of tracheostomy,  return to OR for exploration. We quantified the proportion of patients requiring continuous antihypertensive infusions in the immediate 48-hour postoperative period and assessed differences between this cohort and those who required no antihypertensives or oral agents only, including PICU length of stay, new EKG or echocardiogram changes, and need for oral antihypertensives 12 months postoperatively.
Results: A total of 99 children underwent LT, between 2019 and 2023. Preliminary results from the year 2019 alone included 21 LT:(95% deceased donors, 68% whole livers, 45% male recipients) with the following diagnosis distribution: 29% metabolic/genetic (n=6), 24% biliary atresia (n=5), 19% acute liver failure (n=4), 5% malignancy (n=1), 24% other (n=5). Twelve (57%) required continuous antihypertensive infusions (clevidipine) for a median of 4 (1-7) days and a median length of PICU stay of 11 (5-15) day vs 8 (3-8) days for the non-infusion group. The infusion and non-infusion groups were similar: median age 5.9 (0.6 -6.0) years old vs 5.4 (0.4 -12.6) years old with all patients having MELD/PELD scores > 30, and 4 total, status 1A and 1B in each group. Two patients (from the non-infusion group), developed EKG changes during PICU stay and one had associated echo changes. Of the 18 patients who survived and were not lost to follow up at one year post-transplant, 58% (7/12) from the infusion group and 43% (3/7) from the non-infusion group were on long term antihypertensive medication at one year post transplantation. 
Conclusion: In pediatric LT, this initial analysis shows that hypertension in the immediate postoperative period is common and associated with prolonged ICU stay.  Long term outcomes such as persistent hypertension is common in the pediatric LT.