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. 2018 Mar 9;18(1):29.
doi: 10.1186/s12871-018-0493-9.

Visual quality assessment of the liver graft by the transplanting surgeon predicts postreperfusion syndrome after liver transplantation: a retrospective cohort study

Felix Kork  1 , Alexandra Rimek  2 , Anne Andert  3 , Niklas Jurek Becker  3 , Christoph Heidenhain  4 , Ulf P Neumann  3 , Daniela Kroy  5 , Anna B Roehl  2 , Rolf Rossaint  2 , Marc Hein  2
Affiliations

Visual quality assessment of the liver graft by the transplanting surgeon predicts postreperfusion syndrome after liver transplantation: a retrospective cohort study

Felix Kork et al. BMC Anesthesiol. .

Abstract

Background: The discrepancy between demand and supply for liver transplants (LT) has led to an increased transplantation of organs from extended criteria donors (ECD).

Methods: In this single center retrospective analysis of 122 cadaveric LT recipients, we investigated predictors of postreperfusion syndrome (PRS) including transplant liver quality categorized by both histological assessment of steatosis and subjective visual assessment by the transplanting surgeon using multivariable regression analysis. Furthermore, we describe the relevance of PRS during the intraoperative and postoperative course of LT recipients.

Results: 53.3% (n = 65) of the patients suffered from PRS. Risk factors for PRS were visually assessed organ quality of the liver grafts (acceptable: OR 12.2 [95% CI 2.43-61.59], P = 0.002; poor: OR 13.4 [95% CI 1.48-121.1], P = 0.02) as well as intraoperative norepinephrine dosage before reperfusion (OR 2.2 [95% CI 1.26-3.86] per 0.1 μg kg- 1 min- 1, P = 0.01). In contrast, histological assessment of the graft was not associated with PRS. LT recipients suffering from PRS were hemodynamically more instable after reperfusion compared to recipients not suffering from PRS. They had lower mean arterial pressures until the end of surgery (P < 0.001), received more epinephrine and norepinephrine before reperfusion (P = 0.02 and P < 0.001, respectively) as well as higher rates of continuous infusion of norepinephrine (P < 0.001) and vasopressin (P = 0.02) after reperfusion. Postoperative peak AST was significantly higher (P = 0.001) in LT recipients with PRS. LT recipients with intraoperative PRS had more postoperative adverse cardiac events (P = 0.05) and suffered more often from postoperative delirium (P = 0.04).

Conclusions: Patients receiving ECD liver grafts are especially prone to PRS. Anesthesiologists should keep these newly described risk factors in mind when preparing for reperfusion in patients receiving high-risk organs.

Keywords: Cold ischemia time; Hyponatremia; Steatosis.

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Conflict of interest statement

Ethics approval and consent to participate

The local ethics committee (University Hospital RWTH Aachen, EK 291/13) approved the analysis and waived the requirement of informed consent.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Patients. Flow chart of patient inclusion. PRS: postreperfusion syndrome
Fig. 2
Fig. 2
Hemodynamics. Intraoperative hemodynamics of 122 liver transplant (LT) recipients, 65 with postreperfusion syndrome (PRS, black circles), 57 without postoperative PRS (white circles). LT recipients with PRS were hemodynamically more unstable compared to patients without PRS. Mean arterial pressure after reperfusion was lower (a), accordingly, norepinephrine (b) and vasopressin infusion (c) were higher in LT recipients with PRS compared to recipients without PRS. Heart rate (d) and epinephrine infusion (e) did not differ. At the time of reperfusion, LT recipients with PRS received greater boli of norepinephrine and epinephrine (f). P-values: repeated measures ANOVA; *: post-hoc t-test; mean and standard deviation
Fig. 3
Fig. 3
Clinical chemistry. Postoperative clinical chemistry of 122 liver transplant (LT) recipients, 65 with postreperfusion syndrome (PRS, black circles), 57 without postoperative PRS (white circles). LT recipients with PRS suffered from greater postoperative transplant damage and poorer transplant function during the postoperative course: Aspartat transferase blood concentration was higher (a) and blood hemostasis was poorer (d) compared to LT recipients without postreperfusion syndrome (alanine transferase was higher but did not reach significance, (b) LT recipients with and without PRS did not differ in gall retention (c). Inflammation marker procalcitonin (e) and kidney function marker creatinine (f) were peaking higher during the postoperative course in LT recipients with PRS compared to recipients without PRS but did not reach statistical significance. P-values: repeated measures ANOVA; *: post-hoc t-test; mean and standard deviation
Fig. 4
Fig. 4
Survival. Kaplan-Meier survival analysis of 122 liver transplant (LT) recipients, 65 with postreperfusion syndrome (PRS; solid line) and 57 with PRS (broken line). Survival analyses were conducted for LT recipient survival (a) as well as graft survival (retransplantation or recipient death; (b) PRS: postreperfusion syndrome
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