Hepatic Preservation Injury After Adult Liver Transplantation
Several advances in organ preservation have allowed for improved results after liver transplantation; however, little information is available regarding the clinical impact of preservation injury on the postoperative course. The medical records of 889 liver transplants were retrospectively reviewed. Preservation injury was classified according to postoperative aspartate aminotransferase values as minor (<1000 U/L), moderate (1000-5000 U/L), or severe (>5000 U/L). The following criteria were analyzed and compared according to the extent of preservation injury: patient and graft survival, retransplantation rate, duration of hospitalization and postoperative ventilation, as well as incidence of rejection, infection, and hemodialysis. The majority of patients received a liver with minor preservation injury (75.9%), whereas 22.7% and 1.3% of grafts showed moderate or severe injury. Graft survival was significantly lower in patients with severe preservation injury, when compared to minor or moderate injury. The relative risk for initial nonfunction was 39.36-fold increased (95% confidence interval (ci): 10.3-150.2), as it was increased for duration of postoperative ventilation (6.92-fold; 95%ci: 2.1-22.3) and hemodialysis (6.13-fold; 95%ci: 1.9-19.3). Since the incidence of retransplantation was significantly increased (50%), patient survival remained comparable between all groups. Severe preservation injury had a tremendous impact on the postoperative clinical course, requiring the maximum medical effort to achieve adequate patient survival.
The liver has been one of the most difficult solid organs to preserve; however, several advances in preservation have improved liver transplantation results. Standardization of surgical techniques, advances in anesthetic management, and the introduction of safer and more potent immunosuppressive drugs have further contributed to this development. Today, orthotopic liver transplantation (OLT) has become an accepted therapy for end-stage liver disease and fulminant hepatic failure.
Despite all advances, the results after transplantation are necessarily dependent on the quality of the liver allograft. In this context, preservation injury of the donor graft has a strong impact on the post-transplant liver graft function. The clinical image may substantially vary according to the intensity of the injury, from transient liver enzyme increase or allograft dysfunction to primary allograft nonfunction as the worst event, which is still a major cause of death in liver transplantation.
Detailed information about renal and pulmonary insufficiency, infectious complications, or hepatic allograft dysfunction after liver transplantation has already been reported. However, little information is available on the clinical image of hepatic preservation injury and its relevance during the postoperative course. To arrive at a better understanding of the clinical implications of hepatic preservation injury, we analyzed the postoperative course of 889 liver transplant recipients with special regard to patient survival, graft survival and incidence of retransplantation, as well as postoperative complications like rejection, infection, or need for hemodialysis.