September’s Article of the Month, with commentary from Dr. Scott Byram, examines a 250-patient retrospective study identifying risk factors for postreperfusion syndrome (PRS) in living donor liver transplantation. While most prior PRS literature has focused on DBD recipients, this analysis pinpoints five independent associations specific to LDLT — including two modifiable intraoperative factors (ionized calcium and mean pulmonary artery pressure) that may give anesthesiologists levers to reduce PRS risk before portal vein reperfusion.
Key Findings
- Cohort: 250 adult LDLT recipients (2013–2018); PRS defined as MAP drop ≥ 30% within 5 minutes of portal vein reperfusion lasting > 1 minute
- PRS incidence: 29% (73/250) — higher than typically reported in DBD cohorts
- Protective factor: Higher serum ionized calcium before reperfusion (OR 0.74 per 0.1 mmol/L increase; p < .001)
- Modifiable levers: Ionized calcium and mPAP can be optimized intraoperatively just prior to reperfusion — pointing to potential bedside strategies for risk reduction
- Important caveat: Authors emphasize associations are not causal given retrospective design; RCTs needed before adopting preventative protocols
- Five independent risk factors identified on multivariable analysis:
- Male sex (OR 2.45 vs. female; p = .008)
- Smaller LV end-diastolic diameter on preoperative TTE (OR 0.90 per 1-mm increase; p < .001)
- Prolonged anhepatic period (p = .02)
- Larger graft-to-standard-liver-volume ratio (p = .03)
- High mean PA pressure before reperfusion (p = .003)
