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Approximately 20% of liver retransplantations are performed between postoperative day (POD) 0 and 7 and another 20% between POD 8 and 30 after transplantation. The first period describes the immediate failure of the allograft, while the latter describes the early failure of the allograft.1

Immediate Failure of the Transplanted Liver

Clinical presentation:

  • Increasing or persistently elevated serum lactate after 1 to 2 hours after reperfusion of the allograft (earliest sign of function or dysfunction)

  • Hypoglycemia (failure of gluconeogenesis)

  • Severe acidosis

  • Failure of synthesis of coagulation factors and fibrinogen, resulting in severe coagulopathy

    • Performance of rotational thromboelastometry regularly for assessment of coagulation status is recommended2

  • Poor bile production

    • Only verifiable if T-Tube is present

  • Severe or extreme aminotransferases peak after transplantation3

    • Maximum values usually 6 to 24 hours postoperative

    • Resembling hepatocellular necrosis

    • Repeated measurements should be performed every 6 to 12 hours

  • Declining renal function is commonly observed

    • Oliguria to anuria

    • Increasing retention parameters

  • Cardiovascular insufficiency with need of high vasopressor support

  • Neurologic complications

    • Hepatic encephalopathy

    • Brain edema


  • Hyperacute rejection

    • Occurs within minutes to hours after transplantation

    • Irreversible damage to endothelial cells, platelet aggregation, rapid arterial and venous thrombosis, and subsequent graft infarction

    • Premise: preformed, complement-fixing, donor-specific antibodies (e.g., ABO)

    • Very rare nowadays

    • Relies on mistake in performing bedside test and transplantation across blood group barriers without preparation

  • Hepatic artery thrombosis

    • See the chapter on vascular complications

    • Should be ruled out by sonography/computed tomography (CT) angiography in case of immediate allograft failure

  • Portal vein thrombosis

    • See the chapter on vascular complications

    • Should be ruled out by sonography in case of immediate allograft failure

  • Venous occlusion syndrome

    • See the chapter on vascular complications

    • Should be ruled out by sonography in case of immediate allograft failure

  • Large-for-size syndrome4

    • Insufficient circulating blood volume leads to insufficient perfusion

    • Intraabdominal pressure due to inadequate organ size induces abdominal compartment syndrome

    • Rare in adult transplantation; more common in pediatric recipients

  • Small-for-size syndrome5

    • Transplanted liver mass is too low for demands of the recipient

    • Hyperperfusion of portal vein leads to overpressure, sinusoidal endothelial damage, and hemorrhage

  • Primary nonfunction (PNF)6

    • “True” irreversible graft failure

    • Occurs in approximately 5% of liver transplantations

    • Clear pathogenesis cannot be delineated in most cases

    • Diagnosis of exclusion, relying on the exclusion of other technical reasons for graft failure

    • Inconsistent definition:

      • Usually defined as “graft with poor initial function, requiring retransplantation or leading to death within 7 days after primary procedure without any identifiable cause of graft failure”

    • Ultimate result of severe preservation and subsequent reperfusion injury

      • Resulting in extensive parenchymal necrosis

      • Concerning too much transplanted liver mass, so that the remaining functioning liver mass supplies insufficient function for the recipient’s demands

      • Exceeding the regenerative potential of the allograft

Risk factors for technical complications leading to immediate graft failure will be discussed in ...

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