Chapter 84: Immediate and Early Graft Failure

IMMEDIATE AND EARLY FAILURE OF THE TRANSPLANTED LIVER

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

Etiology:

• 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 ...