Intraoperative Hemodynamic Management during Liver Transplantation and Postoperative Morbidity: A Multicenter Cohort Study

BACKGROUND: The best intraoperative hemodynamic strategy in liver transplantation remains uncertain. No high-quality clinical trials or observational studies have comprehensively assessed the association between intraoperative hemodynamic management and postoperative outcomes in liver transplantation. This study aimed to measure the association between two key components of intraoperative hemodynamic management, fluid balance and vasopressor doses, and 7-day graft dysfunction or nonfunction and other postoperative complications after liver transplantation. METHODS: A multicenter cohort study was conducted across eight liver transplantation centers in Canada and France, including consecutive liver transplant recipients over at least 1 yr between January 2021 and May 2023. The exposures were intraoperative fluid balance (volume of blood products, transfused cell saver, colloids, and crystalloids (divided by 1.5), minus estimated blood loss, expressed in liters) and intraoperative vasopressor doses (expressed in increments of 25 μg/kg norepinephrine equivalents). The primary outcome was 7-day early allograft dysfunction or primary graft nonfunction. The study used regression models adjusted for confounders, including intraoperative hypotension. RESULTS: A total of 852 liver transplant recipients (836 with complete data) were included. Participants had a mean ± SD age of 54 ± 12 yr and a median [quartile 1, quartile 3] Model for End-stage Liver Disease (MELD) 3.0 score of 20 [11, 29]. The incidence of 7-day early allograft dysfunction or primary graft nonfunction was 28% (occurring in 236 patients). Neither fluid balance (adjusted risk ratio = 1.02 [95% CI, 0.97 to 1.06] for each liter of fluid balance) nor vasopressor doses (adjusted risk ratio = 1.03 [95% CI, 0.99 to 1.06] for each increment of 25 μg/kg of norepinephrine equivalent) were associated with the risk of this outcome. CONCLUSIONS: A higher fluid balance and higher doses of vasopressors were not associated with a higher risk of 7-day early allograft dysfunction or primary graft nonfunction after liver transplantation.