The association of intraoperative hypotension during orthotopic liver transplantation and post-transplant outcomes

Abstract

Background: Liver transplantation (LT) is one of the most high-risk noncardiac surgeries. Several risk factors have been associated with adverse outcomes in noncardiac surgery. However, limited evidence exists regarding the association between intraoperative hypotension (IOH) and post-transplant adverse outcomes. Methods: This retrospective cohort study evaluated outcomes in consecutive adult LT patients from January 2002 to October 2021. The study aimed to determine the association between IOH, defined as systolic blood pressure <80 mmHg, and post-transplant adverse outcome, defined as a composition of 30-day mortality and graft failure. Secondary outcomes encompassed postoperative complications and risk factors contributing to IOH. Results: Among the 342 patients, the incidence of IOH was 39.2 %. Post-transplant adverse outcomes were observed in 33 patients (9.7 %). Patients with IOH experienced an increased risk of post-transplant adverse outcome [OR (95%CI): 4.10 (1.88–8.93), p < 0.001]. The effect was amplified with severity and duration of IOH. Moreover, the incidence of various adverse events, including 30-day mortality, reoperation, postoperative acute kidney injury, postoperative renal replacement therapy, and prolonged intubation significantly increased in those with IOH. In multivariable analysis, the independent risk factors for IOH included age over 60 years, a history of LT, preoperative INR >1.5, and intraoperative hyperkalemia. Conclusions: IOH is significantly associated with post-transplant adverse outcomes in liver transplantation patients. The impact was amplified with severity and duration of IOH. Consequently, IOH should be proactively and aggressively managed in patients who exhibit risk factors such as advanced age, a history of LT, coagulopathy, and hyperkalemia.