Post reperfusion syndrome during liver transplantation: From pathophysiology to therapy and preventive strategies

Table 1 Incidence, risk factors and graft effects

Ref.	Title	Type of study	No. subjects	Definition of PRS	PRS pretreatment	Incidence	Risk factors	Graft and recipient effects	Jadad score
Garutti Martinez et al[14]	Response to clamping of the inferior vena cava as a factor for predicting postreperfusion syndrome during liver transplantation	Retrospective	94	30% drop in MAP within 5' lasting for 1'	Fluid challenge to achieve PCWP at least 12 mmHg before clamping the IVC	28.7%	A low increase in SVRI after clamping of IVC is predictive of PRS, this could be correlated to the sensitivity of baroreflexes and hence a more responsive cardiovascular system in those patients who did not develop PRS	N/A	1
Chui et al[5]	Postreperfusion syndrome in orthotopic liver transplantation	Retrospective	321	MAP < 60 mmHg together with classical hemodynamic disturbance (?)	?	12.8%	↑ CIT, ↑ potassium and ↓ bT after reperfusion	-	1
Nanashima et al[8]	Analysis of postrevascularization syndrome after orthotopic liver transplantation: the experience of an Australian liver transplantation center	Retrospective	100	30% drop in MAP within 5' lasting for 1'	?	29%	older donor age	↑ post reperfusion lactate and transaminase; ↑ creatinine on POD 7	1
Ayanoglu et al[13]	Causes of postreperfusion syndrome in living or cadaveric donor liver transplantations	Retrospective	145	30% drop in MAP within 5' lasting for 1'	20% mannitol + Ca gluconate 1-2 g + 30-50 mEq NaHCO3	48.9%	Shorter duration of anhepatic phase, ↑ calcium requirements, ↑ HR pre-post reperfusion, ↓ CVP during the dissection period	-	1
Hilmi et al[2]	The impact of postreperfusion syndrome on short-term patient and liver allograft outcome in patients undergoing orthotopic liver transplantation	Retrospective	338	Hilmi definition	?	55% (significant PRS)	↑ WIT, older recipient age	↑ days on ventilator, ICU stay, hospital stay, need for retransplantation, RBC, FFP, CRYO tansfusions and fibrynolisis, no differences in recipient survival	1
Paugam-Burtz et al[10]	Postreperfusion syndrome during liver transplantation for cirrhosis: outcome and predictors	Prospective	75	30% drop in MAP within 5' lasting for 1'	Colloids, 500 mL	25%	↑ CIT, absence of porto-caval shunt	↑ severe acute renal failure, ↑ 15 d mortality	1
Cordoví de Armas et al[15]	Rapid and homogeneous reperfusion as a risk factor for postreperfusion syndrome during orthotopic liver transplantation	Prospective	94	30% drop in MAP within 5' lasting for 1'	None	32.90%	SQR (reperfusion's speed-quality) can be considered an unambiguous predictor of PRS	N/A	1
Siniscalchi et al[12]	Hyperdinamic circulation in acute liver failure: reperfusion syndrome and outcome following liver transplantation	Retrospective	58	30% drop in MAP within 5' lasting for 1'	N/A	41%	↑ MELD, creatinine, FHF	↑ hospital mortality, ↓ survival rates at 3, 6, 12 mo	0
Khosravi et al[17]	Postreperfusion syndrome and outcome variables after orthotopic liver transplantation	Retrospective	184	Hilmi definition	?	17.4% (significant PRS)	-	↑ post reperfusion blood loss and need for RBC, FFP, PLT. ↑ hospital stay	1
Bukowicka et al[4]	The occurrence of postreperfusion syndrome in orthotopic liver transplantation and its significance in terms of complications and short-term survival	Retrospective	340	30% drop in MAP within 5' lasting for 1'	?	12.10%	↑ CIT, classical technique with VVB, higher HR at the beginning of operation, no correlation with donor' age, and recipient' age or sex	↑ intraoperative RBC and FFP requirements, ↑ early postoperative complications	1
Fukazawa et al[7]	Body surface area index predicts outcome in orthotopic liver transplantation	Retrospective	1228 (3 groups: small for size; controls; large for size)	30% drop in MAP within 5' lasting for 1'	N/A	49% control group, 51% large for size	Lower BSAi is associated with ↓ incidence in PRS, while older donor age ↑ PRS. Note: lower BSAi group had significantly lower age and significantly higher CIT. Low BSAi significantly ↑ arterial hepatic artery thrombosis risk; both low and high BSAi ↓ graft survival	N/A	0
Chung et al[11]	Incidence and predictors of postreperfusion syndrome in living donor liver transplantation	Retrospective	152	30% drop in MAP within 5' lasting for 1'	None	34.2%	Macrovescicular graft steatosis, ↑ recipient MELD score, ↑ preoperative HR, INR, bilirubin and creatinine; lower preoperative haemoglobin, ↑ prereperfusion RBC requirements, lower prereperfusion urine output	↑ Bilirubin peak in the first five POD	0
Xu et al[9]	Postreperfusion syndrome during orthotopic liver transplantation: a single-center experience	Retrospective	330	30% drop in MAP within 5' lasting for 1'	100 mcg phenylephrine, or 10 mcg epinephrine if SBP < 90 mmHg, graft flushed with 500 mL of 5% albumin before reperfusion	17%	Preoperative LVDD, ↑ CIT	↑ Intraoperative mortality, postoperative renal failure, hospital mortality	1
Kim et al[16]	Sympathetic withdrawal is associated with hypotension after hepatic reperfusion	Retrospective	218	30% drop in MAP within 5' lasting for 1'	-	35% (77 PRS vs 141 No-PRS)	Low LF/HF and SBP measured before hepatic graft reperfusion were significantly correlated with subsequent PRS occurrence, suggesting that sympathovagal imbalance and depressed SBP may be key factors predisposing to reperfusion-related severe hypotension in liver transplant recipients	N/A	1
Fukazawa et al[3]	Hemodynamic recovery following postreperfusion syndrome in liver transplantation	Retrospective	715	30% drop in MAP within 5' lasting for 1'	?	31.6%	↑ donor age, DRI, CVP before reperfusion	No effects on graft survival or early graft dysfunction	1

PRS: Post reperfusion syndrome; MAP: Mean arterial pressure; PCWP: Pulmonary capillary wedge pressure; IVC: Inferior vena cava; SVRI: Systemic vascular resistance index; CIT: Cold ischemia time; bT: Body temperature; POD: Post operative day; HR: Heart rate; CVP: Central venous press; FFP: Fresh frozen plasma; CRYO: Cryoprecipitate; SQR: Reperfusion speed-quality; MELD: Model For end-stage liver disease; FHF: Fulminant hepatic failure; PLT: Platelets; VVB: Veno-venous bypass; BSAi: Body surface Area index; SBP: Systolic arterial blood pressure; LVDD: Left ventricular diastolic disease; LF: Low frequency power; HF: High frequency power; DRI: Donor risk index.