YKL-40: Revolutionizing cardiac risk prediction and therapy in liver transplantation

Table 1 Essential perioperative strategies in liver transplantation

Key perioperative considerations	Core objectives	Clinical strategies	Relevance to LT outcomes
Anesthetic management	Optimize hemodynamic stability while minimizing cardiovascular depression	Use of balanced anesthesia with reduced myocardial depressants, individualized ventilation strategies	Reduces intraoperative cardiovascular instability and improves early graft function
Hemodynamic monitoring and support	Maintain adequate perfusion, prevent hypotension, and manage fluid shifts	Continuous invasive hemodynamic monitoring (arterial line, CVP), vasoactive drug titration	Prevents hemodynamic collapse, improves organ perfusion, and reduces renal dysfunction
Intraoperative transfusion strategies	Reduce bleeding risk, optimize coagulation, and prevent transfusion-related complications	Goal-directed transfusion strategies using viscoelastic tests (ROTEM/TEG), use of antifibrinolytics	Minimizes need for massive transfusion, reduces clotting disorders, and improves recovery
Metabolic and electrolyte management	Correct metabolic derangements and optimize acid-base balance	Perioperative glucose control, electrolyte replacement, correction of metabolic acidosis/ alkalosis	Prevents metabolic crises, reduces acidosis-related cardiac dysfunction, and stabilizes electrolytes
Surgical techniques	Enhance graft implantation, reduce ischemia-reperfusion injury, and optimize surgical technique	Use of minimally invasive techniques, normothermic regional perfusion. and/ or veno-venous bypass	Optimizes graft survival, reduces ischemic complications, and improves surgical efficiency
Immunosuppressive strategies	Prevent rejection while minimizing cardiovascular and metabolic toxicity	Induction therapy with IL-2 receptor antagonists, tailored CNI minimization in high-risk patients	Enhances long-term graft survival while mitigating CVD, metabolic, and renal adverse effects

CNI: Calcineurin inhibitor; CVD: Cardiovascular disease; CVP: Central venous pressure; IL-2: Interleukin-2; LT: Liver transplantation; ROTEM: Rotational thromboelastometry; TEG: Thromboelastography.