Published online Sep 8, 2016. doi: 10.4254/wjh.v8.i25.1047
Peer-review started: March 23, 2016
First decision: May 16, 2016
Revised: May 16, 2016
Accepted: July 14, 2016
Article in press: July 18, 2016
Published online: September 8, 2016
Advanced liver cirrhosis is usually accompanied by portal hypertension. Long-term portal hypertension results in various vascular alterations. The systemic hemodynamic state in patients with cirrhosis is termed a hyperdynamic state. This peculiar hemodynamic state is characterized by an expanded blood volume, high cardiac output, and low total peripheral resistance. Vascular alterations do not disappear even long after liver transplantation (LT), and recipients with cirrhosis exhibit a persistent systemic hyperdynamic state even after LT. Stability of optimal systemic hemodynamics is indispensable for adequate portal venous flow (PVF) and successful LT, and reliable parameters for optimal systemic hemodynamics and adequate PVF are required. Even a subtle disorder in systemic hemodynamics is precisely indicated by the balance between cardiac output and blood volume. The indocyanine green (ICG) kinetics reflect the patient’s functional hepatocytes and effective PVF, and PVF is a major determinant of the ICG elimination constant (kICG) in the well-preserved allograft. The kICG value is useful to set the optimal PVF during living-donor LT and to evaluate adequate PVF after LT. Perioperative management has a large influence on the postoperative course and outcome; therefore, key points and unexpected pitfalls for intensive management are herein summarized. Transplant physicians should fully understand the peculiar systemic hemodynamic behavior in LT recipients with cirrhosis and recognize the critical importance of PVF after LT.
Core tip: In patients with advanced cirrhosis who undergo liver transplantation (LT), perioperative management greatly influences the postoperative course and outcome. This review covers key points and unexpected pitfalls of intensive management in these patients. A peculiar systemic hemodynamic state (hyperdynamic state) persists in recipients with cirrhosis even after LT, and stability of optimal systemic hemodynamics is important for adequate portal venous flow (PVF) and successful LT. Reliable parameters for optimal systemic hemodynamics (a balance between cardiac output and blood volume) and adequate PVF (indocyanine clearance) during and after LT are herein described. Transplant physicians should fully understand these peculiar hemodynamic phenomena.