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Background <p>Postreperfusion syndrome (PRS) is a common and clinically important complication during liver transplantation. It is characterized by marked hemodynamic instability after graft reperfusion and has been associated with adverse perioperative outcomes. However, perioperative factors associated with PRS in donation after circulatory death (DCD) liver transplantation remain incompletely defined, and clinically applicable prediction tools are limited. This study aimed to identify perioperative factors associated with PRS, develop an internally validated prediction model, and explore the relationship between PRS and postoperative outcomes.</p> Methods <p>We performed a retrospective cohort study of adult recipients who underwent orthotopic liver transplantation using DCD grafts at the First Affiliated Hospital of Nanjing Medical University between January 2016 and May 2025. PRS was defined as a decrease in mean arterial pressure of at least 30% from the prereperfusion baseline within 5&#xa0;min after reperfusion, lasting for at least 1&#xa0;min. Prespecified donor-, recipient-, and intraoperative variables were screened, and a limited number of clinically plausible candidate predictors were entered into multivariable logistic regression to reduce the risk of overfitting. A nomogram was constructed from the final model. Model performance was assessed using discrimination, calibration, decision curve analysis, and bootstrap internal validation. Kaplan–Meier analysis and Cox regression were used to explore the association between PRS and long-term outcomes.</p> Results <p>Among 430 eligible recipients, 82 developed PRS, yielding an incidence of 19.1%. Multivariable analysis identified donor age ≥ 40 years (OR 3.54, 95% CI 1.65–7.59; <i>P</i> = 0.001), donor ALT ≥ 200 U/L (OR 3.96, 95% CI 1.66–9.46; <i>P</i> = 0.002), hepatic encephalopathy (OR 3.90, 95% CI 1.48–10.27; <i>P</i> = 0.006), severe thrombocytopenia (≤ 30 × 10<sup>9</sup>/L) (OR 3.34, 95% CI 1.34–8.37; <i>P</i> = 0.010), and higher prereperfusion norepinephrine infusion rate (OR 1.12 per 0.1&#xa0;µg/kg/min increase, 95% CI 1.01–1.24; <i>P</i> = 0.031) as independent factors associated with PRS. The model showed modest discrimination (AUC 0.736, 95% CI 0.668–0.804) and reasonable calibration; the optimism-corrected C-index after bootstrap validation was 0.64. Patients with PRS had greater intraoperative blood loss and transfusion requirements, higher postoperative NT-proBNP, serum creatinine, and bilirubin levels, longer ICU stay and mechanical ventilation duration, and higher rates of early allograft dysfunction and acute kidney injury (all <i>P</i> &lt; 0.05). PRS was also associated with higher mortality in the overall cohort (HR 1.55, 95% CI 1.08–2.23; <i>P</i> = 0.02). In subgroup analyses, this association was more evident in recipients with non-malignant liver disease than in those with hepatocellular carcinoma.</p> Conclusions <p>In DCD liver transplantation, older donor age, elevated donor ALT, hepatic encephalopathy, severe thrombocytopenia, and greater prereperfusion norepinephrine requirement were independently associated with PRS. The proposed model may serve as an internally developed perioperative risk-stratification tool, although further external validation is needed. PRS was associated with worse perioperative outcomes, and its relationship with long-term survival appeared to vary across recipient subgroups.</p>

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Risk factors and a perioperative prediction model for postreperfusion syndrome in donation after circulatory death liver transplantation: a retrospective cohort study

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  • 发表日期：

    2026年8月4日

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  • Siyang Li,
  • Zhiying Zheng,
  • Xinyang Liu,
  • Hui Zhang,
  • Yining Chen,
  • Xiongxiong Pan

摘要

Background

Postreperfusion syndrome (PRS) is a common and clinically important complication during liver transplantation. It is characterized by marked hemodynamic instability after graft reperfusion and has been associated with adverse perioperative outcomes. However, perioperative factors associated with PRS in donation after circulatory death (DCD) liver transplantation remain incompletely defined, and clinically applicable prediction tools are limited. This study aimed to identify perioperative factors associated with PRS, develop an internally validated prediction model, and explore the relationship between PRS and postoperative outcomes.

Methods

We performed a retrospective cohort study of adult recipients who underwent orthotopic liver transplantation using DCD grafts at the First Affiliated Hospital of Nanjing Medical University between January 2016 and May 2025. PRS was defined as a decrease in mean arterial pressure of at least 30% from the prereperfusion baseline within 5 min after reperfusion, lasting for at least 1 min. Prespecified donor-, recipient-, and intraoperative variables were screened, and a limited number of clinically plausible candidate predictors were entered into multivariable logistic regression to reduce the risk of overfitting. A nomogram was constructed from the final model. Model performance was assessed using discrimination, calibration, decision curve analysis, and bootstrap internal validation. Kaplan–Meier analysis and Cox regression were used to explore the association between PRS and long-term outcomes.

Results

Among 430 eligible recipients, 82 developed PRS, yielding an incidence of 19.1%. Multivariable analysis identified donor age ≥ 40 years (OR 3.54, 95% CI 1.65–7.59; P = 0.001), donor ALT ≥ 200 U/L (OR 3.96, 95% CI 1.66–9.46; P = 0.002), hepatic encephalopathy (OR 3.90, 95% CI 1.48–10.27; P = 0.006), severe thrombocytopenia (≤ 30 × 109/L) (OR 3.34, 95% CI 1.34–8.37; P = 0.010), and higher prereperfusion norepinephrine infusion rate (OR 1.12 per 0.1 µg/kg/min increase, 95% CI 1.01–1.24; P = 0.031) as independent factors associated with PRS. The model showed modest discrimination (AUC 0.736, 95% CI 0.668–0.804) and reasonable calibration; the optimism-corrected C-index after bootstrap validation was 0.64. Patients with PRS had greater intraoperative blood loss and transfusion requirements, higher postoperative NT-proBNP, serum creatinine, and bilirubin levels, longer ICU stay and mechanical ventilation duration, and higher rates of early allograft dysfunction and acute kidney injury (all P < 0.05). PRS was also associated with higher mortality in the overall cohort (HR 1.55, 95% CI 1.08–2.23; P = 0.02). In subgroup analyses, this association was more evident in recipients with non-malignant liver disease than in those with hepatocellular carcinoma.

Conclusions

In DCD liver transplantation, older donor age, elevated donor ALT, hepatic encephalopathy, severe thrombocytopenia, and greater prereperfusion norepinephrine requirement were independently associated with PRS. The proposed model may serve as an internally developed perioperative risk-stratification tool, although further external validation is needed. PRS was associated with worse perioperative outcomes, and its relationship with long-term survival appeared to vary across recipient subgroups.