Post-reperfusion syndrome in liver transplant recipients: What is new in prevention and management?

Table 1 Potential cellular and physiologic causes of post-reperfusion syndrome

Category	Physiologic change	Hemodynamic change
Release of vasoactive substances	Inflammatory cytokines (nitrous oxide, endothelin-1, bradykinin, reactive oxygen species)	Increased CVP; increased PVR; increased PAP; decreased SVR; decreased ABP; decreased CI; decreased HR; ST changes; T-wave changes
Electrolyte disturbances	Hypothermia; acidosis; hyperkalemia; hypocalcemia; hyperphosphatemia
Embolic phenomena	Thromboembolic; air emboli

ABP: Arterial blood pressure; CI: Cardiac index; CVP: Central venous pressure; HR: Heart rate; PAP: Pulmonary artery pressure; PVR: Pulmonary vascular resistance; SVR: Systemic vascular resistance.

Table 2 Comparison of Techniques for preventing post-reperfusion syndrome including advantages and limitations

Technique	Advantages	Limitations
Static cold storage	Cheaper, current gold standard, many studies showing efficacy	Storage duration is restricted, potential for harm during storage, does not reverse ongoing damage, organ viability can’t be assessed during storage
Hypothermic machine perfusion	Can use on high risk donors, can use in DBD and dcd allografts, lower incidence of graft injury, organ loss, allows for longer mean preservation time, enhance organ availability reduce waitlist mortality	Limited data on long term benefits, need to cool to sub-physiologic temperature
Normothermic machine perfusion	Can use at physiologic temperatures, can use on high-risk donors, can use in DBD and DCD allografts, lower incidence of graft injury, organ loss, allows for longer mean preservation time, enhance organ availability reduce waitlist mortality	Limited data on long term benefits
Normothermic regional perfusion	Very affective for DCD donors	Only used in DCD liver allograft management, ethical considerations with TA-NRP
Caval blood flush vent	Hemodynamic protection cheapest, decreased requirement for vasopressors and inotropes	Limited studies on short and long term benefits
ECMO	Eliminate the need for extensive immunosuppressive treatments, expand the donor organ pool, cheaper than MP	Patients usually very ill with multi-organ failure and systemic infections, bilirubin levels hard to measure in short term, limited data on long term benefits, ethical concerns

DBD: Donation after brain death; DCD: Donation after circulatory death; ECMO: Extracorporeal membrane oxygenation; MP: Machine perfusion; TA-NRP thoracoabdominal normothermic regional perfusion.