Sympathetic withdrawal is associated with hypotension after hepatic reperfusion

Abstract

Objective Post-reperfusion syndrome (PRS), severe hypotension after graft reperfusion during liver transplantation, is an adverse clinical event associated with poorer patient outcomes. The purpose of this study was to determine whether alterations in autonomic control in liver transplant recipients prior to graft reperfusion are associated with the subsequent development of PRS. Methods Heart rate variability (HRV), systolic arterial blood pressure (SBP) variability, and baroreflex sensitivity of 218 liver transplant recipients were evaluated using 5 min of ECG and arterial blood pressure signals 10 min before graft reperfusion along with other clinical parameters. Logistic regression analyses were performed to assess predictors of PRS occurrence. Results Seventy-seven patients (35 %) developed PRS while 141 did not. There were significant differences in SBP (110 ± 16 vs. 119 ± 16 mmHg, P \ 0.001) and the ratio of low frequency power to high frequency power (LF/ HF) of HRV (1.0 ± 1.4 vs. 2.1 ± 3.7, P = 0.003) between the PRS group and No-PRS group. In multivariate logistic regression analysis, predictors were LF/HF (odds ratio 0.817, P = 0.028) and SBP (odds ratio 0.966, P \ 0.001).Interpretation 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.

Factors Associated With Postreperfusion Syndrome in Living Donor Liver Transplantation: A Retrospective Study

“…In contrast, among the 3 previous retrospective studies examining PRS association in LDLT, 14–16 1 study reported that intraoperative calcium supplementation reduced PRS incidence, 14 supporting the results of our study. However, sex 14–16 and anhepatic period 15,16 were not associated with PRS in those previous studies, which might be owing to racial differences and the small sample size of the previous studies. Other factors, including preoperative left ventricular diameter, PAP before reperfusion, and GV, have not been examined in previous studies, which makes our study novel.…”

“…3,6–9,12,20–22 Intriguingly, these factors in LDLT in our study are completely different from those reported in studies with brain-dead donor LT; however, the reason for this discrepancy cannot be clarified and may be owing to the difference in patients. In contrast, among the 3 previous retrospective studies examining PRS association in LDLT, 14–16 1 study reported that intraoperative calcium supplementation reduced PRS incidence, 14 supporting the results of our study. However, sex 14–16 and anhepatic period 15,16 were not associated with PRS in those previous studies, which might be owing to racial differences and the small sample size of the previous studies.…”

Factors Associated With Postreperfusion Syndrome in Living Donor Liver Transplantation: A Retrospective Study

“…In contrast, among the 3 previous retrospective studies examining PRS association in LDLT, 14–16 1 study reported that intraoperative calcium supplementation reduced PRS incidence, 14 supporting the results of our study. However, sex 14–16 and anhepatic period 15,16 were not associated with PRS in those previous studies, which might be owing to racial differences and the small sample size of the previous studies. Other factors, including preoperative left ventricular diameter, PAP before reperfusion, and GV, have not been examined in previous studies, which makes our study novel.…”

“…3,6–9,12,20–22 Intriguingly, these factors in LDLT in our study are completely different from those reported in studies with brain-dead donor LT; however, the reason for this discrepancy cannot be clarified and may be owing to the difference in patients. In contrast, among the 3 previous retrospective studies examining PRS association in LDLT, 14–16 1 study reported that intraoperative calcium supplementation reduced PRS incidence, 14 supporting the results of our study. However, sex 14–16 and anhepatic period 15,16 were not associated with PRS in those previous studies, which might be owing to racial differences and the small sample size of the previous studies.…”

Atrioventricular conduction disturbances immediately after hepatic graft reperfusion and their outcomes in patients undergoing liver transplantation

“…AV block patients without neurocardiogenic reflex etiology are considered to not have this feature. (15) The vagally mediated AV block is consistent with that of our prior study, (10) in that those recipients who have a relative depression in sympathetic tone compared to parasympathetic tone immediately before reperfusion are at greater risk of PRS development.…”

Prediction, prevention, and treatment of post reperfusion syndrome in adult orthotopic liver transplant patients

“…Most of the selected studies adopted a retrospective design except for three which used a prospective study design 16,23,25 . Seven of the 18 studies divided the study population into PRS positive and PRS negative for better comparison 6–8,11,17,20,21 . Three studies compared liver grafts that underwent machine perfusion (hypothermic oxygenated perfusion (HOPE) or normothermic machine perfusion (NMP)) to traditional static cold storage 15,22,23 .…”

“…Kim et al. found that underlying autonomic tone in transplant recipients played a role in the development of PRS 20 . In this study of 218 patients, they performed frequency domain analysis of heart rate variability which they utilize as a reflection of autonomic tone.…”

Factors Associated With Postreperfusion Syndrome in Living Donor Liver Transplantation: A Retrospective Study

“…In contrast, among the 3 previous retrospective studies examining PRS association in LDLT, 14–16 1 study reported that intraoperative calcium supplementation reduced PRS incidence, 14 supporting the results of our study. However, sex 14–16 and anhepatic period 15,16 were not associated with PRS in those previous studies, which might be owing to racial differences and the small sample size of the previous studies. Other factors, including preoperative left ventricular diameter, PAP before reperfusion, and GV, have not been examined in previous studies, which makes our study novel.…”

“…3,6–9,12,20–22 Intriguingly, these factors in LDLT in our study are completely different from those reported in studies with brain-dead donor LT; however, the reason for this discrepancy cannot be clarified and may be owing to the difference in patients. In contrast, among the 3 previous retrospective studies examining PRS association in LDLT, 14–16 1 study reported that intraoperative calcium supplementation reduced PRS incidence, 14 supporting the results of our study. However, sex 14–16 and anhepatic period 15,16 were not associated with PRS in those previous studies, which might be owing to racial differences and the small sample size of the previous studies.…”

Atrioventricular conduction disturbances immediately after hepatic graft reperfusion and their outcomes in patients undergoing liver transplantation

“…AV block patients without neurocardiogenic reflex etiology are considered to not have this feature. (15) The vagally mediated AV block is consistent with that of our prior study, (10) in that those recipients who have a relative depression in sympathetic tone compared to parasympathetic tone immediately before reperfusion are at greater risk of PRS development.…”

Prediction, prevention, and treatment of post reperfusion syndrome in adult orthotopic liver transplant patients

“…Most of the selected studies adopted a retrospective design except for three which used a prospective study design 16,23,25 . Seven of the 18 studies divided the study population into PRS positive and PRS negative for better comparison 6–8,11,17,20,21 . Three studies compared liver grafts that underwent machine perfusion (hypothermic oxygenated perfusion (HOPE) or normothermic machine perfusion (NMP)) to traditional static cold storage 15,22,23 .…”

“…Kim et al. found that underlying autonomic tone in transplant recipients played a role in the development of PRS 20 . In this study of 218 patients, they performed frequency domain analysis of heart rate variability which they utilize as a reflection of autonomic tone.…”

Factors Associated With Postreperfusion Syndrome in Living Donor Liver Transplantation: A Retrospective Study

“…In contrast, among the 3 previous retrospective studies examining PRS association in LDLT, 14–16 1 study reported that intraoperative calcium supplementation reduced PRS incidence, 14 supporting the results of our study. However, sex 14–16 and anhepatic period 15,16 were not associated with PRS in those previous studies, which might be owing to racial differences and the small sample size of the previous studies. Other factors, including preoperative left ventricular diameter, PAP before reperfusion, and GV, have not been examined in previous studies, which makes our study novel.…”

“…3,6–9,12,20–22 Intriguingly, these factors in LDLT in our study are completely different from those reported in studies with brain-dead donor LT; however, the reason for this discrepancy cannot be clarified and may be owing to the difference in patients. In contrast, among the 3 previous retrospective studies examining PRS association in LDLT, 14–16 1 study reported that intraoperative calcium supplementation reduced PRS incidence, 14 supporting the results of our study. However, sex 14–16 and anhepatic period 15,16 were not associated with PRS in those previous studies, which might be owing to racial differences and the small sample size of the previous studies.…”

Atrioventricular conduction disturbances immediately after hepatic graft reperfusion and their outcomes in patients undergoing liver transplantation

“…AV block patients without neurocardiogenic reflex etiology are considered to not have this feature. (15) The vagally mediated AV block is consistent with that of our prior study, (10) in that those recipients who have a relative depression in sympathetic tone compared to parasympathetic tone immediately before reperfusion are at greater risk of PRS development.…”

Prediction, prevention, and treatment of post reperfusion syndrome in adult orthotopic liver transplant patients

“…Most of the selected studies adopted a retrospective design except for three which used a prospective study design 16,23,25 . Seven of the 18 studies divided the study population into PRS positive and PRS negative for better comparison 6–8,11,17,20,21 . Three studies compared liver grafts that underwent machine perfusion (hypothermic oxygenated perfusion (HOPE) or normothermic machine perfusion (NMP)) to traditional static cold storage 15,22,23 .…”

“…Kim et al. found that underlying autonomic tone in transplant recipients played a role in the development of PRS 20 . In this study of 218 patients, they performed frequency domain analysis of heart rate variability which they utilize as a reflection of autonomic tone.…”