Primary Nonfunction After DCD Liver Transplant
A 62-year-old woman with NASH cirrhosis and MELD-Na 30 undergoes deceased donor liver transplantation. The graft is from a donation after circulatory death donor, age 55, with 35 minutes of warm ischemia and 9 hours of cold ischemia. Postoperative day 1: she is intubated, on norepinephrine 0.08 mcg/kg/min, urine output 15 mL/h, lactate 9.2 mmol/L, INR 3.1, total bilirubin 8 mg/dL, AST 6,200 U/L, ALT 7,100 U/L, and platelet count 42,000/µL. Abdominal ultrasound shows patent hepatic artery and portal vein with elevated resistive indices. She has received 12 units of packed red blood cells. The bile output is scant and dark. The surgical team asks whether to relist her emergently.
1. What is the most likely diagnosis, and how does it differ from early allograft dysfunction?
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Most likely diagnosis: primary nonfunction of the graft. The combination of POD1 lactic acidosis, INR 3.1, oliguria, vasopressor dependence, markedly elevated transaminases, and scant dark bile after a DCD graft with 35 minutes of warm ischemia and 9 hours of cold ischemia is typical. Primary nonfunction is a clinical diagnosis of a graft that will not recover; it is distinguished from early allograft dysfunction, which is a day-7 construct (bilirubin ≥10 mg/dL, INR ≥1.6, and AST or ALT ≥2000 U/L) and often recovers. At POD1, the trajectory matters more than any single enzyme level. The ultrasound excludes hepatic artery thrombosis and portal vein thrombosis, but a biopsy may be considered if the diagnosis is uncertain.
2. What immediate supportive measures and diagnostic evaluations would you pursue?
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Support with ICU care, optimize perfusion, and avoid nephrotoxins. Start continuous renal replacement therapy for oliguric renal failure and severe acidosis, correct coagulopathy only for bleeding or procedures, and maintain glucose and nutrition. Continue broad-spectrum antibiotics only if infection is suspected, and screen for hemolysis and bleeding. Do not use excessive fluid to chase urine output. A repeat Doppler or CT angiogram can be considered if vascular patency is doubtful. Prostaglandin therapy is not proven to rescue primary nonfunction and should not delay retransplant evaluation. The key is serial assessment of lactate, INR, urine output, and mental status over 24-72 hours.
3. What factors determine whether to list for emergency retransplant?
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I would list for emergency retransplant if there is no meaningful improvement in lactate, INR, urine output, or hemodynamics over 24-72 hours, especially with worsening encephalopathy or renal failure. Persistent absence of bile and escalating vasopressor needs support the decision. Before listing, I would exclude active uncontrolled infection, severe cardiopulmonary disease, and other contraindications, and confirm that the patient is a candidate for another major operation. Primary nonfunction is an indication for urgent retransplant, and delay increases mortality. If the graft begins to recover, supportive care can continue with close monitoring.