Factors associated with major complications defined by Clavien–Dindo classification 3–5 after liver transplantation: a prospective multicenter cohort study

Background: We aimed to explore factors preoperative and intraoperative, associated with Clavien-Dindo classification 3-5 (CDC 3-5) after LT. Methods: Secondary analysis of multicenter prospective cohort data for 305 consecutive patients. European Clinical Trials Database -EudraCT 2018-002510-13. The primary outcome was the incidence of CDC 3-5 complications recorded during the ICU stay. We used a log-binomial regression model to evaluate associations. Results: Cardiac-death donors provided 30.16% of grafts. Vena cava preservation was performed in nearly all patients, and a temporary portacaval shunt was used in 41.91%. Intraoperative red blood cell (RBC) transfusion was required in 51.48%, and 27.37% required additional transfusions within 24 h of LT. CDC 3-5 status occurred in 97 patients (31.80%, 95% CI, 26.58%-37.03%). Thrombotic events occurred in 19 patients (6.25%): 6 in portal veins, 5 in hepatic arteries, 2 in mesenteric veins, and 6 in deep veins. Two patients were retransplanted. Twenty-two (7.21%) required reinterventions; 2 were retransplanted; and 20 (6.57%) were readmitted to the ICU. Adjusted relative risk (aRR) calculation found associations with a MELD score >23 (aRR, 1.92; 95% CI, 1.28-2.8), baseline hemoglobin concentration (aRR, 0.98; 95% CI, 0.97-0.99), zero RBC transfusion (aRR, 0.37; 95% CI, 0.28-0.72), an RBC transfusion cut point of >2.5 (aRR, 1.96; 95% CI, 1.29-2.96), PRS (aRR, 2.11; 95% CI, 1.43-3.10), and fibrinogen administration (aRR, 1.07; 95% CI, 1.05-1.09). We found no associations with temporary portocaval shunt (aRR, 1.02; 95% CI (0.7-1.48), cold and warm ischemia times or surgical time and intraoperative fluid administration. Conclusion: We conclude that PRS at reperfusion of the liver graft and the volume of RBCs transfused are the main modifiable factors that influence major complications reflected by CDC 3-5 status after LT. Clinical Trial Registration: https://clinicaltrials.gov/, identifier NCT04405518.