Development and validation of A nomogram for predicting postreperfusion syndrome in pediatric living-donor liver transplantation patients

Background Postreperfusion syndrome (PRS) is a severe intraoperative complication in children undergoing living-donor liver transplantation (LDLT) and is associated with poor postoperative outcomes. Objective To develop and validate a nomogram for predicting PRS following LDLT. Methods We retrospectively analyzed the data of 459 pediatric LDLT patients treated from October 2019 to February 2022 (training cohort, n = 340) and from July 2024 to March 2026 (validation cohort, n = 119). Forty-three perioperative variables were preliminarily screened with least absolute shrinkage and selection operator (LASSO) regression, after which independent predictive factors were identified via multivariable logistic regression. The identified factors were then incorporated into a nomogram. Model performance was evaluated on the basis of the area under the receiver operating characteristic curve (AUC), and calibration curve and decision curve analysis (DCA) were used to assess model accuracy and clinical applicability, respectively. Results PRS occurred in 193 patients (42.05%). A high pretransplant neutrophil-to-lymphocyte ratio (NLR); a graft cold ischemia time (CIT) ≥92.5 min; an anhepatic time ≥52.5 min; and a prereperfusion temperature <36 °C (risk factors); and a high preoperative left ventricular ejection fraction (LVEF) (protective factor) were identified as independent predictors of PRS. In the training cohort, the AUC of the nomogram was 0.833 [95% confidence interval (CI): 0.790–0.876], the specificity was 70.8%, and the sensitivity was 82.1%. In the validation cohort, the AUC was 0.799 (95% CI: 0.716–0.882), the specificity was 73.2%, and the sensitivity was 77.1%. In both cohorts, the Spiegelhalter's Z- test revealed no significant difference between the predicted and observed probabilities of PRS ( P > 0.05). DCA demonstrated that the prediction model offered a favorable net benefit. Conclusions A high pretransplant NLR, an elevated CIT, a prolonged anhepatic time, and prereperfusion hypothermia are independent risk factors for PRS in pediatric LDLT patients, whereas a high LVEF is a protective factor against PRS. The proposed nomogram provides accurate predictions and has potential clinical utility in guiding perioperative management.