Serum bilirubin over 50 μmol/l on postoperative day 5: causes, consequences and outcome

Introduction

The 50–50 criteria (serum bilirubin (SeBi) > 50 μmol/l, serum prothrombin index (PI) < 50%) on postoperative 5 day is a predictor of mortality after liver transplantation [1]. The aim of this study was to analyse the perioperative causes, consequences and outcome of early excretion liver dysfunction.

Methods

In 96 liver transplanted patients the graft dysfunction was defined in PI > 50% and SeBi > 50 μmol/l. The multiorgan donation data including liver biopsies results were recorded. During and after liver transplantation, volumetric hemodynamic, global oxygenation and regional splanchnic perfusion parameters were measured. The hepatic and renal functions were analysed. Based on the postoperative fifth-day SeBi levels, the patients were divided in two groups: group A (SeBi < 50 μmol/l, n = 47) and group B (SeBi > 50 μmol/l, n = 49). The postoperative complications bleeding, renal and respiratory failure, infection were noticed and mortality was recorded. Statistical analyses were performed with the Wilcoxon signed rank test, chi-squared test and Kaplan–Meyer model.

Results

Before organ retrieval, more group B donors received dopamine (P < 0.04), compared with group A donors who received noradrenalin (P < 0.004). The occurrence of donors' fatty liver was the same in both groups. In group B, more Child–Pugh C recipients (P < 0.004) with higher Model for End-Stage Liver Disease (MELD) score (P < 0.001) had longer transplantations (P < 0.05). Worse volumetric hemodynamic (intrathoracic blood volume index, cardiac index, p < 0.03), global oxygenation (oxygen delivery index, P < 0.04) and regional splanchnic perfusion parameters (intramucosal gastric pH; P < 0.02) were found in group B only after portal and arterial reperfusion. In group B the occurrence of continuous renal replacement therapy and sepsis were higher (P < 0.02), the ICU therapy was longer (P < 0.02), and the 1-year mortality was 47% compared with 4% of group A (P < 0.004).

Conclusion

Early billiary injury after liver transplantation can be connected with the vasopressor therapy of the donor, the severity of cirrhosis, and the worse oxygenation and hemodynamic parameters after reperfusion.