Post-Transplant Sepsis After Liver Transplantation: Clinical Characteristics and Therapeutic Challenges

Background: Sepsis is one of the leading causes of early death after a liver transplant, with a frequency of up to 45% and a high death rate of 50% in more severe forms. Standard diagnostic and therapeutic algorithms are often not applicable to this specific population, where immunosuppression, reperfusion injury, and systemic inflammation overlap and generate a clinical picture that is significantly different from sepsis in immunocompetent patients. Methods: This paper analyzes the available literature and clinical experiences of characteristic immune and hemodynamic profiles of sepsis after liver transplants. Biomarkers (IL-6, IL-10, HLA-DR, lactate, and IgM) are discussed as tools for assessing immune status and guiding timely interventions, including the early application of continuous renal replacement therapy (CRRT) and the selective use of IgM-enriched immunoglobulins. Results: Sepsis after liver transplantation frequently unfolds in two phases, an initial hyper-inflammatory response driven by cytokine release and reperfusion injury and a second phase of secondary immunoparalysis characterized by reduced HLA-DR expression and increased anti-inflammatory signaling. The immunometabolic shift appears to influence the clinical course and may inform therapeutic decision-making. The immunoparalysis phase is accompanied by mitochondrial dysfunction and impaired vascular reactivity. This type of mechanism contributes to hemodynamic instability and a reduced response to standard therapy. Individualized monitoring and early use of hemofiltration and immunomodulatory measures can improve results in carefully selected patients. Conclusions: In this setting, an individualized immunometabolic approach may complement standard sepsis management in liver transplant recipients. The introduction of biomarkers of immune function into routine practice and the recognition of early signs of exhaustion of the immune response can assist in timely therapeutic decision-making and improve survival.