Perioperative management strategies to minimize graft dysfunction in liver transplant

Despite major advancements in liver transplantation, graft dysfunction remains a key challenge for long-term success. The use of extended criteria donors, including donation after circulatory death, grafts with prolonged warm ischemia, steatotic grafts, and older donors, is often associated with delayed function or primary non-function. These risk factors must be accounted for when tailoring intraoperative and postoperative strategies. Intraoperatively, maintaining adequate hepatic perfusion, typically requiring mean arterial pressures above 55 millimeters of mercury through careful titration of vasopressors and fluids, is essential. Various monitoring modalities can support perfusion optimization. To minimize microcirculatory injury, anesthetic management can be optimized, and advanced microcirculation-monitoring tools such as videomicroscopy, contrast-enhanced ultrasound, and laser speckle contrast imaging should be considered. Additionally, ischemic preconditioning and postconditioning may help reduce postoperative graft dysfunction. Routine use of ultrasound in the postoperative period allows for early detection and treatment of vascular complications such as thrombosis or hepatic outflow obstruction. Use of machine perfusion and normothermic regional perfusion during organ procurement can help to ameliorate microcirculatory problems and improve the survival of extended criteria donors. This expert opinion paper outlines key aspects of hepatic graft monitoring and management aimed at improving outcomes in liver transplantation.