Persistent Intraoperative Shock and Acute Kidney Injury After Liver Transplantation

Background/Objectives: Acute kidney injury (AKI) is a common complication after liver transplantation. Although intraoperative hypotension has been associated with its development, the impact of shock persistence and its hemodynamic profile remains poorly defined. Methods: This was a single-center retrospective observational study including 226 adult patients undergoing liver transplantation. Intraoperative shock was defined as a mean arterial pressure < 60 mmHg or a ≥30% decrease from baseline and was classified as hypovolemic, distributive, cardiogenic, or mixed based on pulmonary artery catheter data. AKI was defined according to Kidney Disease: Improving Global Outcomes (KDIGO) criteria within the first 7 postoperative days. Associations were assessed using adjusted logistic regression models. Results: Intraoperative shock occurred in 35.8% of patients, and the incidence of AKI was 52.2%. The presence of shock was not independently associated with AKI (adjusted OR 1.66; 95% CI 0.94-2.95). However, shock occurring in multiple phases of the procedure was associated with a higher incidence of AKI (81.8% vs. 50%; p = 0.010), greater severity, and higher mortality (27.3% vs. 3.4%; p = 0.002). In exploratory analyses, mixed shock was associated with an increased need for renal replacement therapy within 30 days (p = 0.006), persistent renal dysfunction at day 30 (p = 0.048), and higher mortality (p = 0.01), while hypovolemic shock was associated with moderate AKI (OR 6.60; p = 0.011). Conclusions: The presence of intraoperative shock alone is not independently associated with AKI. In contrast, its persistence is strongly associated with AKI development and worse clinical outcomes.