Intraoperative Anesthetic Parameters Predict Early Allograft Dysfunction in Pediatric Living Donor Liver...

Early allograft dysfunction (EAD) is a major complication of pediatric liver transplantation associated with prolonged ICU stay, increased mortality, and graft loss. Existing risk models focus on donor and surgical variables; the contribution of intraoperative anesthetic management remains poorly characterized in pediatric living donor liver transplantation (LDLT).

We conducted a retrospective single-center cohort study of 124 consecutive pediatric LDLT recipients. Three intraoperative anesthetic parameters were evaluated as predictors of EAD (Olthoff criteria): relative mean arterial pressure (MAP) drop (%), norepinephrine (NE) infusion duration (min), and peak intraoperative lactate (mmol/L). Discriminative performance was assessed by receiver operating characteristic (ROC) analysis. Multivariable Firth penalized logistic regression addressed near-complete separation. Internal validation used bootstrap resampling (1000 iterations).

The cohort (median age 18.5 months, IQR 8.0-96.0; biliary atresia the most common indication) included 50 patients (40.3%) with EAD. All three parameters showed excellent univariable discrimination: NE duration (AUC = 0.993), peak lactate (AUC = 0.936), and MAP drop (AUC = 0.894); all p < 0.001. Three preoperative variables (hemoglobin, bilirubin, albumin) reached univariable significance (all p < 0.05) but with modest discrimination (AUC 0.384-0.617), markedly inferior to all intraoperative parameters (AUC 0.894-0.996). In the multivariable model, MAP drop (OR 22.27; 95% CI 1.80-275.4; p = 0.016) and NE duration (OR 3066657; p = 0.018) independently predicted EAD. The combined model achieved AUC = 0.999 (bootstrap 95% CI: 0.994-1.000; Brier score = 0.013). NE duration ≥ 70 min yielded sensitivity 1.000 and NPV 1.000. EAD-positive patients had significantly longer ICU stay (5 vs. 3 days; p = 0.004) and mechanical ventilation duration (24 vs. 0 h; p < 0.001).

Intraoperative anesthetic parameters-particularly NE duration and MAP drop-are powerful independent predictors of EAD in pediatric LDLT, substantially outperforming preoperative variables, three of which reached statistical significance but with markedly lower discriminative power. Intraoperative hemodynamic management may represent a modifiable determinant of early graft outcomes. External validation is warranted.