Surgery Blog for Surgeons

Hyperacute rejection in liver transplantation?

The hyperacute rejection in transplant surgery is a devastating event. Prior to the introduction of the crossmatch for kidney transplantation, the hyperacute rejection was not uncommon. However the crossmatch is currently of no importance in the organs other than the kidney.
Despite some published case reports, most transplant surgeons do not even believe in hyperacute (or also antibody-mediated) rejection in liver allotransplantation. In fact, this attitude has been almost supported by most of these papers - they are just not convincing!

Having written the above, I will describe here a case that I have no (other) explanation for its course.

Case report

The patient was a 64 years old female with cryptogenic cirrhosis and a solitary HCC diagnosed by multiple MRI's in segment 3 within the Milan criteria, which was chemoembolized 3 months ago. In addition 2 benign appearing lesions (hemangiomas) in segments 3 and 7 were demonstrated. Her calculated MELD score was 14, the organ was offered because of tumor exception points. She arrived in a generally good condition. The only remarkable item in the previous history was hypertension for which she was treated with beta-blockers. She had three uncomplicated pregnancies, one blood transfusion in the past, and no previous transplants.

The donor was a 37 years old obese (BMI: 36) female with hypertension and intracranial bleeding but no other problems. On visualisation the liver looked almost perfect (just a little fatty as expected); the organ procurement was uneventful.

The recipient hepatectomy was performed without any problems, the implant was also uneventful; the cold ischemia time was 11.5 hours. The vital signs, ABG and Lactate were all normal at reperfusion.

About one hour after reperfusion the lactate was reported to have raised from 1.5 to 4.5 mmol/L. There was no morphological evidence of any ischemia of the liver at this time; the organ appeared well perfused. The portal vein was patent, the artery had a nice thrill, the good flows were confirmed by an intraoperative duplex. There was no gross bleeding.
30 minutes later the lactate was 8.7 mmol/L. In addition, a diffuse oozing started and with the time increased in intensity. In addition to packed red blood cell (PRBC) units, the following was given with the hope to stop the oozing: packed platelet units, Desmopressin (DDAVP), Cryoprecipitate, fresh frozen plasma (FFP) and Factor VII. The abdomen was packed with towels and provisionally closed for about 30 minutes on two occasions. The situation could not be significantly improved. The lactate raised to 15.6 mmol/L. The liver appeared now "patchy". The (later evaluated) post-perfusion biopsy showed 70% necrosis of the hepatocytes.
We discussed removing the liver and making the patient anhepatic while awaiting for another liver after emergently relisting her. Unfortunately the condition of the patient did not allow this; the blood pressure had to be maintained on three pressors and she could not have survived this approach.

The patient was transferred to the ICU and required overnight all the blood products and clotting factors as well as albumin and pressors. In the morning the situation was discussed with the family and the support was withdrawn.


The postperfusion course in this case was undoubtedly a primary non-function of the transplanted liver.
The organ did not work at any time. The transaminases raised to several thousands U/L, the total bilirubin was as high as 23 mg/dL. There was obviously no production of albumin or any clotting factors and no metabolism of the endogenous vasodilators.
There is no mechanism helping establishing a possible hyperacute rejection. The role of the C4d staining and even the crossmatch result is not clear in liver transplantation.
Reviewing the literature, I could not find any report about this kind of early and complete non-function of a liver. In the setting of kidney transplantation, a similar situation would be called "hyperacute rejection".
I don't know how (else) to call it in this unfortunate liver transplantation case.