Introduction:

• Liver transplantation has greatly improved outcomes for patients with acute and chronic liver failure over the past 50 years.
• The number of liver transplants ranges from approximately 400 in Australia to over 1000 in the UK and over 8000 in the United States each year, with survival rates between 75% and 85%.

Donor Selection:

• Liver transplantation is an option for patients with chronic liver diseases caused by various factors such as alcohol use disorder, viral hepatitis, and metabolic or autoimmune conditions.
• The Model for End-Stage Liver Disease (MELD) score is commonly used for transplantation listing, while critically ill patients and those with acute liver failure (ALF) may also be eligible for transplantation.

Systems-based Approach:

• The management of post–liver transplant patients requires a systematic and coordinated approach to address cardiovascular, respiratory, renal, gastrointestinal, neurologic, coagulation, and immune system challenges.
• The hemodynamic changes and management of cirrhosis are crucial in the postoperative period, and invasive monitoring in the ICU is necessary for optimizing graft function.

Cardiovascular:

• Patients with end-stage liver disease have a unique cardiovascular profile characterized by a hyperdynamic circulation and low systemic vascular resistance.
• Hemodynamic instability during the peritransplant period requires invasive monitoring and judicious use of fluid resuscitation to address hypotension and postreperfusion vasoplegia.

Cardiovascular Implications:

• Management implications in the postoperative period include ensuring normovolemia and preventing significant fluid shifts to maintain hemodynamic stability.
• Patients with underlying cardiovascular diseases, particularly coronary artery disease, have poorer outcomes posttransplantation and require risk assessment and consideration for revascularization.

Respiratory Complications:

• Over 50% of liver transplant recipients experience respiratory complications, including prolonged mechanical ventilation, pleural effusions, and pulmonary edema due to large volumes of intraoperative fluid administration.
• Overt postoperative respiratory failure is associated with significant morbidity and mortality, and risk factors include older age, elevated MELD score, and preexisting respiratory compromise.

Acute Lung Injury/ARDS:

• Acute lung injury/acute respiratory distress syndrome (ALI/ARDS) occurs in 4-16% of posttransplantation cases, primarily due to blood product administration, fluid shifts, and preexisting hypoalbuminemia.