CASE 04•8–10 minutes•Liver transplantation · Graft dysfunction · Hepatic artery thrombosis · Retransplantation

The deteriorating patient after liver transplantation

A recent liver transplant recipient becomes acidotic and haemodynamically unstable. Work through early graft dysfunction, vascular catastrophe and when retransplantation needs to enter the conversation.

For clinicians working in liver critical care, transplantation, anaesthesia and general intensive care.

Separate early allograft dysfunction from catastrophic primary graft failure and technical complications.

Prioritise urgent vascular assessment when graft dysfunction is unexplained or abrupt.

Recognise that retransplant decisions depend on trajectory and reversibility rather than one laboratory threshold.

Post-op hour 8 · Liver ICU

The first night

Stage 1 of 5

The transaminases are enormous. Is the graft failing?

A 61-year-old recipient returns from an uncomplicated deceased-donor liver transplant. Eight hours later AST is 6,800 IU/L and ALT 4,900 IU/L. Lactate is falling, noradrenaline requirements are low and decreasing, urine output is preserved and INR has improved from the pre-operative value.

AST6,800 IU/L

ALT4,900 IU/L

Lactate5.2 → 2.8 mmol/L

INR2.4 → 1.8

NoradrenalineFalling dose

Urine output0.8 mL/kg/h

Your decision

Which interpretation is most appropriate?

Choose an approach to reveal the discussion and supporting evidence.

Educational content only. The case is fictional and does not replace local guidance, specialist advice or individual clinical judgement.

Clinical review: Dr Tom Dixon · 2026-09-28

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