Obviation of prereperfusion rinsing and decrease in preservation/reperfusion injury in liver transplantation by portal blood flushing

Liver allografts are traditionally rinsed with cold lactated Ringer’s (LR) prereperfusion to clear K⁺-rich preservation solution from the hepatic vasculature. LR has been shown, however, to be injurious to the graft. By restoring portal blood flow without rinsing and discarding the initial blood traversing the liver (PB flush), we sought to eliminate rinsing without inducing hyperkalemia. Between August 1988 and December 1992, 481 OLTx were performed in 412 pts. Four rinsing methods were used sequentially: group 1 (157 pts)—low-flow-rate cold LR rinse (500 ml, 100 ml/ min via standard i.v. tubing at 100 cm H₂O [LFLR]) during lower caval anastomosis; Group 2 (120 pts)—LFLR as in group 1, at reperfusion, 500 ml PB flush via IVC catheter; group 3 (66 pts)—high-flow-rate LR rinse (500 ml, 1 L/min using large-bore tubing with 100 cm H₂O rinsing pressure [HFLR]), PB flush as in group 2; Group 4 (62 pts)—no LR rinse; PB flush as in groups 2 and 3. Poor early graft function (PEGF) was defined as peak ALT or AST >2500 U or PT >16 sec (on POD 2); PEGF causing re-OLTx or death within 14 days was called primary nonfunction (PNF). Group 1 and Group 3 had high PEGF rates. Group 4 had significantly less PEGF than Group 1, with a trend toward a significant difference from Group 3. In Group 1, 3 pts. had intra-operative hyperkalemic cardiac arrest; this did not occur when PB flush was performed. PB flush without prior rinsing optimizes graft function without risk of hyperkalemia. LR rinse, alone or followed by PB flush, is unnecessary and may be deleterious.