Intra-operative restricted fluid therapy in adult living donor liver transplant – Insights from a single-centre historical cohort study

Background and Aims: With the evolution of liver transplant anaesthesia, judicious intraoperative fluid management has been widely recommended. However, existing literature on a weight-based restricted fluid strategy is limited. Our institution follows a weight-based, restrictive fluid approach with maintenance therapy at 4 ml/kg/h (2 ml/kg/h crystalloids + 2 ml/kg/h 4% albumin solution) and goal-directed fluid boluses (4 ml/kg 4% albumin solution). Methods: This retrospective study analysed 106 adult living donor liver transplant recipients managed with a protocolised restrictive fluid strategy and compared them with 148 historical controls who received conventional fluid therapy. The primary outcomes were early extubation (extubated on table or within 6 hours post-operatively) and incidence of post-operative acute kidney injury (AKI) on post-operative days (POD) 1 and 3. Secondary outcomes included intra-operative blood transfusion requirement, vasopressor use, and vascular complication rate. Data were analysed using statistical package for the social sciences version 22 and Epi Info version 7.2.1. Results: The restrictive group received significantly lower total fluid volumes (3284 ± 833 ml vs. 3979 ± 1524 ml; P < 0.001), had higher on-table extubation rates (83% vs. 71.3%; P = 0.031), and experienced zero AKI by POD3 compared to 13.6% in the conventional group ( P < 0.001). Serum creatinine was lower on POD1 and POD3 in the restrictive group. Vasopressin use was higher ( P < 0.001) in the cases, while noradrenaline and blood transfusion requirements were comparable between the groups. Conclusion: Our protocolised weight-based restrictive fluid regimen was associated with improved pulmonary outcomes without increased renal dysfunction. However, prospective studies with larger cohorts are required to validate our findings.