The resuscitation of patients immediately following a liver transplant is similar in concept to that of cirrhotic individuals who have or are experiencing a bout of variceal hemorrhage. Like the cirrhotic patient who is suffering from gastrointestinal bleeding, the transplanted patient should be repleted to euvolemia to maximize end-organ perfusion and function. Excessive hydration of the variceal bleeder will exacerbate blood loss by further elevating central venous pressure (CVP) and portal hypertension. Likewise, overaggressive volume resuscitation of the liver recipient produces elevation of the CVP, resulting in distention of the transplanted organ and diminished liver perfusion pressure.

Allocation of livers for transplantation is currently triaged according to the Model for End-stage Liver Disease (MELD) system. Under MELD, each patient is assigned a score calculated from his or her most recent blood values of creatinine, bilirubin, and prothrombin time. MELD scores range from 6 to a capped maximum of 40 and correlate directly with the risk of 3-month mortality over a wide spectrum of etiologies of cirrhosis. Those with the highest scores within their respective blood group are the next individuals to be transplanted. Inclusion of renal function (as measured by serum creatinine) in the MELD equation recognizes the significant contribution of hepatorenal syndrome to mortality, as a late manifestation of severe cirrhotic liver disease. Using this allocation algorithm results in a significant proportion of recipients undergoing transplantation with renal insufficiency or even acute renal failure secondary to changes in renal function precipitated by their advanced liver failure. Thus, urinary output, often the best measure of tissue perfusion in the trauma or postsurgical patient, may fail to accurately represent an adequate volume of resuscitation in the liver-transplant recipient. In addition, intraoperative blood loss and hypotension, as well as the elimination of massive amounts of ascites and resultant reformation, may further worsen the patient’s already tenuous renal status. In liver-transplant recipients, trends in CVP, pulmonary artery diastolic or wedge pressure, and cardiac output may better represent the hydration status of the patient.