Elective Liver Transplantation Research Articles

First consensus document of waiting list prioritization for liver transplantation by the Spanish Society of Liver Transplantation (SETH).

Spain is worldwide leader in deceased donation rates per million habitants and count on a strong network of twenty-five liver transplant institutions. Although the access to liver transplantation is higher than in other countries, approximately 10% of patients qualifying for liver transplantation in Spain will die in the waiting list or would be excluded due to clinical deterioration. A robust waiting list prioritization system is paramount to grant the sickest patients with the first positions in the waiting list for an earlier access to transplant. In addition, the allocation policy may not create or perpetuate inequities, particularly in a public and universal healthcare system. Hitherto, Spain lacks a unique national allocation system for elective liver transplantation. Most institutions establish their own rules for liver allocation and only two autonomous regions, namely Andalucía and Cataluña, share part of their waiting list within their territory to provide regional priority to patients requiring more urgent transplantation. This heterogeneity is further aggravated by the recently described sex-based disparities for accessing liver transplantation in Spain, and by the expansion of liver transplant indications, mainly for oncological indications, in absence of clear guidance on the optimal prioritization policy. The present document contains the recommendations from the first consensus of waiting list prioritization for liver transplantation issued by the Spanish Society of Liver Transplantation (SETH). The document was supported by all liver transplant institutions in Spain and by the Organización Nacional de Trasplantes (ONT). Its implementation will allow to homogenize practices and to improve equity and outcomes among patients with end-stage liver disease.

GEMA-Na and MELD 3.0 severity scores to address sex disparities for accessing liver transplantation: a nationwide retrospective cohort study

The Gender-Equity Model for liver Allocation corrected by serum sodium (GEMA-Na) and the Model for End-stage Liver Disease 3.0 (MELD 3.0) could amend sex disparities for accessing liver transplantation (LT). We aimed to assess these inequities in Spain and to compare the performance of GEMA-Na and MELD 3.0. Nationwide cohort study including adult patients listed for a first elective LT (January 2016-December 2021). The primary outcome was mortality or delisting for sickness within the first 90 days. Independent predictors of the primary outcome were evaluated using multivariate Cox's regression with adjusted relative risks (RR) and 95% confidence intervals (95% CI). The discrimination of GEMA-Na and MELD 3.0was assessed using Harrell c-statistics (Hc). The study included 6071 patients (4697 men and 1374 women). Mortality or delisting for clinical deterioration occurred in 286 patients at 90 days (4.7%). Women had reduced access to LT (83.7% vs. 85.9%; p=0.037) and increased risk of mortality or delisting for sickness at 90 days (adjusted RR=1.57 [95% CI 1.09-2.28]; p=0.017). Female sex remained as an independent risk factor when using MELD or MELD-Na but lost its significance in the presence of GEMA-Na or MELD 3.0. Among patients included for reasons other than tumours (n=3606; 59.4%), GEMA-Na had Hc=0.753 (95% CI 0.715-0.792), which was higher than MELD 3.0 (Hc=0.726 [95% CI 0.686-0.767; p=0.001), showing both models adequate calibration. GEMA-Na and MELD 3.0 might correct sex disparities for accessing LT, but GEMA-Na provides more accurate predictions of waiting list outcomes and could be considered the standard of care for waiting list prioritization. Instituto de Salud Carlos III, Agencia Estatal de Investigación (Spain), and European Union.

Preoperative Evidence-Based Practice for Prevention of Early Postoperative Infections in Patients Receiving a Liver Transplant.

BACKGROUND This study aimed to evaluate the effectiveness of implementing evidence-based preoperative nursing interventions in reducing postoperative infections and intensive care unit (ICU) length of stay among liver transplant recipients. MATERIAL AND METHODS A controlled study was conducted, comparing postoperative outcomes between an intervention group receiving standardized, evidence-based preoperative care and a control group receiving routine preoperative care. Patients undergoing elective liver transplantation from September 2020 to March 2021 were included and assigned to either the intervention or control group. The intervention group received preoperative interventions based on best available evidence, while the control group received standard preoperative care. The primary outcomes measured were postoperative infection rates and length of ICU stay. RESULTS In the control group the overall Intensive Care Unit (ICU) length of stay was 3 days and the infection rate was 33.30%, while in the intervention group it was 3 days and 13.80% (P<0.05). There was no significant difference in the length of ICU stay between the control and the intervention groups (P>0.05). There was a significant improvement in the awareness, acceptance, and compliance of doctors and nurses. CONCLUSIONS Using the best evidence-based intervention for preoperative nursing of liver transplantation patients can standardize preoperative nursing behavior. Although we did not find significant differences in outcomes before and after the intervention, it is necessary to prevent postoperative infection and improve nursing compliance.

SAT-010 Elaboration of a one-year mortality score for first elective liver transplantation recipients over 60 years based on the results of the french national cohort between 2007 and 2017

SAT-010 Elaboration of a one-year mortality score for first elective liver transplantation recipients over 60 years based on the results of the french national cohort between 2007 and 2017

Graft Inflow Modulation by Splenic Artery Ligation for Portal Hyper Perfusion does not Decrease Rates of Early Allograft Dysfunction in Adult Live Donor Liver Transplantation: A Randomized Control Trial.

The primary objective was to compare the rates of early allograft dysfunction (EAD) in patients undergoing elective adult live donor liver transplantation (ALDLT) with and without graft portal inflow modulation (GIM) for portal hyper-perfusion. The secondary objectives were to compare time to normalization of bilirubin and International Normalized Ratio (INR), day 14 ascitic output more than 1liter, small-for-size syndrome (SFSS), intensive care unit / high dependency unit and total hospital stay, and 90 day morbidity and mortality. GIM can prevent EAD in ALDLT patients with portal hyper-perfusion. A single-center randomized trial with and without GIM for portal hyper-perfusion by splenic artery ligation (SAL) in ALDLT was performed. After reperfusion, patients with portal venous pressure (PVP)>15mm Hg with a gradient (PVP - central venous pressure) of ≥ 7mm Hg and/or portal venous flow (PVF)>250mL/min/100 grams of liver were randomized into two groups: GIM and No GIM. 75 of 209 patients satisfied the inclusion criteria, and 38 underwent GIM. Baseline PVF and PVP were comparable between the GIM and no GIM groups. SAL significantly reduced the PVF and PVP (P<0.001). There were no differences in the primary and secondary outcomes between the two groups. In the subgroup analysis, with a Graft to Recipient Weight Ratio (GRWR)≤0.8, there were no significant differences in the primary and secondary outcomes. SAL significantly decreased PVP and PVF, but did not decrease rates of EAD in adult LDLT.

To compare the outcome of temporary portocaval shunt during recipient hepatectomy versus No shunt in adult elective live donor liver transplantation- A Prospective Randomized controlled study

To compare the outcome of temporary portocaval shunt during recipient hepatectomy versus No shunt in adult elective live donor liver transplantation- A Prospective Randomized controlled study

Gene therapy for organic acidemias: Lessons learned from methylmalonic and propionic acidemia.

Organic acidemias (OA) are a group of rare autosomal recessive disorders of intermediary metabolism that result in a systemic elevation of organic acid. Despite optimal dietary and cofactor therapy, OA patients still suffer from potentially lethal metabolic instability and experience long-term multisystemic complications. Severely affected patients can benefit from elective liver transplantation, which restores hepatic enzymatic activity, improves metabolic stability, and provides the theoretical basis for the pursuit of gene therapy as a new treatment for patients. Because of the poor outcomes reported in those with OA, especially methylmalonic and propionic acidemia, multiple gene therapy approaches have been explored in relevant animal models. Here, we review the results of gene therapy experiments performed using MMA and PA mouse models to illustrate experimental paradigms that could be applicable for all forms of OA.

Predictive Value of Perioperative Cardiac Troponin I in Patients Undergone Liver Transplantation: A Retrospective Cohort Study.

To examine the change rule and clinical significance of cardiac troponin I (cTnI) in the perioperative period of liver transplantation in adults, as well as its association with 28-day mortality. This was a retrospective cohort study: patients who underwent elective orthotopic liver transplantation (OLT) in Beijing Chao-Yang Hospital between June 2015 and June 2020 were selected, and plasma cTnI values were collected through the electronic medical record system within 7 days after surgery. Furthermore, the baseline clinical data of these patients were collected, and the change curve of cTnI values following liver transplantation was plotted. Using univariate and multivariate logistic regression models, the relationship between the level of postoperative cTnI and short-term mortality was investigated. The primary study endpoint was mortality within 28 days after surgery. We included 414 patients who had undergone liver transplantation in this study, 48 of whom died within 28 days after surgery. cTnI, a specific marker of myocardial injury, could predict that the postoperative cardiovascular complications were higher in the death group and significantly affect the short-term prognosis of patients; however, its prognostic cut-off value was approximately 0.545 ng/mL (13×URL), indicating that a minor elevation of cTnI after liver transplantation did not significantly affect the prognosis. Moreover, a comparison of the baseline data and postoperative ICU management scores of the two groups revealed that diabetes, maximum value of cTnI >0.545 ng/mL within 7 days, and the need for postoperative renal replacement therapy (RRT) were independent prognostic factors of death within 28 days after liver transplantation. Within 7 days after surgery, an increase in cTnI to the maximum value of 0.545 ng/mL (13×URL) could have a significant impact on the short-term prognosis of patients. Diabetes and postoperative RRT were two independent prognostic factors for liver transplantation perioperative mortality.

Portal hypertension has no role in perioperative bleeding during liver transplantation with systematic porto-caval shunt

BackgroundMore than a half of patients undergoing liver transplantation (LT) receive intraoperative transfusion. Portal hypertension (PHT) may contribute to perioperative blood loss. We study the relationship between preoperative hepatic venous pressure gradient (HVPG) values and intraoperative transfusion requirements in adult patients undergoing LT. Methods160 cirrhotic patients undergoing first elective LT (2009–2019) with an HVPG measurement within the previous 6 months were included. Surgical technique was piggyback with portocaval shunt (PCS). The association of HVPG and other variables with transfusion requirements and blood loss were studied. ResultsBlood loss (ml/kg) was positively correlated with HVPG, among other variables, but at multivariable analysis it only remained associated with MELD-Na and HCC indication. Regarding RBC transfusion, MELD-Na and hemoglobin were independently associated with the need and magnitude of RBC transfusion. Subanalysis by surgical stage (hepatectomy, anhepatic, neohepatic) and by serial HVPG cut-offs found no clear associations with either bleeding or transfusion. DiscussionThe severity of PHT plays a minor role on bleeding and transfusion during LT in a contemporary cohort with systematic PCS. Main determinants of transfusion are liver function and baseline hemoglobin, which would seem the suitable goal to optimize transfusion in LT.

To compare the outcome of temporary portocaval shunt during recipient hepatectomy versus No shunt in adult elective live donor liver transplantation: A Prospective Randomized controlled study

To compare the outcome of temporary portocaval shunt during recipient hepatectomy versus No shunt in adult elective live donor liver transplantation: A Prospective Randomized controlled study

Temporal trends of waitlistings for liver transplantation in Italy: The ECALITA (Evolution of IndiCAtion in LIver transplantation in ITAly) registry study

BackgroundOver the last decades relevant epidemiological changes of liver diseases have occurred, together with greatly improved treatment opportunities. AimTo investigate how the indications for elective adult liver transplantation and the underlying disease etiologies have evolved in Italy. MethodsWe recruited from the National Transplant Registry a cohort comprising 17,317 adults patients waitlisted for primary liver transplantation from January-2004 to December-2020. Patients were divided into three Eras:1(2004–2011),2(2012–2014) and 3(2015–2020). ResultsWaitlistings for cirrhosis decreased from 65.9% in Era 1 to 46.1% in Era 3, while those for HCC increased from 28.7% to 48.7%. Comparing Eras 1 and 3, waitlistings for HCV-related cirrhosis decreased from 35.9% to 12.1%, yet those for HCV-related HCC increased from 8.5% to 26.7%. Waitlistings for HBV-related cirrhosis remained almost unchanged (13.2% and 12.4%), while those for HBV-related HCC increased from 4.0% to 11.6%. ALD-related cirrhosis decreased from 16.9% to 12.9% while ALD-related HCC increased from 1.9% to 3.9%. ConclusionsA sharp increase in liver transplant waitlisting for HCC and a concomitant decrease of waitlisting for cirrhosis have occurred In Italy. Despite HCV infection has noticeably decreased, still remains the primary etiology of waitlisting for HCC, while ALD and HBV represent the main causes for cirrhosis.

Treatment of metabolic disorders using genomic technologies: Lessons from methylmalonic acidemia.

Hereditary methylmalonic acidemia (MMA) caused by deficiency of the enzyme methylmalonyl-CoA mutase (MMUT) is a relatively common and severe organic acidemia. The recalcitrant nature of the condition to conventional dietary and medical management has led to the use of elective liver and combined liver-kidney transplantation in some patients. However, liver transplantation is intrinsically limited by organ availability, the risks of surgery, procedural and life-long management costs, transplant comorbidities, and a remaining underlying risk of complications related to MMA despite transplantation. Here, we review pre-clinical studies that present alternative approaches to solid organ transplantation as a treatment for MMUT MMA, including adeno-associated viral gene addition therapy, mRNA therapy, and genome editing, with and without nuclease enhancement.

Invasive coronary angiography as a tool in cardiac evaluation for liver transplant candidates

BackgroundCardiovascular assessment is central to evaluation of liver transplant (LT) candidates. However, there is a lack of consensus on the diagnostic algorithm for screening for coronary artery disease (CAD), and the place for invasive coronary angiography (ICA) remains undefined. MethodsWe retrospectively analysed 1201 adults who underwent elective LT assessment over a 5-year period. For patients who underwent LT, survival data to 5 years post-LT was collected. ResultsICA was performed in 259 (21.6%): 134 no CAD, 58 mild, 33 moderate, and 34 severe. Detection of CAD was associated with age (OR 1.08, P < 0.01), current smoking (OR 4.92, P < 0.01) and prior CAD (OR 8.93, P < 0.001). Poor performance on cardiopulmonary exercise test (CPET) was associated with age (OR 1.02, P < .05) and diabetes mellitus (OR 1.54, P < 0.05). 122 (10.2%) patients were declined due to severity of cardiovascular disease.169/779 (21.7%) patients listed for LT had undergone ICA, and CAD was present in 73/169 (43.2%). The non-risk-adjusted all-cause post-LT 5-year survival was 82.6%, with no difference in survival in those with and without CAD on ICA. In patients with CAD, diabetes was associated with reduced survival (OR 3.78, P < 0.05). ConclusionsMulti-modality cardiac evaluation is useful in high-risk patients undergoing LT assessment. ICA can be used with non-invasive assessments and risk factors to delineate candidacy. In selected patients with CAD, LT has been undertaken with comparable post-LT survival.

Massive impact of coronavirus disease 2019 pandemic on gastroenterology and hepatology departments and doctors in Spain.

Significant human and material resources have been diverted to coronavirus disease 2019 (COVID-19). Healthcare workers are at high risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We assess the impact of the COVID-19 pandemic on gastroenterology and hepatology departments and specialists in Spain. This study involves a nationwide survey addressing the impact of COVID-19 on resources, procedures, and physicians of gastroenterology and hepatology departments in 81 hospitals representative of the Spanish National Health Service. Overall, 41.8% of hospital beds and 40.7% of gastroenterology and hepatology beds were allocated to COVID-19 patient care, as well as 24.8% of gastroenterologists and 58.3% of residents. Outpatient visits, abdominal ultrasounds, and endoscopies were reduced by 81.8-91.9%. Nine large university hospitals had 75% and 89% reductions in therapeutic endoscopies and hepatocellular carcinoma surgery, respectively, with cancelation of elective liver transplant and transjugular intrahepatic portosystemic shunt. Prevalence of infected physicians was 10.6% and was dependent on regional population incidence (r=0.74, P=0.001), with 11% hospitalized and one physician dying. Up to 63.4% of physicians may have been infected before or shortly after Spain entered lockdown, 57% of them having recently performed endoscopies. Adequate protection was acknowledged in >80% hospitals, but only 2.9% performed regular SARS-CoV-2 testing. The impact of the COVID-19 pandemic on healthcare delivery has been massive. A wave of gastroenterology-related complications is expected because of resource diversion. Gastroenterologists have a high prevalence of infection, although they may have been infected during a first phase of lower awareness and protection. Regular SARS-CoV-2 screening, adequate protection, and quick reorganization of healthcare resources are still needed.

Analysis of the organ allocation system for liver transplantation in Chile

In Chile, organ allocation for liver transplantation (LT) in adults is prioritized according to the MELD-Na score. Exceptions such as Hepatocellular Carcinoma (HCC) and other non-HCC exceptions receive a score called Operational MELD score. To evaluate the effectiveness of the MELD-Na score and the operational MELD score as a prioritization system for LT in Chile. Retrospective analysis of the waiting list (WL) of adult candidates (≥ 15 years) for elective LT in Chile from 2011 to 2017. The probability of leaving the WL, defined by death or contraindication for LT was compared in three groups: 1) Cirrhotic patients prioritized according to their real MELD-Na score (CPM), 2) HCC and 3) other non-HCC exceptions. We analyzed 730 candidates for LT, with a median age of 57 years, 431 (56%) were men. In the study period, 352 LT were performed (48%). The annual exit rate was significantly higher in the CPM group (45.5%) compared to HCC (33.1%) and non-HCC (29.3%), (p < 0.001). Post LT survival was 86% at 1 year and 85% at 5 years, without significant differences between groups. In the CPM group, post-transplant survival was significantly lower (p < 0.05) in patients with MELD-Na ≥ 30 at transplant (81% per year) compared to patients with patients with MELD-Na < 30 (91% per year). MELD-Na score can discriminate very well patients who have a higher risk of death in the short and medium term. However, the assignment of operational scores for situations of exception produces inequities in the allocation of organs for LT and must therefore be carefully adjusted.

Procalcitonin versus C-reactive protein as indicator of acute rejection during orthotropic liver transplanation

Abstract Background Procalcitonin is the precursor for the hormone calcitonin (CT), which is found in the thyroid C cells and the pulmonary endocrine cells, it has a metabolic role in calcium homeostasis. In normal subjects, PCT is found in the blood at a very low concentration but during bacterial infection, there is more than 1,000 fold increase in its blood concentration as it is released by many other tissues as Liver, Spleen and Lungs. Aim of the Work to compare between procalcitonin and CRP as a markers of infection versus rejection in orthotropic liver transplantation; this comparison with their plasma level and the clinical difference during postoperative period. Patients and Methods This study was conducted on 25 patients aged 2-60 years old of both sexes scheduled for elective liver transplantation from living donors; after ethical committee approval and informed consent from patients and/or their first degree relatives, Ain Shams Specialized Hospitals. Results The study revealed that the normal course after liver transplantation for postoperative 28 days was (48%), rejection (16%), sepsis (24%) and rejection and sepsis (12%). Conclusion Procalcitonin is a good early diagnostic marker and is superior to CRP and WBCs in early detection of postoperative sepsis after orthotropic liver transplantation.

Weight Gain and De Novo Metabolic Disorders after Liver Transplantation.

The development of nutritional and metabolic abnormalities represents an important burden in patients after liver transplantation (LT). Our study aimed at evaluating the incidence, time of onset, and risk factors for nutritional and metabolic abnormalities in patients after LT. The study was a single-center retrospective study. Consecutive patients undergoing elective LT from 2000 to 2016 were enrolled. The presence of at least two among arterial hypertension (AH), diabetes mellitus (DM), dyslipidemia, and obesity (BMI ≥ 30 Kg/m2) was utilized to define patients with the metabolic disorder (MD). Three hundred and fifteen patients were enrolled; the median age was 56 years (68% males). Non-alcoholic steatohepatitis (NASH) was the origin of liver disease in 10% of patients. During follow-up, 39% of patients developed AH, 18% DM, and 17% dyslipidemia. Metabolic disorders were observed in 32% of patients. The NASH etiology (OR: 6.2; CI 95% 0.5–3; p = 0.003) and a longer follow-up (OR: 1.2; CI 95% 0.004–0.02; p = 0.002) were associated with de novo MD. In conclusion, nutritional and metabolic disorders are a frequent complication after LT, being present in up to one-third of patients. The NASH etiology and a longer distance from LT are associated with de novo MD after LT.

Impact of Regional Organ Sharing and Allocation in the UK Northern Liver Alliance on Waiting Time to Liver Transplantation and Waitlist Survival.

In the United Kingdom, liver transplantation (LT) is undertaken in 7 supraregional centers. Until March 2018, liver grafts were offered to a center and allocated to a patient on their elective waiting list (WL) based on unit prioritization. Patients in Newcastle, Leeds, and Edinburgh with a United Kingdom Model for End-Stage Liver Disease (UKELD) score ≥62 were registered on a common WL and prioritized for deceased-donor liver allocation. This was known as the Northern Liver Alliance (NLA) "top-band scheme." Organs were shared between the 3 centers, with a "payback" scheme ensuring no patient in any center was disadvantaged. We investigated whether the NLA had improved WL survival and waiting time (WT) to transplantation. Data for this study were obtained from the UK Transplant Registry maintained by National Health Service Blood and Transplant. This study was based on adult patients registered for first elective liver transplant between April 2013 and December 2016. Non-NLA centers were controls. The Kaplan-Meier method was used to estimate WL survival and median WT to transplant, with the log-rank test used to make comparisons; a Bonferroni correction was applied post hoc to determine pairwise differences. WT was significantly lower at NLA centers compared with non-NLA centers for top-band patients (23 versus 99 days, P < 0.001). However, WL survival was not significantly different for top-band patients (P > 0.999) comparing NLA with non-NLA centers. WL survival for nontop-band patients was no different (P > 0.999) comparing NLA with non-NLA centers. The NLA achieved its aim, providing earlier transplantation to patients with the greatest need. Nontop-band patients did not experience inferior survival.

Recovery of the Psoas Muscle Index in Living Donors after a Right Lobe Hepatectomy for Liver Transplantation: A Single-Center Experience

ObjectiveThe development of sarcopenia leads to adverse postoperative outcomes. However, no study has investigated perioperative loss in core muscle and the correlation between core muscle and residual liver volume in living donors for liver transplant. Patients and MethodsA total of 457 adult healthy donors who underwent a right lobe hepatectomy without the middle hepatic vein for elective liver transplant were retrospectively analyzed. Abdominal computed tomography was performed within 1 month before surgery and the first week and 3 months after the surgery. The average psoas muscle area between lumbar vertebrae 3 and 4 was measured and normalized by height squared (psoas muscle index [PMI] = psoas muscle area/height2). The initial whole liver volume and remnant left lobe volume were measured on computed tomography images. ResultsThe study cohort included 279 men (61.1%) and 178 women (38.9%). The median preoperative PMIs were 420.9 mm2/m2 (interquartile range, 360.6–487.0 mm2/m2) in men and 280.9 mm2/m2 (interquartile range, 243.5–318.7 mm2/m2) in women. The PMIs in men and women significantly decreased during the first week after surgery, and gradually recovered to preoperative levels during the first 3 months after surgery. Based on the ratio between the remnant left lobe and initial whole liver volume (≥30%), the increase in remnant left lobe volume was not correlated with the decrease in PMI on postoperative day 7. A postoperative U-shaped recovery in the core muscles was present in both male and female donors, independent of the remnant liver ratio. ConclusionsDespite the requirements of partial liver regeneration and surgical wound repair, healthy donors did not suffer from sustained core muscle loss after surgery.

Pharmacodynamics of cisatracurium intravenously infused during liver transplantation

Objective To evaluate the pharmacodynamics of cisatracurium intravenously infused during liver transplantation. Methods Twenty American Society of Anesthesiologists physical status Ⅲ or Ⅳ patients of both sexes, aged 18-60 yr, with body mass index of 20-30 kg/m2, scheduled for elective living donor liver transplantation, were enrolled in this study.Total intravenous anesthesia was used.The induction dose of cisatracurium for anesthesia was 0.15 mg/kg.When T1/T0 was restored to 10%, cisatracurium was injected intravenously at an initial rate of 1.5 μg·kg-1·min-1.The infusion rate was adjusted according to the monitoring results of muscle relaxation, and T1/T0 was maintained at 10%.The total amount of cisatracurium infused and infusing time were recorded during dissection phase, anhepatic phase and neohepatic phase, and the consumption of cisatracurium per unit time was calculated.Before skin incision, at 5 and 30 min of anhepatic phase, at 5 and 30 min of neohepatic phase and at the end of operation, the body temperature and stroke volume variation were recorded, blood samples were collected from the radial artery for blood gas analysis and for measurement of blood K+, Mg2+ and Ca2+ concentrations, and blood samples were collected from the internal jugular vein for determination of serum creatinine (Cr), urea nitrogen (BUN) and β2 microspheres protein (β2-MG) concentrations. Results There was no significant difference in the amount of cisatracurium per unit time between dissection phase and anhepatic phase (P>0.05). The amount of cisatracurium per unit time was significantly higher in neohepatic phase than in dissection phase and anhepatic phase (P<0.05). Compared with baseline before skin incision, blood pH value was significantly decreased at 30 min of anhepatic phase and 5 min of neohepatic phase, serum Mg2+ concentrations were decreased at 5 and 30 min of neohepatic phase and at the end of operation, the serum Cr, BUN and β2-MG concentrations were increased, the serum Ca2+ concentration was decreased at 5 min of anhepatic phase, and SVV was increased at 5 and 30 min of anhepatic phase (P< 0.05 or 0.01). Conclusion Muscle relaxation induced by cisatracurium infused intravenously in the anhepatic phase of liver transplantation is weakened. Key words: Atracurium; Liver transplantation; Infusions, intravenous; Dose-response relationship, drug