Ask the Experts - Retransplantation for Primary Liver Graft Nonfunction?
Should retransplantation be considered in the patient with primary graft nonfunction after liver transplantation for acetaminophen-induced acute liver failure?

Primary graft nonfunction (PNF) is a devastating complication of liver transplantation with a reported incidence ranging from 2% to 10%. Potential causes can be related to donor factors, procurement and preservation-related factors, and recipient factors. Recipient factors contributing to PNF include immunologic events such as antibody deposition, drug toxicities, and unrecognized disease (can include residual toxins that contributed to the demise of the native liver).

Retransplantation remains the most effective treatment for PNF. Although overall 1-year survival for emergency retransplantation has been reported as low as 40% to 50%, reasonable survival can be expected in patients transplanted before the onset of multisystem organ failure. Patients with failure of fewer than 4 organ systems is associated with long-term survival, whereas failure of more than 4 organ systems is associated with very low survival. Indeed, the most common cause of death in patients retransplanted for PNF is sepsis associated with multisystem organ failure.

There has been one reported case of recurrent acute liver failure after retransplantation related to carbon tetrachloride poisoning. The liver injury was attributed to residual toxin still present in the patient. Treatment of patients with PNF after transplantation for acetaminophen-induced fulminant hepatic failure is no different than for patients with PNF after transplant for other disease states. Presumably, the acetaminophen has been appropriately removed. In such cases, the prognosis is dependent on the degree of failure of other organ systems. In particular, the progression of encephalopathy and development of cerebral edema is a poor prognostic sign. Additionally, the presence of sepsis has a negative impact on outcome of retransplantation. Thus, the decision to retransplant for PNF after liver transplantation for acetaminophen-induced fulminant hepatic failure should be based on the condition of the patient at the time an organ becomes available.