**3.8.1 Early complications (Table 4)**

**Hypothermia:** In the intensive care units it takes 3-8 hours to warm a patient; during this period of hypothermia and warming there is always a risk of arrhtyhmias. Also during this period, shivering causes the metabolic rate to increase.

**Prolonged mechanical ventilation:** Over 72 hours of mechanical ventilation is required for 15% of the patients; mainly due to preoperative malnutrition, postoperative hemmorhage and primary non-functioning donor graft.

**Bleeding:** The requirements for blood transfusion continues also in the postoperative period. In reoperations a bleeding site is often found, however in a majority of patients this can also be caused by coagulopathy. Prothrombin time may remain high in the postoperative period and also trombocytopenia may develop because of the sequestration during recirculation. Thromboelastogram is a useful monitor also for the coagulopathy in the postoperative period.

**Hypertension:** The hyperdynamic circulatory state tends to become normal during the posttransplantation period, however in 55-85% of patients hypertension may develop, resulting in intracranial hemorrhage.

**Impaired liver function tests:** Within the first 48-72 hours, inadequate perfusion of the graft, venous congestion and edema may lead to functional impairment. However, in the following period coagulopathy improves, whereas aminotransferase, alkalene phosphatase and bilirubin levels start to decrease.

**Malnutrition:** The patients with end-stage liver disease are often malnourished and have depleted protein stores. Following transplantation protein catabolism occurs, leading to a negative nitrogen balance within a month. This protein catabolism results in an increase in urinary 3-methylhistidine levels, revealing this catabolism originates from muscle.

**The primary non-functioning of donor graft:** The increase in the levels of liver enzymes within 1 week after transplantation refers to acute cellular rejection, which requires biopsy for the definitive diagnosis. Retransplantation is necessary before the other organs are affected.

**Sepsis:** Most of the patients are transfered back to the ICU because of sepsis, following their discharge from ICU. Selective intestine decontamination may limit bacterial infections, however non-bacterial organisms contribute to a major problem.

**Others:** Bile leak, thrombosis of hepatic artery and portal vein may be major complications during this period. Moreover, hyperglycemia, renal insufficiency and neurologic impairments may also occur, as side-seffects of immunsuppressive therapy.
