Interpreting the hazard zone: Factor V and lactate as critical indicators in severe early allograft injury

Abstract

Graft failure is the worst complication of organ transplantation. Considering liver transplantation, aminotransferase levels have been demonstrated to be a precursor of severe graft failure, in particular when they exceed 5000 U/L in the immediate post-operation. However, some studies show that the outcome of the transplanted liver is not determinable by biochemistry alone. One of the most relevant studies is the one published by Lazzarotto-da-Silva et al. In this retrospective study, 341 transplanted livers are considered. In 25 cases, this severe biochemical insult has been reported. But despite this event, more than half had significant long-term survival. One of the most valuable elements that emerge from this work is the identification of two easily measurable markers - serum factor V and arterial lactate, which independently can indicate the graft's 90-day outcome. This finding provides a key clinical picture to distinguish patients who are most likely to recover from those destined for irreversible graft loss. In a time where organs are increasingly scarce, these discoveries could facilitate more prudent use of retransplantation, improving both individual outcomes and the overall distribution of resources. This study contributes significantly to a deeper understanding of early graft injury, although larger prospective studies are needed. It highlights the need to move beyond singular value thresholds and toward integrated, evidence-based decision making during the crucial early post-transplant period. This study not only captures risk but also provides a tool for intervention.

Keywords: Liver transplantation; Early allograft failure; Factor V; Arterial lactate; Biomarker-guided decision-making

Core Tip: In liver transplant recipients, quick identification of grafts susceptible to failure continues to be a clinical challenge, especially when aminotransferase levels exceed 5000 U/L during the early postoperative phase. Although generally considered concerning, these increases do not always indicate poor prognosis. For this reason, the use of functional biomarkers, such as serum factor V and arterial lactate levels, is highly considered to more accurately distinguish patients with a greater chance of recovery from those at risk of early transplant failure. Incorporating these elements into daily clinical practice can improve decision making, minimize retransplantations, optimizing patient outcomes and organ preservation.