# Recipient warm ischemic time negatively influences biliary complications and graft survival – a single center retrospective analysis

## TL;DR

This study found that longer recipient warm ischemic time in liver transplants may lead to worse outcomes, including higher bilirubin levels and more blood transfusions.

## Contribution

The study explores the impact of recipient warm ischemic time on biliary complications in liver transplantation.

## Key findings

- Prolonged rWIT was associated with higher bilirubin levels on day 5 post-transplant.
- Patients with rWIT >30 minutes required more intraoperative blood transfusions.
- There was a trend toward more biliary strictures in the rWIT >30-minute group, though not statistically significant.

## Abstract

Recipient warm ischemia time (rWIT) in liver transplantation (LT) – which is defined as the time from removal of the graft from cold storage until reperfusion with portal and/or arterial blood flow – has been linked to negative outcomes. Biliary complications, particularly biliary strictures, are a major cause of morbidity after LT. However, the relationship between rWIT in donation after brain death (DBD) LT and biliary strictures has not been well explored. This single-center study retrospectively analyzed data from 162 DBD-LT recipients (2013-2022). Patients were divided into two groups: rWIT ≤30 minutes (n=33) and rWIT >30 minutes (n=129). Livers did not undergo any in situ or ex situ machine perfusion techniques. Biliary complications occurred at similar rates in both groups (p=0.5). Biliary strictures tended to be more common in the rWIT >30 minutes group, although without statistical significance (40% vs. 24%; p=0.1). The median serum bilirubin levels on day 5 were significantly higher in the rWIT >30-minute group (5.2 (IQR 2.6, 8.9) mg/dl vs. 3.7 (IQR 1.9, 5.9) mg/dl; p=0.013). Patients with rWIT >30 minutes required significantly more blood transfusions intraoperatively (p=0.021). There was a high tendency for higher severe complication rates in the rWIT >30-minute group, which was not significant (58% vs. 39%; p=0.054). Prolonged rWIT in LT was associated with a trend toward a higher incidence of bile duct strictures and elevated liver enzymes. However, due to the retrospective design and risk of selection bias, rWIT should be interpreted as one of several contributing factors. Our findings suggest that minimizing rWIT may support better outcomes, but causality cannot be definitively established.