What is the optimal anesthetic monitoring regarding immediate and short-term outcomes after liver transplantation?-A systematic review of the literature and expert panel recommendations.

BACKGROUND: Liver transplant centers vary in approach to intraoperative vascular accesses, monitoring of cardiac function and temperature management. Evidence is limited regarding impact of selected modalities on postoperative outcomes. OBJECTIVES: To review the literature and provide expert panel recommendations on optimal intraoperative arterial blood pressure (BP), central venous pressure (CVP), and vascular accesses, monitoring of cardiac function and intraoperative temperature management regarding immediate and short-term outcomes after orthotopic liver transplant (OLT). METHODS: Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. Recommendations made for: (1) Vascular accesses, arterial BP and CVP monitoring, (2) cardiac function monitoring, and (3) Intraoperative temperature management (CRD42021239908). RESULTS: Of 2619 articles screened 16 were included. Studies were small, retrospective, and observational. Vascular access studies demonstrated low rates of insertion complications. TEE studies demonstrated low rates of esophageal hemorrhage. One study found lower hospital-LOS and 30-day mortality in patients monitored with both PAC and TEE. Other monitoring studies were heterogenous in design and outcomes. Temperature studies showed increased blood transfusion and ventilation times in hypothermic groups. CONCLUSIONS: Recommendations were made for; routine arterial and CVP monitoring as a minimum standard of practice, consideration of discrepancy between peripheral and central arterial BP in patients with hemodynamic instability and high vasopressor requirements, and routine use of high flow cannulae while monitoring for extravasation and hematoma formation. Availability and expertise in PAC and/or TEE monitoring is strongly recommended particularly in hemodynamic instability, portopulmonary HT and/or cardiac dysfunction. TEE use is recommended as an acceptable risk in patients with treated esophageal varices and is an effective diagnostic tool for emergency cardiovascular collapse. Maintenance of intraoperative normothermia is strongly recommended.

Validation of predictive models identifying patients at risk for massive transfusion during liver transplantation and their potential impact on blood bank resource utilization.

BACKGROUND: Intraoperative massive transfusion (MT) is common during liver transplantation (LT). A predictive model of MT has the potential to improve use of blood bank resources. STUDY DESIGN AND METHODS: Development and validation cohorts were identified among deceased-donor LT recipients from 2010 to 2016. A multivariable model of MT generated from the development cohort was validated with the validation cohort and refined using both cohorts. The combined cohort also validated the previously reported McCluskey risk index (McRI). A simple modified risk index (ModRI) was then created from the combined cohort. Finally, a method to translate model predictions to a population-specific blood allocation strategy was described and demonstrated for the study population. RESULTS: Of the 403 patients, 60 (29.6%) in the development and 51 (25.5%) in the validation cohort met the definition for MT. The ModRI, derived from variables incorporated into multivariable model, ranged from 0 to 5, where 1 point each was assigned for hemoglobin level of less than 10 g/dL, platelet count of less than 100 × 109 /dL, thromboelastography R interval of more than 6 minutes, simultaneous liver and kidney transplant and retransplantation, and a ModRI of more than 2 defined recipients at risk for MT. The multivariable model, McRI, and ModRI demonstrated good discrimination (c statistic [95% CI], 0.77 [0.70-0.84]; 0.69 [0.62-0.76]; and 0.72 [0.65-0.79], respectively, after correction for optimism). For blood allocation of 6 or 15 units of red blood cells (RBCs) based on risk of MT, the ModRI would prevent unnecessary crossmatching of 300 units of RBCs/100 transplants. CONCLUSIONS: Risk indices of MT in LT can be effective for risk stratification and reducing unnecessary blood bank resource utilization.

Outcomes After Extracorporeal Cardiopulmonary Resuscitation of Pediatric In-Hospital Cardiac Arrest: A Report From the Get With the Guidelines-Resuscitation and the Extracorporeal Life Support Organization Registries.

OBJECTIVES: The aim of this study was to determine cardiac arrest- and extracorporeal membrane oxygenation-related risk factors associated with unfavorable outcomes after extracorporeal cardiopulmonary resuscitation. DESIGN: We performed an analysis of merged data from the Extracorporeal Life Support Organization and the American Heart Association Get With the Guidelines-Resuscitation registries. SETTING: A total of 32 hospitals reporting to both registries between 2000 and 2014. PATIENTS: Children younger than 18 years old who suffered in-hospital cardiac arrest and underwent extracorporeal cardiopulmonary resuscitation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of the 593 children included in the final cohort, 240 (40.5%) died prior to decannulation from extracorporeal membrane oxygenation and 352 (59.4%) died prior to hospital discharge. A noncardiac diagnosis and preexisting renal insufficiency were associated with increased odds of death (adjusted odds ratio, 1.85 [95% CI, 1.19-2.89] and 4.74 [95% CI, 2.06-10.9], respectively). The median time from onset of the cardiopulmonary resuscitation event to extracorporeal membrane oxygenation initiation was 48 minutes (interquartile range, 28-70 min). Longer time from onset of the cardiopulmonary resuscitation event to extracorporeal membrane oxygenation initiation was associated with higher odds of death prior to hospital discharge (adjusted odds ratio for each 5 additional minutes of cardiopulmonary resuscitation prior to extracorporeal membrane oxygenation initiation, 1.04 [95% CI, 1.01-1.07]). Each individual adverse event documented during the extracorporeal membrane oxygenation course, including neurologic, pulmonary, renal, metabolic, cardiovascular and hemorrhagic, was associated with higher odds of death, with higher odds as the cumulative number of documented adverse events during the extracorporeal membrane oxygenation course increased. CONCLUSIONS: Outcomes after extracorporeal cardiopulmonary resuscitation reported by linking two national registries are encouraging. Noncardiac diagnoses, preexisting renal insufficiency, longer time from onset of the cardiopulmonary resuscitation event to extracorporeal membrane oxygenation initiation, and adverse events during the extracorporeal membrane oxygenation course are associated with worse outcomes.

Predictive Modeling of Massive Transfusion Requirements During Liver Transplantation and Its Potential to Reduce Utilization of Blood Bank Resources.

BACKGROUND: Patients undergoing liver transplantation frequently but inconsistently require massive blood transfusion. The ability to predict massive transfusion (MT) could reduce the impact on blood bank resources through customization of the blood order schedule. Current predictive models of MT for blood product utilization during liver transplantation are not generally applicable to individual institutions owing to variability in patient population, intraoperative management, and definitions of MT. Moreover, existing models may be limited by not incorporating cirrhosis stage or thromboelastography (TEG) parameters. METHODS: This retrospective cohort study included all patients who underwent deceased-donor liver transplantation at the Johns Hopkins Hospital between 2010 and 2014. We defined MT as intraoperative transfusion of > 10 units of packed red blood cells (pRBCs) and developed a multivariable predictive model of MT that incorporated cirrhosis stage and TEG parameters. The accuracy of the model was assessed with the goodness-of-fit test, receiver operating characteristic analysis, and bootstrap resampling. The distribution of correct patient classification was then determined as we varied the model threshold for classifying MT. Finally, the potential impact of these predictions on blood bank resources was examined. RESULTS: Two hundred three patients were included in the study. Sixty (29.6%) patients met the definition for MT and received a median (interquartile range) of 19.0 (14.0-27.0) pRBC units intraoperatively compared with 4.0 units (1.0-6.0) for those who did not satisfy the criterion for MT. The multivariable model for predicting MT included Model for End-stage Liver Disease score, whether simultaneous liver and kidney transplant was performed, cirrhosis stage, hemoglobin concentration, platelet concentration, and TEG R interval and angle. This model demonstrated good calibration (Hosmer-Lemeshow goodness-of-fit test P = .45) and good discrimination (c statistic: 0.835; 95% confidence interval, 0.781-0.888). A probability cutoff threshold of 0.25 was found to misclassify only 4 of 100 patients as unlikely to experience MT, with the majority such misclassifications within 4 units of the working definition for MT. For this threshold, a preoperative blood ordering schedule that allocated 6 units of pRBCs for those unlikely to experience MT and 15 for those who were likely to experience MT would prevent unnecessary crossmatching of 338 units/100 transplants. CONCLUSIONS: When clinical and laboratory parameters are included, a model predicting intraoperative MT in patients undergoing liver transplantation is sufficiently accurate that its predictions could guide the blood order schedule for individual patients based on institutional data, thereby reducing the impact on blood bank resources. Ongoing evaluation of model accuracy and transfusion practices is required to ensure continuing performance of the predictive model.

Plasma Biomarkers of Brain Injury as Diagnostic Tools and Outcome Predictors After Extracorporeal Membrane Oxygenation.

OBJECTIVE: To determine if elevations in plasma brain injury biomarkers are associated with outcome at hospital discharge in children who require extracorporeal membrane oxygenation. DESIGN: Prospective observational study. SETTING: Single tertiary-care academic center. PARTICIPANTS: Eighty children who underwent extracorporeal membrane oxygenation between June 2010 and December 2013. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We measured six brain injury biomarkers (glial fibrillary acidic protein, monocyte chemoattractant protein 1/chemokine (C-C motif) ligand 2, neuron-specific enolase, S100b, intercellular adhesion molecule-5, and brain-derived neurotrophic factor) daily during extracorporeal membrane oxygenation, using an electrochemiluminescent multiplex assay. We recorded clinical, neuroimaging, and extracorporeal membrane oxygenation course data. We analyzed the association of biomarker concentrations with favorable versus unfavorable outcome at hospital discharge. Favorable outcome was defined as Pediatric Cerebral Performance Category 1, 2, or no change from baseline. Patients had a median age of 3 days (interquartile range, 1 d-10 mo), and 56% were male. Thirty-three of 80 (41%) had unfavorable outcome, and 22 of 70 (31%) had abnormal neuroimaging findings during or after extracorporeal membrane oxygenation. Peak concentrations were significantly higher in patients with unfavorable outcome than in those with favorable outcome for glial fibrillary acidic protein (p = 0.002), monocyte chemoattractant protein 1/chemokine (C-C motif) ligand 2 (p = 0.030), neuron-specific enolase (p = 0.006), and S100b (p = 0.015) and in patients with versus without abnormal neuroimaging findings for glial fibrillary acidic protein (p = 0.001) and intercellular adhesion molecule-5 (p = 0.001). The area under the receiver operator characteristic curve for unfavorable outcome was 0.73 for a noncollinear biomarker combination. After removing collinear biomarkers, the adjusted odds ratios for unfavorable outcome were 2.89 (95% CI, 1.09-7.73) for neuron-specific enolase, using a cutoff of 62.0 ng/mL, and 2.15 (95% CI, 1.06-4.38) for glial fibrillary acidic protein, using a cutoff of 0.46 ng/mL. CONCLUSIONS: Elevated plasma brain injury biomarker concentrations during the extracorporeal membrane oxygenation course are associated with unfavorable outcome and/or the presence of neuroimaging abnormalities. Combinations of brain-specific proteins increase the sensitivity and specificity for outcome prediction.

Patterns of medication exposures in hospitalized pediatric patients with acute renal failure requiring intermittent or continuous hemodialysis.

OBJECTIVES: Care for the pediatric patient with acute renal failure who requires hemodialysis (including continuous renal replacement therapy) is made more complex, as this intervention may significantly affect drug clearance, potentially altering, to a degree that is largely unknown, the effectiveness and safety of the multiple medications used to manage this complex patient population. This study aims to describe patterns of drug utilization among a large cohort of pediatric patients requiring hemodialysis and to document the easily accessible existing data available for dosing guidance of frequently prescribed medications. STUDY DESIGN: Retrospective cohort using the Pediatric Health Information System database. SETTING: Forty freestanding children's hospitals throughout the United States. PATIENTS: Two thousand seven hundred thirty-eight pediatric patients with acute renal failure treated with hemodialysis from 2007 to 2011. INTERVENTION: A retrospective review of all patients requiring hemodialysis from 2007 to 2011 was conduction using the Pediatric Health Information System Database. MAIN RESULTS: Over 6% of pediatric patients with acute renal failure treated with hemodialysis were exposed to hemodialysis for over 2 weeks. Cumulative exposure to distinct drugs increased substantially with more prolonged courses of hemodialysis. Of the 50 most frequently prescribed medications in the cohort with acute renal failure treated with hemodialysis, 10% have readily available and easily accessible information to guide dosing adjustments with the use of hemodialysis. Furthermore, only 18% of these medications have clear recommendations for dosing in pediatric patients of all age groups with renal failure. CONCLUSIONS: Pediatric patients with acute renal failure managed with hemodialysis are exposed to a broad variety of medications, with a high prevalence of polypharmacy. There is a trend for longer courses of hemodialysis in these patients, which leads to an increase in cumulative drug exposure, complexity of drug interactions, and potential toxicity. For the vast majority of medications that are being used to treat this complex patient population, pediatric dosing guidance is not easily accessible. These findings underscore the need for targeted pharmacologic studies of medications used in the pediatric population managed with hemodialysis.

Donor BMI and Post-living Donor Liver Transplantation Outcomes: A Preliminary Report.

Living liver donor obesity has been considered a relative contraindication to living donation given the association with hepatic steatosis and potential for poor donor and recipient outcomes. We investigated the association between donor body mass index (BMI) and donor and recipient posttransplant outcomes. Methods: We studied 66 living donors and their recipients who underwent living donor liver transplant at our center between 2013 and 2020. BMI was divided into 3 categories (<25, 25-29.9, and ≥30 kg/m2). Magnetic resonance imaging-derived proton density fat fraction was used to quantify steatosis. Donor outcomes included length of stay (LOS), emergency department visits within 90 d, hospital readmissions within 90 d, and complication severity. Recipient outcomes included LOS and in-hospital mortality. The Student t test was used to compare normally distributed variables, and Kruskal-Wallis tests were used for nonparametric data. Results: There was no difference in donor or recipient characteristics based on donor BMI. There was no significant difference in mean magnetic resonance imaging fat percentage among the 3 groups. Additionally, there was no difference in donor LOS (P = 0.058), emergency department visits (P = 0.64), and hospital readmissions (P = 0.66) across BMI category. Donor complications occurred in 30 patients. There was no difference in postdonation complications across BMI category (P = 0.19); however, there was a difference in wound complications, with the highest rate being seen in the highest BMI group (0% versus 16% versus 37%; P = 0.041). Finally, there was no difference in recipient LOS (P = 0.83) and recipient in-hospital mortality (P = 0.29) across BMI category. Conclusions: Selecting donors with BMI ≥30 kg/m2 can result in successful living donor liver transplantation; however, they are at risk for perioperative wound complications. Donor counseling and perioperative strategies to mitigate wound-related issues should be used when considering obese living donors.

High Coronary Artery Calcium Score Is Associated With Increased Major Adverse Cardiac Events After Liver Transplantation.

Liver transplantation (LT) candidates frequently have multiple cardiovascular risk factors, and cardiovascular disease is a major cause of morbidity and mortality after LT. Coronary artery calcium (CAC) scores are a noninvasive assessment of coronary artery disease using computed tomography. This study examines CAC scores and cardiac risk factors and their association with outcomes after LT. Methods: Patients who underwent LT between January 2010 and June 2019 with a pretransplant CAC score were included in this study. Patients were divided by CAC score into 4 groups (CAC score 0, CAC score 1-100, CAC score 101-400, CAC score >400). Major adverse cardiovascular events (MACEs) were defined as myocardial infarction, stroke, revascularization, heart failure, atrial fibrillation, and cardiovascular death. Associations between CAC score and MACE or all-cause mortality within the 5-y post-LT follow-up period were analyzed using Cox regression. Statistical significance was defined as P < 0.05. Results: During the study period, 773 adult patients underwent their first LT, and 227 patients met our study criteria. The median follow-up time was 3.4 (interquartile range 1.9, 5.3) y. After 5 y, death occurred in 47 patients (20.7%) and MACE in 47 patients (20.7%). In multivariable analysis, there was no difference in death between CAC score groups. There was significantly higher risk of MACE in the CAC score >400 group, with a hazard ratio 2.58 (95% confidence interval 1.05, 6.29). Conclusions: CAC score was not associated with all-cause mortality. Patients with CAC score >400 had an increase in MACEs within the 5-y follow-up period compared with patients with a CAC score = 0. Further research with larger cohorts is needed to examine cardiac risk stratification in this vulnerable patient population.

Comprehensive quality initiative leads to immediate postoperative extubation following liver transplant.

BACKGROUND: Immediate postoperative extubation (IPE) can reduce perioperative complications and length of stay (LOS), however it is performed variably after liver transplant across institutions and has historically excluded high-risk recipients from consideration. In late 2012, we planned and implemented a single academic institution structured quality improvement (QI) initiative to standardize perioperative care of liver transplant recipients without exceptions. We hypothesized that such an approach would lead to a sustained increase in IPE after primary (PAC) and delayed abdominal closure (DAC). METHODS: We retrospectively studied 591 patients from 2013 to 2018 who underwent liver transplant after initiative implementation. We evaluated trends in incidence of IPE versus delayed extubation (DE), and reintubation, LOS, and mortality. RESULTS: Overall, 476/591 (80.5%) recipients underwent PAC (278 IPE, 198 DE) and 115/591 (19.5%) experienced DAC (39 IPE, 76 DE). When comparing data from 2013 to data from 2018, the incidence of IPE increased from 9/67 (13.4%) to 78/90 (86.7%) after PAC and from 1/12 (8.3%) to 16/23 (69.6%) after DAC. For the same years, the incidence of IPE after PAC for recipients with MELD scores ≥30 increased from 0/19 (0%) to 12/17 (70.6%), for recipients who underwent simultaneous liver-kidney transplant increased from 1/8 (12.5%) to 4/5 (80.0%), and for recipients who received massive transfusion (>10 units of packed red blood cells) increased from 0/17 (0%) to 10/13 (76.9%). Reintubation for respiratory considerations <48 h after IPE occurred in 3/278 (1.1%) after PAC and 1/39 (2.6%) after DAC. IPE was associated with decreased intensive care unit (HR of discharge: 1.92; 95% CI: 1.58, 2.33; P < 0.001) and hospital LOS (HR of discharge: 1.45; 95% CI: 1.20, 1.76; P < 0.001) but demonstrated no association with mortality. CONCLUSION: A structured QI initiative led to sustained high rates of IPE and reduced LOS in all liver transplant recipients, including those classified as high risk.

Intraoperative Type I Acute Myocardial Infarction During Liver Transplant Requiring Intra-Aortic Balloon Pump: A Case Report.

We describe a complex case of liver transplant in a 70-year-old male patient with no known history of coronary artery disease, normal preoperative left ventricular function, and negative preoperative cardiac workup who developed progressive intra-operative left ventricular myocardial dysfunction secondary to class I acute myocardial infarction, ultimately requiring intraoperative intra-aortic balloon pump insertion to optimize myocardial perfusion. Management of myocardial ischemia was complicated by bleeding in the setting of coagulopathy necessitating correction. Once hemostasis was achieved, the patient immediately underwent coronary angiography and bare metal stent placement in the mid-left anterior descending coronary artery for an acute plaque rupture.

Transplant of SARS-CoV-2-infected Living Donor Liver: Case Report.

Given the high community prevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), transplant programs will encounter SARS-CoV-2 infections in living donors or recipients in the perioperative period. There is limited data on SARS-CoV-2 viremia and organotropism beyond the respiratory tract to inform the risk of transplant transmission of SARS-CoV-2. We report a case of a living donor liver transplant recipient who received a right lobe graft from a living donor with symptomatic PCR-confirmed SARS-CoV-2 infection 3 d following donation. The donor was successfully treated with remdesivir, dexamethasone, and coronavirus disease 2019 (COVID-19) convalescent plasma. No viral transmission was identified, and both donor and recipient had excellent postoperative outcomes.

Neurologic Outcomes in a Two-Center Cohort of Neonatal and Pediatric Patients Supported on Extracorporeal Membrane Oxygenation.

Contemporary studies of long-term outcomes in children supported on extracorporeal membrane oxygenation (ECMO) in the United States are limited. We enrolled 99 ECMO patients between July 2010 and June 2015 in a two-center prospective observational study that included neurologic and neuropsychologic evaluation at 6 and 12 months, using standardized outcome measures. Pre-ECMO, 20 (20%) had a pre-existing neurologic diagnosis, 40 (40%) had cardiac arrest, and 10 of 47 (21%) children with neuroimaging had acute abnormal findings. Of 50 children eligible for follow-up at 6 or 12 months, 40 (80%) returned for at least one visit. At the follow-up visit of longest interval from ECMO, the median Vineland Adaptive Behavior Scales-II (VABS-II) score was 91 (interquartile range [IQR], 81-98), the median Pediatric Stroke Outcome Measure (PSOM) score was 1 (IQR, 0-2), and the median Mullen Scales of Early Learning composite score was 85 (IQR, 72-96). Presence of new neuroimaging abnormalities during ECMO or within 6 weeks post-ECMO was associated with VABS-II score <85 or death within 12 months after ECMO. The Pediatric Cerebral Performance Category at hospital discharge showed a strong relationship with unfavorable VABS-II and PSOM scores at 6 or 12 months after ECMO. In this study, we report a higher prevalence of pre-ECMO neurologic conditions than previously described. In survivors to hospital discharge, median scores for adaptive behavior and cognitive, neurologic, and quality of life assessments were all below the general population means, but most deficits would be considered minor within each of the domains tested.

Cardiac Events Within the 30-Day Postoperative Period Is Associated With Increased 1-Year Mortality Among Deceased-Donor Liver Transplant Recipients.

OBJECTIVES: Each year in the United States, approximately 40000 patients with a liver disorder will progress to end-stage liver disease and about 30000 of those patients will subsequently die from this condition. Liver transplant remains the definitive treatment option for end-stage liver disease, and understanding the causes of posttransplant mortality is an ongoing area of investigation. MATERIALS AND METHODS: In this retrospective cohort study, patients who underwent orthotopic liver transplant between January 2012 and January 2015 at the Johns Hopkins Hospital Liver Transplant Program were reviewed by a single reviewer for cardiac events in the 30 days after transplant or during the index admission. RESULTS: Of the 145 patients included, 30 (20.6%) were identified as having experienced a cardiac event during the defined postoperative period. Overall 1-year mortality for the cohort of 145 patients was 11.7%; however, 1-year mortality in those who had a cardiac event was 36.7% compared with 5.2% in the noncardiac event group (odds ratio = 18.17; P < .001). Although there was a statistically significant difference in age between the groups (58.6 vs 52.3 years old), once accounted for in multivariate analysis, a posttransplant cardiac event was still a statistically significant variable in 1-year mortality (odds ratio = 89.16; 95% confidence interval, 2.71-2933.95; P = .012). Similarly, hepatocellular carcinoma, sex, age, and presence of diabetes had little effect on 1-year mortality when we compared those patients who experienced a cardiac event in the first 30 days versus those who did not (odds ratio = 100.82; 95% confidence interval, 2.15-4726.12; P = .019). CONCLUSIONS: Recipients who experience cardiac events within 30 days after transplant have increased 1-year posttransplant mortality. This highlights the importance of cardiac risk stratification before transplant.

Use of Intravenous Acetaminophen in Children for Analgesia After Spinal Fusion Surgery: A Randomized Clinical Trial.

OBJECTIVES: Opioid pharmacotherapy is the cornerstone of postoperative analgesia. Despite its effectiveness, it has a variety of potential adverse effects. Therefore, a multimodal approach with non-opioid analgesics would be optimal. The aim of this study was to determine if intravenous (IV) acetaminophen would reduce opioid requirements and improve clinical outcomes in children after surgery. METHODS: A single-center, randomized, double-blind study was conducted in 57 children (10-18 years old) undergoing posterior spine fusion surgery between July 2011 to May 2014. All subjects received either acetaminophen or placebo at the end of surgery, followed by repeated doses every 6 hours for a total of 8 doses. RESULTS: In the first 24 postoperative hours, the average opioid consumption was lower for the active group compared with the placebo group (p = 0.02). The total unadjusted time to patient controlled analgesia (PCA) discontinuation was also longer in the placebo group than the active group (90 hours vs. 73 hours, p = 0.02); however, this was not statistically significant after normalizing for body weight. Additionally, time to first solid intake was longer without the use of acetaminophen (69 hours vs. 49 hours, p = 0.01). CONCLUSIONS: Postoperative use of IV acetaminophen was associated with earlier time to diet advancement and discontinuation of IV analgesics and may result in lower opioid consumption.

Preoperative Echocardiographic Differences and Transplant Outcomes Among Patients Receiving Simultaneous Liver-Kidney Versus Liver Transplant Alone.

OBJECTIVES: Liver transplant and simultaneous liver-kidney transplant are major surgeries performed on high-risk individuals with end-stage liver disease and end-stage renal disease. We sought to examine the relationship between pretransplant echocardiographic parameters and outcomes in our simultaneous liver-kidney transplant and liver transplant-alone populations. MATERIALS AND METHODS: In our retrospective analysis, we included adult patients who underwent index transplant from January 1, 2010 to December 31, 2015 at Johns Hopkins Comprehensive Transplant Center. RESULTS: Our study included 312 patients, 266 who underwent liver transplant alone and 46 who underwent simultaneous liver-kidney transplant. Baseline population demographics were similar in both groups of patients. Primary diagnosis at transplant was similar in both groups except that patients undergoing liver transplant were more likely to have a diagnosis of hepatocellular carcinoma, whereas those undergoing simultaneous liver-kidney transplant were more likely to have polycystic kidney disease. Within the liver transplant-alone group, the strongest demographic predictor of poor outcome was age at transplant. The strongest echocar diographic predictors were related to elevated left ventricular ejection fraction and right ventricular systolic pressure. CONCLUSIONS: In our investigation regarding whether the pretransplant cardiovascular evaluation predicted outcomes for patients undergoing liver transplant alone and patients undergoing simultaneous liver-kidney transplant, we found that elevations in right ventricular systolic pressure and left ventricular ejection fraction may be associated with poor outcomes in the posttransplant period.