Higher vs standard mean arterial pressure target in the immediate postoperative period of liver transplantation to prevent acute kidney injury: A randomized clinical trial (LIVER-PAM).

Acute kidney injury (AKI) is a frequent complication after liver transplantation, with an incidence up to 81%, and is associated with impaired long-term renal function, graft survival, and increased mortality. Hypotension is a modifiable risk factor, and while maintaining a mean arterial pressure (MAP) >65 mmHg is standard practice, higher targets may improve outcomes. The LIVER-PAM trial was an open-label, single-center, randomized clinical trial including 174 adult patients treated in an intensive care unit after liver transplantation. Patients were randomized to a higher MAP target (85-90 mmHg) or a standard target (65-70 mmHg) during the first 24 postoperative hours. The primary outcome was AKI incidence within 7 days. Secondary outcomes included major adverse kidney events at 28 days, graft rejection, and 11 additional endpoints. AKI occurred in 69.7% of patients in the higher MAP group and 69.4% in the standard MAP group (relative risk [RR], 1.00; 95% confidence interval (CI), 0.82-1.22; P = .97). Major adverse kidney events at 28 days was lower in the higher MAP group (56.1% vs 72.9%; RR 0.77, 95% CI, 0.61-0.96, P = .02. Graft rejection requiring pulse therapy was more frequent in the higher MAP group (12.5% vs 3.5%; RR, 3.54; 95% CI, 1.02-12.25; P = .03). A higher MAP target did not reduce AKI incidence within 7 days postliver transplantation.