Intraoperative Anesthetic Parameters Predict Early Allograft Dysfunction in Pediatric Living Donor Liver Transplantation

Background: Early allograft dysfunction (EAD) is a major complication of pediatric liver transplantation associated with prolonged ICU stay, increased mortality, and graft loss. Existing risk models focus on donor and surgical variables; the contribution of intraoperative anesthetic management remains poorly characterized in pediatric living donor liver transplantation (LDLT). Methods: We conducted a retrospective single-center cohort study of 124 consecutive pediatric LDLT recipients. Three intraoperative anesthetic parameters were evaluated as predictors of EAD (Olthoff criteria): relative mean arterial pressure (MAP) drop (%), norepinephrine (NE) infusion duration (min), and peak intraoperative lactate (mmol/L). Discriminative performance was assessed by receiver operating characteristic (ROC) analysis. Multivariable Firth penalized logistic regression addressed near-complete separation. Internal validation used bootstrap resampling (1000 iterations). Results: The cohort (median age 18.5 months, IQR 8.0–96.0; biliary atresia the most common indication) included 50 patients (40.3%) with EAD. All three parameters showed excellent univariable discrimination: NE duration (AUC = 0.993), peak lactate (AUC = 0.936), and MAP drop (AUC = 0.894); all p < 0.001. Three preoperative variables (hemoglobin, bilirubin, albumin) reached univariable significance (all p < 0.05) but with modest discrimination (AUC 0.384–0.617), markedly inferior to all intraoperative parameters (AUC 0.894–0.996). In the multivariable model, MAP drop (OR 22.27; 95% CI 1.80–275.4; p = 0.016) and NE duration (OR 3066657; p = 0.018) independently predicted EAD. The combined model achieved AUC = 0.999 (bootstrap 95% CI: 0.994–1.000; Brier score = 0.013). NE duration ≥ 70 min yielded sensitivity 1.000 and NPV 1.000. EAD-positive patients had significantly longer ICU stay (5 vs. 3 days; p = 0.004) and mechanical ventilation duration (24 vs. 0 h; p < 0.001). Conclusions: Intraoperative anesthetic parameters—particularly NE duration and MAP drop—are powerful independent predictors of EAD in pediatric LDLT, substantially outperforming preoperative variables, three of which reached statistical significance but with markedly lower discriminative power. Intraoperative hemodynamic management may represent a modifiable determinant of early graft outcomes. External validation is warranted.