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The aim of this study was to investigate the impact of hypoxia and hypotension during the agonal phase of donor warm ischemia time (DWIT) on hepatic ischemia/reperfusion injury (IRI) and complications in donation after circulatory death (DCD) liver transplantation. A retrospective single‐center study of 93 DCD liver transplants (Maastricht type III) was performed. DWIT was divided into 2 periods: the agonal phase (from withdrawal of treatment [WoT] until circulatory arrest) and the asystolic phase (circulatory arrest until cold perfusion). A drop to <80% in peripheral oxygenation (SpO 2 ) was considered as hypoxia in the agonal phase (SpO 2 ‐agonal) and a drop to <50 mm Hg as hypotension in the agonal phase (SBP‐agonal). Peak postoperative aspartate transaminase level >3000 U/L was considered as severe hepatic IRI. SpO 2  dropped within 2 minutes after WoT <80%, whereas the systolic blood pressure dropped to <50 mm Hg after 9 minutes, resulting in a longer SpO 2 ‐agonal (13 minutes) than SBP‐agonal (6 minutes). In multiple logistic regression analysis, only duration of SpO 2 ‐agonal was associated with severe hepatic IRI ( P  = 0.006) and not SBP‐agonal ( P  = 0.32). Also, recipients with long SpO 2 ‐agonal (>13 minutes) had more complications with a higher Comprehensive Complication Index during hospital admission (43.0 versus 32.0;  P  = 0.002) and 90‐day graft loss (26% versus 6%;  P  = 0.01), compared with recipients with a short SpO 2 ‐agonal (≤13 minutes). Furthermore, Cox proportional hazard modeling identified a long SpO 2 ‐agonal as a risk factor for longterm graft loss (hazard ratio, 3.30; 95% confidence interval, 1.15‐9.48;  P  = 0.03). In conclusion, the onset of hypoxia during the agonal phase is related to the severity of hepatic IRI and postoperative complications. Therefore, SpO 2  <80% should be considered as the start of functional DWIT in DCD liver transplantation.

Onset of Donor Warm Ischemia Time in Donation After Circulatory Death Liver Transplantation: Hypotension or Hypoxia?