Table 2.
Risk factors for posthepatectomy liver failure
| Patient-associated | |
| Sex | Risk double in males, especially males with HCC |
| Female hormones show proliferative effect in animal models, inhibiting effect of testosterone on immune system | |
| NAFLD, lower postoperative risk than other chronic liver diseases, higher incidence in postmenopausal women | |
| Age | Still unclear, possible changes in bile flow and acute-phase protein production |
| Age-related sinusoidal pseudocapillarization, rescue in animal models through serotonin agonist injection | |
| Sepsis | Bacterial endotoxins decrease cytokine production needed for liver regeneration |
| Kupffer cell and hepatocyte function in liver regeneration inhibited | |
| Metabolism | Insulin induces expression of IGF and HGF |
| High BMI and malnutrition associated with PHLF | |
| Other | Serum bilirubin, low platelets, insufficient renal function, cardiopulmonary disease, associated with PHLF |
| Liver-associated | |
| Steatosis | Leads to changes in the hepatic microenvironment and higher risk for ischaemia–reperfusion injury |
| Neoadjuvant chemotherapy | Chemotherapy-associated liver injury and steatohepatitis are known complications after neoadjuvant chemotherapy |
| Fibrosis grade | Functional liver tissue reserve is reduced, patients often present with several comorbidities |
| Cholestasis | Jaundice increases morbidity after surgery; in animal models, bile duct ligation leads to reduced growth factor expression |
| Portal hypertension | High preoperative portal pressure in cirrhosis associated with increased risk of PHLF |
| Surgery-associated | |
| Future liver remnant | ‘Small-for-flow’ syndrome negatively impacts hepatic haemodynamics |
| Increase in portal pressure leads to altered hepatic microcirculation and hepatocyte damage | |
| Blood loss | Leads to intravascular fluid shifts, introduction of bacterial endotoxins into the hepatic microenvironment |
| Increased risk of sepsis, coagulopathy and PHLF | |
| Surgical technique | Vascular occlusion can cause ischaemia–reperfusion injury and in increases PHLF risk |
| Long Pringle manoeuvre leads to increased oxidative stress and overshooting inflammatory response | |
| Extensive vascular resection can cause PHLF | |
HCC, hepatocellular carcinoma; NAFLD, non-alcoholic fatty liver disease; IGF, insulin-like growth factor; HGF, hepatocyte growth factor; PHLF, posthepatectomy liver failure.