Cumulative Postoperative Change In Serum Albumin Levels And Organ Failure After Living-donor Liver Transplantation: A Retrospective Cohort Analysis

Yoonjee Cho, Ja Eun Lee, Heejoon Jeong, Ji-Hye Kwon, Yu Jeong Bang, Gaabsoo Kim


Many studies have reported that hypoalbuminemia could be associated with organ failure after liver transplantation. However, most of them focused on serum albumin levels measured at specific time points and not on the trend of serum albumin change. We investigated whether a cumulative postoperative change in serum albumin level up to postoperative day (POD) 5 is related to organ failure in patients who underwent living-donor liver transplantation (LDLT). Data of adult recipients who underwent LDLT between January 2016 and December 2020 at a single tertiary hospital were reviewed (n = 399). After screening, three patients were excluded because of insufficient data. A cumulative change in serum albumin level was demonstrated using the area under the threshold (AUT, threshold = 3.0 g/dL) of the serum albumin curve up to POD 5. Based on the AUT, the patients were divided into a high-decrease group (n = 156) and a low-decrease group (n = 240). 


Liver transplantation is a life-saving procedure for patients with end-stage liver disease [1]. Despite advances in medical therapy, liver transplantation has become the most effective treatment option for end-stage liver disease [2]. Recently, living-donor liver transplantation (LDLT) compared with deceased-donor liver transplantation, has offed a clear survival benefit to patients undergoing early transplantation [3]. LDLT can reduce the risk of worsening the recipient’s liver condition and result in better outcomes for the recipients because they are receiving a relatively healthy liver compared to deceased donor liver transplantation [4]. Moreover, improvements in surgical techniques and perioperative management have contributed to the recent widespread use of LDLT [4].

Materials and Methods

Study design and ethical statements

The present study was a retrospective analysis of the medical records of all patients who received living-donor liver transplantation at a single tertiary medical center in South Korea. The study was approved by the Institutional Review Board of the Samsung Medical Center (approval no: SMC 2021-04-012-001; date of approval: April 6, 2021). The Institutional Review Board waived the need for written informed consent from participants due to the non-interventional design of the retrospective study. We adhered to the Strengthening the Reporting of Observational Studies in Epidemiology checklist for reporting this study [13]. All methods were performed in accordance with the ethical principles of the 1964 Declaration of Helsinki and its later amendments and were carried out following the approved guidelines.


A total of 399 patients underwent LDLT at our institute between January 2016 and December 2020. After screening their medical records, three patients were excluded because of insufficient data: death within five days postoperatively (n = 1) and no preoperative serum albumin data (n = 2). Therefore, a total of 396 patients were included in the analysis. After 1:1 propensity score matching, 162 patients (81 in each group) were analyzed (Fig 2). The patient demographics and perioperative data are shown in Table 1.


Therefore, we explored different methods that focus on the cumulative change in serum albumin levels. According to a previous study, a feasible method using the area under the threshold can provide comprehensive insight to assess variables that frequently change during the study period, such as blood pressure [16]. Considering that serum albumin levels also frequently change after LDLT, the postoperative course of serum albumin can be identified more clearly through the new approach. Moreover, the AUT method added up only the area below the threshold. Even if serum albumin level rose over the threshold after supplementation of human albumin, it was not counted toward the final AUT value. This is thought to have contributed to reducing the bias caused by albumin supplementation during the study period.


In conclusion, a cumulative postoperative change in serum albumin levels up to POD 5 could predict postoperative organ failure in patients who underwent LDLT. A prospective controlled trial is warranted to determine the feasibility of new measurement using the area under the threshold of the serum albumin curve.

Citation: Cho Y, Lee JE, Jeong H, Kwon J-H, Bang YJ, Kim G (2023) Cumulative postoperative change in serum albumin levels and organ failure after living-donor liver transplantation: A retrospective cohort analysis. PLoS ONE 18(5): e0285734.

Editor: Robert Jeenchen Chen, Stanford University School of Medicine, UNITED STATES

Received: January 10, 2023; Accepted: April 28, 2023; Published: May 11, 2023

Copyright: © 2023 Cho et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: Data file is available from the figshare database (

Funding: the authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

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