Impact of De Novo Portal Vein Thrombosis on Liver Transplantation Outcomes in the US.

Abstract

Although portal vein thrombosis (PVT) is well-characterized in the pretransplant setting, de novo PVT after liver transplantation (LT) remains poorly defined. Little is known about its incidence, timing patterns, or impact on long-term outcomes in adult deceased-donor LT (DDLT). Using a national multicenter electronic health record network (~101 million US adults), this retrospective cohort identified DDLT recipients without preexisting or intraoperative PVT (1995 to 2025). De novo PVT was defined as new thrombosis after postoperative day 1 (POD 1) and classified as early (POD 1 to 30) or late (>POD 30). Propensity score matching (1:1) balanced demographics, comorbidities, medications, and laboratory data. Outcomes included all-cause mortality, retransplantation, early allograft dysfunction, all-cause hospitalization, and rejection. Risks were estimated using Cox and logistic regression, with survival evaluated by Kaplan-Meier analysis. Among 21,758 DDLT recipients, 1,049 (4.8%) developed de novo PVT, 71% after POD 30. After matching (1,018 per group), de novo PVT was associated with higher 5-year risks of mortality (adjusted hazard ratio [aHR] 1.29; 95% CI 1.03 to 1.63), retransplantation (aHR 2.08; 1.51 to 2.88), all-cause hospitalization (aHR 1.19; 1.08 to 1.31), and rejection (aHR 1.57; 1.37 to 1.79). Early allograft dysfunction odds were also increased (adjusted odds ratio 1.46; 1.22 to 1.75). Risk patterns persisted across 1-, 3-, and 5-year follow-up. Kaplan-Meier showed lower overall survival (p = 0.027) and reduced freedom from retransplantation (p < 0.0001) in the PVT group. Early and late PVT had comparable mortality and hospitalization risks, but late PVT carried higher rejection risk. De novo PVT affects ~5% of DDLT recipients and is associated with worse outcomes. This underrecognized complication warrants closer surveillance and further study.