Abstract Objectives: An optimal initial graft function after living- donor liver transplant depends on optimal graft hemodynamics. Nonmechanical impediments to free hepatic venous outflow, due to elevated central venous pressure, may obstruct the “functional” hepatic venous outflow. Here, we evaluated whether central venous pressure affected early graft function and outcomes in adult living-donor liver transplant recipients. Materials and Methods: This prospective observational study included 61 living-donor liver transplant recipients without technical complications who received transplants from August 2013 to November 2014. Hemodynamic variables were measured preoperatively, at anhepatic phase, 30 minutes postreperfusion, at end of surgery, and during postoperative days 1-5. Results: Patients with high central venous pressure showed functional hepatic venous outflow obstruction, which caused delayed recovery of graft function. Although postoperative central venous pressure was the only identified independent risk factor for mortality, all 5 deaths in our study group occurred in those who had high central venous pressure at the anhepatic, postreperfusion, end of surgery, and postoperative phases. A postoperative central venous pressure value of ~11 mm Hg was determined to be the cutoff for high-risk mortality, with area under the curve of 0.859 (sensitivity of 80%, specificity of 68%). Increased central venous pressure was associated with increased portal venous pressure (increase of 45%, range, 28%-89%; P = .001). Central venous pressure at end of surgery (r = 0.45, P ≤ .001) and at posttransplant time points (r = 0.29, P = .02) correlated well with portal venous pressure at end of surgery. Other risk factors for early allograft dysfunction were Model for End-Stage Liver Disease and cardiac output post- transplant. Conclusions: High central venous pressure, modulating portal venous pressure, can result in functional hepatic venous outflow obstruction, causing delayed graft function recovery and increased risk of mortality. Maintaining a central venous pressure below 11 mm Hg is beneficial. Key words: Central venous pressure, Endotoxemia, Graft dysfunction, Mortality, Portal venous pressure Introduction Optimal initial graft function after living-donor liver transplant (LDLT) depends on graft hemodynamics, which is influenced by inflow, outflow, and graft- related factors such as graft recipient weight ratio and compliance. 1,2 Consensus regarding the ideal hemodynamic goals during liver transplant or post- operatively is mixed. How mechanical components of inflow and outflow affect graft outcomes has been well studied, and a number of technical refinements such as venoplasty and inflow modulation have been suggested to optimize these. 1,3,4 Studies have revealed that preservation of functional liver mass and prevention of an outflow obstruction are essential to prevent small-for-size syndrome in size- reduced livers. 5 Outflow obstruction in the form of middle hepatic venous occlusion has also been identified as an independent predictor of mortality. 6 However, one other important factor that might Copyright © Başkent University 2018 Printed in Turkey. All Rights Reserved. Impact of Functional Hepatic Venous Outflow Obstruction on Perioperative Outcome After Living-Donor Liver Transplant Murali Appukuttan, 1 Senthil Kumar, 1 Kishore Gurumoorthy Subramanya Bharathy, 1 Vijay Kant Pandey, 2 Viniyendra Pamecha 1 From the 1 Department of Liver Transplantation and Hepato Pancreatico Biliary Surgery and the 2 Department of Anaesthesiology, Institute of Liver and Biliary Sciences, New Delhi, India Acknowledgements: The authors have no sources of funding for this study and have no conflicts of interest to declare. V. Pamecha contributed to study concept and design; M. Appukuttan and V. K. Pandey contributed to acquisition of data; M. Appukuttan and V. Pamecha contributed to analysis and interpretation of data; M. Appukuttan, V. Pamecha, and S. Kumar contributed to manuscript drafting; all authors contributed to critical revision of the manuscript for important intellectual content and approval of the final manuscript. We thank Guresh Kumar and Ajeet Singh Bhadoria for providing statistical analyses. Corresponding author: Viniyendra Pamecha, Liver Transplantation & Hepato-Pancreatico- Biliary Surgery, Institute of Liver & Biliary Sciences, D1, Vasant Kunj, New Delhi 110070, India Phone: +91 9540946803 E-mail: viniyendra@yahoo.co.uk Experimental and Clinical Transplantation (2018) ArtIcle DOI: 10.6002/ect.2017.0138