*Purpose: Hepato-pulmonary syndrome (HPS) is a complication of liver disease with liver transplantation as the only curative treatment. However these patients can develop severe hypoxemia early after transplantation, defined as a need of 100% oxygen to maintain a saturation of >85 %. The data regarding the predictive factors or treatment for post-transplant severe hypoxemia and its impact on outcome is scarce.

*Methods: Retrospective analysis of prospectively maintained database of 1862 patients who had liver transplants in our unit between 2007 and 2020, from which patients with a diagnosis of HPS were identified. Pre transplant variables related to HPS and postoperative oxygen requirement, duration of intubation, ICU stay, postoperative complications and survival data were collected.

*Results: 51 (n=51) patients with HPS were identified during the study period. The median pre-transplant PaO2 on room air, diffusing capacity of the lung (DLCO), alveolar-arterial oxygen gradient (AaDo2), and intrapulmonary shunt ratio on radionuclide study were 55.3 mmHg, 49.0%, 59.0 mmHg and 18.0% (2.4 -47.8%), respectively. Postoperative severe hypoxemia occurred in 12 patients (24%). Among 12 patients, 2 patients was treated successfully by using extracorporeal membrane oxygenation (ECMO). Predictors of severe hypoxemia include intrapulmonary shunt ratio >20% and DLCO <40%. ICU stay, readmission rate and medical cost of the hospital stay were significantly higher in patients who developed severe hypoxemia than the others. Overall 1 and 3 years post-transplant survival of HPS patients were 84.3% and 82.4%.

*Conclusions: Intrapulmonary shunt and DLCO predict the development of postoperative severe hypoxemia, which is associated with high morbidity and mortality. ECMO could be one of effective treatment for post-transplant severe hypoxia caused by HPS.

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