---
title: "Out-of-Hours Liver Transplantation and Increased Morbidity: A Swedish National Study"
id: "pubmed-42681564"
canonical_url: "https://medichelpline.com/clinical-feed/pubmed-42681564"
content_type: "clinical_feed_article"
specialty: "Critical Care"
source_name: "PubMed / NCBI"
source_url: "https://pubmed.ncbi.nlm.nih.gov/42681564/"
doi: "10.1097/SLA.0000000000007185"
published_at: "2026-09-02T00:00:00.000Z"
evidence_level: "Journal Article"
license: "CC-BY-NC-4.0 / Informational Use"
---
# Out-of-Hours Liver Transplantation and Increased Morbidity: A Swedish National Study
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/pubmed-42681564
- **Specialty:** [Critical Care](https://medichelpline.com/clinical-feed/critical-care.md)
- **Primary Source:** PubMed / NCBI
- **Source URL:** [Original Journal Publication](https://pubmed.ncbi.nlm.nih.gov/42681564/)
- **DOI:** [10.1097/SLA.0000000000007185](https://doi.org/10.1097%2FSLA.0000000000007185)
- **Published At:** 2026-09-02T00:00:00.000Z
- **Evidence Rating:** Journal Article
## Executive GIST (TL;DR)
- This national, multicenter retrospective study analyzed 764 adult **liver transplantations** in Sweden performed between 2019 and 2023 using a data-driven approach to define an **out-of-hours (OOH)** high-risk window. - The investigators applied permutations and linear regression across 552 one-hour start-time intervals to identify the time period most strongly associated with the primary endpoint, the 3-month **Comprehensive Complication Index (CCI)**. - The analysis identified 17:00 to 05:59 as the OOH window with the greatest negative impact on CCI. - After adjustment for covariates, procedures starting in this interval had a significantly higher CCI (β = 7.41; 95% CI: 4.27–10.56; P < 0.01). - OOH operations were associated with increased rates of higher-grade complications (Clavien-Dindo IIIb and IV), a greater risk of liver-transplant–related reoperations (OR 1.61; 95% CI: 1.11–2.36), and a longer intensive care unit stay (+1.16 days). - One-year graft and patient survival did not differ significantly between OOH and daytime procedures. - Health care costs were higher for OOH transplants, with an increase of 169,629 SEK (reported as approximately €15,500) per patient over the 3-month follow-up. - The study concludes that a data-driven OOH window beginning at 17:00—earlier than many traditional nighttime definitions—is linked to increased morbidity and costs; authors call for further work to evaluate mitigation strategies to enable daytime transplantation. - The authors report no conflicts of interest.
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Online ahead of print. # The Impact of Out-of-Hours Liver Transplantation on Outcomes: A Swedish National Study [Mathias V A Vidgren](https://pubmed.ncbi.nlm.nih.gov/?term=Vidgren+MVA&cauthor_id=42681564)[ 1 ](https://pubmed.ncbi.nlm.nih.gov/42681564/#full-view-affiliation-1 "Department of Clinical Science, Intervention and Technology, Division of Transplantation Surgery, Karolinska Institutet, Stockholm, Sweden.")[ 2 ](https://pubmed.ncbi.nlm.nih.gov/42681564/#full-view-affiliation-2 "ME Transplantation, Tema ARM, Karolinska University Hospital, Stockholm, Sweden."), [Rose Matin](https://pubmed.ncbi.nlm.nih.gov/?term=Matin+R&cauthor_id=42681564)[ 3 ](https://pubmed.ncbi.nlm.nih.gov/42681564/#full-view-affiliation-3 "Department of Transplantation Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.")[ 4 ](https://pubmed.ncbi.nlm.nih.gov/42681564/#full-view-affiliation-4 "Department of Transplantation Surgery, The Institute of Clinical Sciences, Gothenburg University, Gothenburg, Sweden."), [Samuel A E Lundgren](https://pubmed.ncbi.nlm.nih.gov/?term=Lundgren+SAE&cauthor_id=42681564)[ 1 ](https://pubmed.ncbi.nlm.nih.gov/42681564/#full-view-affiliation-1 "Department of Clinical Science, Intervention and Technology, Division of Transplantation Surgery, Karolinska Institutet, Stockholm, Sweden.")[ 2 ](https://pubmed.ncbi.nlm.nih.gov/42681564/#full-view-affiliation-2 "ME Transplantation, Tema ARM, Karolinska University Hospital, Stockholm, Sweden."), [Antonio Romano](https://pubmed.ncbi.nlm.nih.gov/?term=Romano+A&cauthor_id=42681564)[ 1 ](https://pubmed.ncbi.nlm.nih.gov/42681564/#full-view-affiliation-1 "Department of Clinical Science, Intervention and Technology, Division of Transplantation Surgery, Karolinska Institutet, Stockholm, Sweden.")[ 2 ](https://pubmed.ncbi.nlm.nih.gov/42681564/#full-view-affiliation-2 "ME Transplantation, Tema ARM, Karolinska University Hospital, Stockholm, Sweden."), [Amanda L M Habermann](https://pubmed.ncbi.nlm.nih.gov/?term=Habermann+ALM&cauthor_id=42681564)[ 1 ](https://pubmed.ncbi.nlm.nih.gov/42681564/#full-view-affiliation-1 "Department of Clinical Science, Intervention and Technology, Division of Transplantation Surgery, Karolinska Institutet, Stockholm, Sweden.")[ 2 ](https://pubmed.ncbi.nlm.nih.gov/42681564/#full-view-affiliation-2 "ME Transplantation, Tema ARM, Karolinska University Hospital, Stockholm, Sweden."), [Malin E Aram](https://pubmed.ncbi.nlm.nih.gov/?term=Aram+ME&cauthor_id=42681564)[ 1 ](https://pubmed.ncbi.nlm.nih.gov/42681564/#full-view-affiliation-1 "Department of Clinical Science, Intervention and Technology, Division of Transplantation Surgery, Karolinska Institutet, Stockholm, Sweden.")[ 2 ](https://pubmed.ncbi.nlm.nih.gov/42681564/#full-view-affiliation-2 "ME Transplantation, Tema ARM, Karolinska University Hospital, Stockholm, Sweden."), [Sebastian P Forssten](https://pubmed.ncbi.nlm.nih.gov/?term=Forssten+SP&cauthor_id=42681564)[ 1 ](https://pubmed.ncbi.nlm.nih.gov/42681564/#full-view-affiliation-1 "Department of Clinical Science, Intervention and Technology, Division of Transplantation Surgery, Karolinska Institutet, Stockholm, Sweden.")[ 2 ](https://pubmed.ncbi.nlm.nih.gov/42681564/#full-view-affiliation-2 "ME Transplantation, Tema ARM, Karolinska University Hospital, Stockholm, Sweden."), [William F D Bennet](https://pubmed.ncbi.nlm.nih.gov/?term=Bennet+WFD&cauthor_id=42681564)[ 3 ](https://pubmed.ncbi.nlm.nih.gov/42681564/#full-view-affiliation-3 "Department of Transplantation Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.")[ 4 ](https://pubmed.ncbi.nlm.nih.gov/42681564/#full-view-affiliation-4 "Department of Transplantation Surgery, The Institute of Clinical Sciences, Gothenburg University, Gothenburg, Sweden."), [Gabriel C Oniscu](https://pubmed.ncbi.nlm.nih.gov/?term=Oniscu+GC&cauthor_id=42681564)[ 1 ](https://pubmed.ncbi.nlm.nih.gov/42681564/#full-view-affiliation-1 "Department of Clinical Science, Intervention and Technology, Division of Transplantation Surgery, Karolinska Institutet, Stockholm, Sweden.")[ 2 ](https://pubmed.ncbi.nlm.nih.gov/42681564/#full-view-affiliation-2 "ME Transplantation, Tema ARM, Karolinska University Hospital, Stockholm, Sweden.") Affiliations Expand ### Affiliations * 1 Department of Clinical Science, Intervention and Technology, Division of Transplantation Surgery, Karolinska Institutet, Stockholm, Sweden. * 2 ME Transplantation, Tema ARM, Karolinska University Hospital, Stockholm, Sweden. * 3 Department of Transplantation Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden. * 4 Department of Transplantation Surgery, The Institute of Clinical Sciences, Gothenburg University, Gothenburg, Sweden. * PMID: **42681564** * DOI: [ 10.1097/SLA.0000000000007185 ](https://doi.org/10.1097/sla.0000000000007185) Item in Clipboard # The Impact of Out-of-Hours Liver Transplantation on Outcomes: A Swedish National Study Mathias V A Vidgren et al. Ann Surg. 2026. Show details Display options Display options Format Abstract PubMed PMID Ann Surg Actions * [ Search in PubMed ](https://pubmed.ncbi.nlm.nih.gov/?term=%22Ann+Surg%22%5Bjour%5D&sort=date&sort_order=desc) * [ Search in NLM Catalog ](https://www.ncbi.nlm.nih.gov/nlmcatalog?term=%22Ann+Surg%22%5BTitle+Abbreviation%5D) * [ Add to Search ](https://pubmed.ncbi.nlm.nih.gov/42681564/) . 2026 Sep 2. doi: 10.1097/SLA.0000000000007185. Online ahead of print. ### Authors [Mathias V A Vidgren](https://pubmed.ncbi.nlm.nih.gov/?term=Vidgren+MVA&cauthor_id=42681564)[ 1 ](https://pubmed.ncbi.nlm.nih.gov/42681564/#short-view-affiliation-1 "Department of Clinical Science, Intervention and Technology, Division of Transplantation Surgery, Karolinska Institutet, Stockholm, Sweden.")[ 2 ](https://pubmed.ncbi.nlm.nih.gov/42681564/#short-view-affiliation-2 "ME Transplantation, Tema ARM, Karolinska University Hospital, Stockholm, Sweden."), [Rose Matin](https://pubmed.ncbi.nlm.nih.gov/?term=Matin+R&cauthor_id=42681564)[ 3 ](https://pubmed.ncbi.nlm.nih.gov/42681564/#short-view-affiliation-3 "Department of Transplantation Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.")[ 4 ](https://pubmed.ncbi.nlm.nih.gov/42681564/#short-view-affiliation-4 "Department of Transplantation Surgery, The Institute of Clinical Sciences, Gothenburg University, Gothenburg, Sweden."), [Samuel A E Lundgren](https://pubmed.ncbi.nlm.nih.gov/?term=Lundgren+SAE&cauthor_id=42681564)[ 1 ](https://pubmed.ncbi.nlm.nih.gov/42681564/#short-view-affiliation-1 "Department of Clinical Science, Intervention and Technology, Division of Transplantation Surgery, Karolinska Institutet, Stockholm, Sweden.")[ 2 ](https://pubmed.ncbi.nlm.nih.gov/42681564/#short-view-affiliation-2 "ME Transplantation, Tema ARM, Karolinska University Hospital, Stockholm, Sweden."), [Antonio Romano](https://pubmed.ncbi.nlm.nih.gov/?term=Romano+A&cauthor_id=42681564)[ 1 ](https://pubmed.ncbi.nlm.nih.gov/42681564/#short-view-affiliation-1 "Department of Clinical Science, Intervention and Technology, Division of Transplantation Surgery, Karolinska Institutet, Stockholm, Sweden.")[ 2 ](https://pubmed.ncbi.nlm.nih.gov/42681564/#short-view-affiliation-2 "ME Transplantation, Tema ARM, Karolinska University Hospital, Stockholm, Sweden."), [Amanda L M Habermann](https://pubmed.ncbi.nlm.nih.gov/?term=Habermann+ALM&cauthor_id=42681564)[ 1 ](https://pubmed.ncbi.nlm.nih.gov/42681564/#short-view-affiliation-1 "Department of Clinical Science, Intervention and Technology, Division of Transplantation Surgery, Karolinska Institutet, Stockholm, Sweden.")[ 2 ](https://pubmed.ncbi.nlm.nih.gov/42681564/#short-view-affiliation-2 "ME Transplantation, Tema ARM, Karolinska University Hospital, Stockholm, Sweden."), [Malin E Aram](https://pubmed.ncbi.nlm.nih.gov/?term=Aram+ME&cauthor_id=42681564)[ 1 ](https://pubmed.ncbi.nlm.nih.gov/42681564/#short-view-affiliation-1 "Department of Clinical Science, Intervention and Technology, Division of Transplantation Surgery, Karolinska Institutet, Stockholm, Sweden.")[ 2 ](https://pubmed.ncbi.nlm.nih.gov/42681564/#short-view-affiliation-2 "ME Transplantation, Tema ARM, Karolinska University Hospital, Stockholm, Sweden."), [Sebastian P Forssten](https://pubmed.ncbi.nlm.nih.gov/?term=Forssten+SP&cauthor_id=42681564)[ 1 ](https://pubmed.ncbi.nlm.nih.gov/42681564/#short-view-affiliation-1 "Department of Clinical Science, Intervention and Technology, Division of Transplantation Surgery, Karolinska Institutet, Stockholm, Sweden.")[ 2 ](https://pubmed.ncbi.nlm.nih.gov/42681564/#short-view-affiliation-2 "ME Transplantation, Tema ARM, Karolinska University Hospital, Stockholm, Sweden."), [William F D Bennet](https://pubmed.ncbi.nlm.nih.gov/?term=Bennet+WFD&cauthor_id=42681564)[ 3 ](https://pubmed.ncbi.nlm.nih.gov/42681564/#short-view-affiliation-3 "Department of Transplantation Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.")[ 4 ](https://pubmed.ncbi.nlm.nih.gov/42681564/#short-view-affiliation-4 "Department of Transplantation Surgery, The Institute of Clinical Sciences, Gothenburg University, Gothenburg, Sweden."), [Gabriel C Oniscu](https://pubmed.ncbi.nlm.nih.gov/?term=Oniscu+GC&cauthor_id=42681564)[ 1 ](https://pubmed.ncbi.nlm.nih.gov/42681564/#short-view-affiliation-1 "Department of Clinical Science, Intervention and Technology, Division of Transplantation Surgery, Karolinska Institutet, Stockholm, Sweden.")[ 2 ](https://pubmed.ncbi.nlm.nih.gov/42681564/#short-view-affiliation-2 "ME Transplantation, Tema ARM, Karolinska University Hospital, Stockholm, Sweden.") ### Affiliations * 1 Department of Clinical Science, Intervention and Technology, Division of Transplantation Surgery, Karolinska Institutet, Stockholm, Sweden. * 2 ME Transplantation, Tema ARM, Karolinska University Hospital, Stockholm, Sweden. * 3 Department of Transplantation Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden. * 4 Department of Transplantation Surgery, The Institute of Clinical Sciences, Gothenburg University, Gothenburg, Sweden. * PMID: **42681564** * DOI: [ 10.1097/SLA.0000000000007185 ](https://doi.org/10.1097/sla.0000000000007185) Item in Clipboard Cite Display options Display options Format Abstract PubMed PMID ## Abstract **Objectives:** This national, multicenter retrospective study of 764 adult liver transplantations (LT) in Sweden (2019-2023) employed a data-driven approach to identify the out-of-hours (OOH) high-risk window and evaluate its impact on patient outcomes and health care costs. **Summary background data:** LT logistics often necessitate OOH surgery, but the evidence for an impact on outcomes remains conflicting, partly due to arbitrary window definitions. **Methods:** Using the mathematical principle of permutations and linear regression analysis of 1-hour start-time intervals across 552 temporal windows, we identified the period with the greatest impact on the primary endpoint: the 3-month Comprehensive Complication Index (CCI). Secondary outcomes included intensive care unit length of stay, Clavien-Dindo complications, reoperations, patient and graft survival, and health care costs. **Results:** The 17:00 to 05:59 window was identified as having the greatest negative impact on CCI. After adjusting for covariates, procedures initiated during this timeframe were associated with significantly higher CCI (β=7.41, 95% CI: 4.27-10.56, P<0.01), increased Clavien-Dindo IIIb and IV complications, 1.16 days longer intensive care unit stay and a higher risk of LT-related reoperations (odds ratio: 1.61, 95% CI: 1.11-2.36). One-year graft and patient survival were comparable between groups. Health care costs were 169.629 SEK (€15,500) higher per patient operated OOH, during the 3-month follow-up. **Conclusion:** This data-driven analysis identified a high-risk OOH window beginning earlier than previously reported (17:00 vs. traditional nighttime definitions). LT starting in this interval is associated with significantly increased morbidity and health care costs. Further studies are needed to evaluate mitigating strategies to enable daytime transplantation. **Keywords:** CCI; complications; cost analysis; liver transplantation; out-of-hours. Copyright © 2026 Wolters Kluwer Health, LLC. All rights reserved. [PubMed Disclaimer](https://pubmed.ncbi.nlm.nih.gov/disclaimer/) ## Conflict of interest statement The authors report no conflicts of interest. 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