Why is the FLAG model needed?

There is no consensus on the definition of primary graft dysfunction. Since Makowka’s definition in 1987 to the 2023 proposal by Halle-Smith et al. involving C-reactive protein (CRP) and urea, various authors have suggested different criteria to define both EAD and PNF.

Currently, the most commonly used criteria are those proposed by Olthoff, which are based on INR, transaminase, and bilirubin levels during the first 7 postoperative days. This delayed diagnosis has led to the recent proposal of promising new criteria, validated by various groups, in an effort to address the lack of consensus.

All of these more recent authors define graft loss as the need for retransplantation or death, most of them within the first 3 months. Some have attempted to define PNF separately from EAD, using death or retransplantation at 7, 10, or even 14 days as the defining event. The relevance of this lies in the prognosis of these patients and the implications of their only therapeutic option: urgent retransplantation.

All of the above highlights the need for reliable and early parameters to allow for prompt detection of primary graft dysfunction and guide the urgent indication for retransplantation.

Why is the FLAG model needed?

Some proposed criteria of primary nonfunction

1987 – Makowka et al.

1993 – Ploeg et al.

1994 – D'Alessandro et al.

1994 – Gonzalez et al.

1998 – Deschenes et al.

1999 – Ardite et al.

2002 – Nanashima et al.

2009 – Cieslak et al.

2010 – Dhillon et al.

2010 – Lock et al.

2010 – Nemes et al.