Objectives: Liver transplant currently is the best treatment option for end-stage liver disease. During liver transplant, there is major blood loss due to surgery and primary disease. By using a cell saver, the need for blood transfusion is markedly reduced. In this study, we aimed to evaluate the efficacy of cell saver use on morbidity and mortality in living-donor liver transplant.

Materials and Methods: We retrospectively evaluated 178 living-donor liver transplants, performed from 2005 to 2013 in our center. Child-Turcotte-Pugh A patients, deceased-donor liver transplants, and liver transplants performed for fulminant hepatic failure were not included in this study. Intraoperative blood transfusion was done in all patients to keep hemoglobin level between 10 and 12 g/dL. Cell saver was used in all liver transplants except in patients with malignancy, hepatitis B, and hepatitis C.

Results: We included 126 patients in the study. Cell saver was used in 84 liver transplants (66%). In 42 patients (34%), liver transplant was performed without a cell saver. In living-donor liver transplant with cell saver use, 10 mL/kg blood (range, 2-50 mL/kg blood) was transfused from the cell saver; in addition, 5 to 10 mL/kg allogeneic blood was transfused. In living-donor liver transplant without cell saver, 20 to 25 mL/kg allogeneic blood was transfused.

Conclusions: During liver transplant, major blood transfusion is needed because of surgery and primary disease. Cell saver use markedly decreases the need for allogeneic blood transfusion and avoids adverse events of massive transfusion.

Key words : Blood, End-stage liver disease, Transfusion

Introduction

Liver transplant currently is the best treatment option for end-stage liver disease. Patients undergoing liver transplant often present with coagulopathy, have massive intraoperative blood loss, and require large amounts of blood transfusion. Massive transfusion has been correlated with morbidity and reduced survival. Various surgical and anesthesic procedures have been used for the past 20 years to prevent excessive bleeding and reduce blood use. Presently, 40% operations are performed without blood transfusion.^1,2 During liver transplant, there is a major amount of blood loss because of surgery and primary disease. By using a cell saver, the need for blood transfusion is markedly reduced. Although massive transfusion is related to postoperative morbidity, there has not been a defined relation between the number of packed red cells transfused and survival.^3,4

Liver transplant is associated with major use of allogeneic blood products, which places major demands on finite resources and increases recipient exposure to viral, bacterial, and protozoal diseases associated with transfusion—undesirable events in immunosuppressed patients.¹ During this procedure, abnormal bleeding typically occurs as a consequence of surgery, hemostatic dysfunction, and portal hypertension. The cause of abnormalities of hemostasis is multifactorial, including deficits in platelets and coagulation factors related to the existing liver disease and increased fibrinolysis.² Lack of tissue plasminogen activator clearance during the anhepatic phase, and the burst release of tissue plasminogen activator associated with reperfusion of the ischemic graft, result in large amounts of circulating tissue plasminogen activator, with consequent pathologic activation of the fibrinolytic system.

Intraoperative red blood cell salvage (IRBCS) with autologous transfusion is not used routinely because cost effectiveness is a major concern. In this study, we aimed to evaluate the efficacy of cell saver use on morbidity and mortality in living-donor liver transplant.

Materials and Methods

We retrospectively evaluated 178 living-donor liver transplants that were performed from 2005 to 2013 in our center. Child-Turcotte-Pugh A patients, deceased-donor liver transplants, and liver transplants performed for fulminant hepatic failure were not included in this study. Intraoperative blood transfusion was done in all patients to keep hemoglobin levels from 10 to 12 g/dL. A cell saver (Figure 1) was used in all liver transplants except in patients with malignancy, hepatitis B, and hepatitis C.

Blood transfusions were administered on the basis of clinical and hemodynamic criteria. The replacement of other blood components was not analyzed; volume replacement was performed with crystalloid and colloid solutions. Anesthetic induction and maintenance was performed with a combination of intravenous drugs such as propofol, fentanyl, and pancuronium. Hemodynamic moni­toring included an arterial line and pulmonary artery catheter. Body temperature was maintained with warming blankets and intravenous fluid warmers.

The analyzed variables for recipients included age, sex, disease, Child-Turcotte-Pugh classification, body weight, height, warm ischemic time, and Model for End-Stage Liver Disease (MELD) score. Statistical analyses were performed using t test, Cox hazard regression, Kaplan-Meier method, and log rank test.

Results

We included 126 patients in the study. A cell saver was used in 84 liver transplants (66%). In 42 patients (34%), liver transplant was performed without a cell saver (Table 1). In living-donor liver transplant with cell saver use, 10 mL/kg blood (range, 2-50 mL/kg blood) was transfused from the cell saver; in addition, 5 to 10 mL/kg allogeneic blood was transfused. In living-donor liver transplant without a cell saver, 20 to 25 mL/kg allogeneic blood was transfused (Figure 2).

Discussion

Although the number of patients is small for significant statistical analysis, this study gives us an important opportunity to evaluate the transfusion practice and strategies employed in liver transplant. Most patients in both groups were Child-Turcotte-Pugh B, and median MELD score was 20 ± 5 in patients with IRBCS and 22 ± 3 in patients without IRBCS.

The patients had cirrhosis, predominantly of moderate severity. The median duration of surgery was an average 30 minutes less in patients with than without IRBCS. This coincided with the experience gained by the surgical team. The blood loss during surgery also reflected this technical refinement, with less intraoperative blood loss in the group with IRBCS (with cell saver, 5-10 mL/kg allogeneic blood was transfused; without cell saver, 20-25 mL/kg allogeneic blood was transfused). When IRBCS was used, > half of the blood lost was recovered (600 ± 300 mL) and this was mostly available for reinfusion after processing (400 ± 250 mL). We also observed a substantial reduction in fresh frozen plasma transfusion and a lesser reduction in platelet requirement in the IRBCS group. Technical refinements also were partly responsible for the reduction in heterologous transfusion requirements. Although significant statistical studies could not be performed, there seemed to be a definite tendency toward reduced transfusion requirement with the use of IRBCS.

The presence of hepatocellular carcinoma was considered a contraindication for the use of IRBCS because of the theoretical risk of reintroducing neoplastic cells into the circulation. Although a recent study did not detect any difference in the incidence of neoplastic recurrence with the use of IRBCS, this remains a concern and should be confirmed.³ Perhaps in the future, the use of IRBCS can be extended to patients with hepatocellular carcinoma.

The use of IRBCS or any other strategy that reduces the demand for heterologous transfusion is welcome because it reduces exposure to transmissible infectious diseases–viral, bacterial, and protozoal.⁵ Routine use of thromboelastography in the operating room is another way to reduce transfusion of blood components, especially fresh frozen plasma and platelets. This method may reduce transfusion in liver transplant and reduce surgical costs.

In this study, as in other reports, the use of IRBCS showed a tendency to reduce transfusion of blood components. In a prospective study published recently, the use of IRBCS reduced transfusions and was cost effective.⁶ Despite the fact that major blood use has been related to reduced survival after liver transplant, massive transfusion has not been considered an independent predictor of post­operative prognosis.⁷

During liver transplant, major amounts of blood transfusion are needed because of surgery and primary disease. Cell saver use markedly decreases the need for allogeneic blood transfusion and avoids adverse events of massive transfusion.

In summary, IRBCS has the potential to reduce the need for heterologous transfusion, reduces the risks of disease transmission, and may reduce cost. If all methods available for reducing transfusion were used, liver transplant could possibly be a safer and less costly procedure.

References:

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2. Ickx BE, van der Linden PJ, Melot C, et al. Comparison of the effects of aprotinin and tranexamic acid on blood loss and red blood cell transfusion requirements during the late stages of liver transplantation. Transfusion. 2006;46(4):595-605.
3. Muscari F, Suc B, Vigouroux D, et al. Blood salvage autotransfusion during transplantation for hepatocarcinoma: does it increase the risk of neoplastic recurrence? Transpl Int. 2005;18(11):1236-1239.
4. Siemionow M, Agaoglu G. Role of blood transfusion in trans­plantation: a review. J Reconstr Microsurg. 2005;21(8):555-563.
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