What are the variables used to predict transfusion requirements in liver transplantation?

Updated: Apr 19, 2019
  • Author: Vanessa A Olcese, MD, PhD; Chief Editor: Ron Shapiro, MD  more...
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Important variables affecting transfusion requirements include the severity of disease or Child classification, preoperative PT, history of abdominal operations, and factor V levels. Other factors identified as independent predictors of transfusion include the preoperative hematocrit value, use of the piggyback transplantation method, and operative time. [4]

The Child classification is a measure of disease severity that includes assessments of ascites, encephalopathy, and muscle wasting and measurements of serum bilirubin and albumin. In a retrospective study, Motschman and colleagues found that the presence of ascites and a preoperative PT greater than 15 seconds were predictive of intraoperative blood loss during OLT. [5]

This study also reported a statistically significant difference in non-PRBC (packed red blood cells) blood product use among 3 diagnostic groups undergoing liver transplantation. Patients with chronic active hepatitis had more advanced disease and required more blood products than patients with primary sclerosing cholangitis or primary biliary cirrhosis.

The predictive value of the PT is unclear. A study by Ozier et al in children undergoing OLT found that the PT was correlated with blood loss only with univariate analysis; the multivariate analysis performed to eliminate confounding factors failed to demonstrate that preoperative PT was a significant predictor of blood loss. [6]

A retrospective study of 300 liver transplantation procedures reported no correlation among preoperative platelet count, aPTT, PT, thrombin time, fibrinogen, or antithrombin III and intraoperative blood loss or transfusion requirements. A retrospective review of 263 adult OLT patients found a significant correlation between intraoperative median PT and aPTT (5 min before reperfusion) and median volume of blood transfused within the first 70 minutes after reperfusion.

Portal vein hypoplasia and decreased donor liver size were predictive of blood loss in a series of 95 consecutive pediatric liver transplantation patients. The presence of portal vein hypoplasia is a technical challenge for the surgeons and a correlate of coexisting congenital abnormalities (eg, polysplenia syndrome). Use of a partial liver graft, as in living-donor liver transplantation, creates a graft with a raw surface that can bleed after reperfusion. [7]

A study to assess the risk factors associated with massive transfusion (administration of red blood cells ≥100% of the total blood volume during liver transplantation) found high white blood cell (WBC) count, low platelet count, and cadaveric donors were significant predictive factors. The graft failure rate within 6 months in the massive transfusion group tended to be higher than that in the no-massive transfusion group (6.6% vs. 1.8%, P = 0.068). However, the patient mortality rate within 6 months did not differ significantly between the two groups.{ref

Both severity of disease and PT/aPTT were compared with blood requirements during OLT. One retrospective study of 263 patients found a correlation between aPTT or/and PT and blood requirements in persons with alcoholic liver disease, chronic active hepatitis, primary biliary cirrhosis, or primary sclerosing cholangitis. However, laboratory analysis of coagulation factors was not helpful for predicting blood loss in retransplantation patients.

In a retrospective review of 205 transplantation patients, multivariate analysis identified an elevated serum creatinine level, low platelet counts, and an elevated aPTT as risk factors for large transfusion requirements, with a sensitivity of 60% and a specificity of 69%. [51] The authors concluded that because of the great variability of transfusion requirements, preoperative factors were not helpful in predicting large-volume loss and large transfusion requirements; however, large transfusion requirements were predictive of outcome.

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