Background: Orthotopic liver transplant (LT) is often associated with massive blood loss and significant transfusion requirements. Recent recommendations for resuscitation strategy in bleeding patients include transfusion of balanced blood products, fresh frozen plasma (FFP), platelets, red blood cells (PRBC), and restricted use of crystalloids.
Objectives: To evaluate whether the intraoperative transfusion ratio of fresh frozen plasma to packed red blood cells units (FFP: PRBC ≤1:1 versus >1:1) plays a positive role in reducing PRBC transfusion in LT.
Methods: This is a retrospective study of 84 liver transplant recipients who received at least one PRBC unit during the surgery. The patients were grouped: into those who received intraoperative FFP: PRBC ratio ≤ 1:1 (low) versus the ratio > 1:1 (high). Selected perioperative variables were compared between the two groups. The variables included; baseline characteristics of the patients, intraoperative transfused PRBC and blood products, postoperative mean hemoglobin, platelets, international normalized ratio, postoperative transfused PRBC and blood component, early postoperative complications as re-operation due to bleeding, portal vein thrombosis, and duration of stay in the intensive care unit.
Results: There was a significant difference between the two groups in preoperative BMI (P = 0.04) and hemoglobin (P = 0.005), and the two variables were higher in the high-ratio group. Patients in the ≤1: 1 group versus >1:1 had lower intraoperative requirements for PRBC (P<0.001). Importantly, the postoperative mean PRBC transfused units in the high ratio group were 1.76 times that of the low ratio group (incidence rate ratio [IRR], 1.76; 95% CI, 1.07 –2.90).
Conclusion: In patients undergoing LT, intraoperative plasma transfusion with a PRBC ratio of ≤1:1 was associated with a reduced need for PRBC transfusion.
Hannaman MJ, Hevesi ZG. Anesthesia care for liver transplantation. Transplant Rev (Orlando). 2011;25(1):36-43. doi:10.1016/j.trre.2010.10.004. PMID: 21126662
Stine JG, Argo CK, Pelletier SJ, Maluf DG, Northup PG. Liver transplant recipients with portal vein thrombosis receiving an organ from a high-risk donor are at an increased risk for graft loss due to hepatic artery thrombosis. Transpl Int. 2016;29(12):1286-1295. doi:10.1111/tri.12855. PMID: 27714853.
de Boer MT, Christensen MC, Asmussen M, et al. The impact of intraoperative transfusion of platelets and red blood cells on survival after liver transplantation. Anesth Analg. 2008;106(1): 32-44.. doi:10.1213/01.ane.0000289638.26666.ed. PMID: 18165548.
Pereboom IT, de Boer MT, Haagsma EB, Hendriks HG, Lisman T, Porte RJ. Platelet transfusion during liver transplantation is associated with increased postoperative mortality due to acute lung injury. Anesth Analg. 2009;108(4):1083-1091. doi:10.1213/ane.0b013e3181948a59. PMID: 19299765.
Benson AB, Burton JR Jr, Austin GL, et al. Differential effects of plasma and red blood cell transfusions on acute lung injury and infection risk following liver transplantation. Liver Transpl. 2011;17(2):149-158. doi:10.1002/lt.22212. PMID: 21280188.
Ramos E, Dalmau A, Sabate A, et al. Intraoperative red blood cell transfusion in liver transplantation: influence on patient outcome, prediction of requirements, and measures to reduce them. Liver Transpl. 2003;9(12):1320-1327. doi:10.1016/jlts.2003.50204. PMID: 14625833.
Hogen R, Dhanireddy K, Clark D, et al. Balanced blood product transfusion during liver transplantation. Clin Transplant. 2018;32(3):e13191. doi:10.1111/ctr.13191. PMID: 29314246.
Pagano MB, Metcalf RA, Hess JR, Reyes J, Perkins JD, Montenovo MI. A high plasma: red blood cell transfusion ratio during liver transplantation is associated with decreased blood utilization. Vox Sang. 2018;113(3):268-274. doi:10.1111/vox.12634. PMID: 29359471.
Tripodi A, Mannucci PM. The coagulopathy of chronic liver disease. N Engl J Med. 2011;365(2):147-156. doi:10.1056/NEJMra1011170. PMID: 21751907.
Feng S, Goodrich NP, Bragg-Gresham JL, et al. Characteristics associated with liver graft failure: the concept of a donor risk index [published correction appears in Am J Transplant. 2018 Dec;18(12):3085]. Am J Transplant. 2006;6(4):783-790. doi:10.1111/j.1600-6143.2006.01242.x. PMID: 16539636.
Krasnodębski M, Grąt M, Stypułkowski J, et al. Impact of Donor Risk Index on Risk of Hepatic Artery Thrombosis in Patients After Orthotopic Liver Transplantation. Transplant Proc. 2018;50(7):2006-2008. doi:10.1016/j.transproceed.2018.02.151. PMID: 30177098.
Milani S, Shahroudi A, Morovatdar N, Zirak N, Jafari Farkhod M. Perioperative Changes in Platelet Counts During Adult Liver Transplantation. Exp Clin Transplant. 2021;19(2):137-141. doi:10.6002/ect.2020.0195. PMID: 33605209.
Esmat Gamil M, Pirenne J, Van Malenstein H, et al. Risk factors for bleeding and clinical implications in patients undergoing liver transplantation. Transplant Proc. 2012;44(9):2857-2860. doi:10.1016/j.transproceed.2012.09.085. PMID: 23146542.
LaMattina JC, Foley DP, Fernandez LA, et al. Complications associated with liver transplantation in the obese recipient. Clin Transplant. 2012; 26(6):910-918. doi:10.1111/j.1399-0012.2012.01669.x. PMID: 22694047.
Spengler EK, O'Leary JG, Te HS, et al. Liver Transplantation in the Obese Cirrhotic Patient. Transplantation. 2017;101(10):2288-2296. doi:10.1097/TP.0000000000001794. PMID: 28930104.
Yanaral TU, Karaaslan P. The Impact of Body Mass Index on Intraoperative Blood Loss, Blood Transfusion and Fluid Management in Patients Undergoing Liver Transplantation: A Retrospective Analysis from a Tertiary Referral Center. Haseki Tıp Bülteni. 2021;59(4):302-7. DOI: 10.4274/Haseki.gales.2021.7247.
Bhangui P, Fernandes ESM, Di Benedetto F, Joo DJ, Nadalin S. Current management of portal vein thrombosis in liver transplantation. Int J Surg. 2020;82S:122-127. doi:10.1016/j.ijsu.2020.04.068. PMID: 32387201.
Doenecke A, Tsui TY, Zuelke C, et al. Pre-existent portal vein thrombosis in liver transplantation: influence of pre-operative disease severity. Clin Transplant. 2010;24(1):48-55. doi:10.1111/j.1399-0012.2009.00977.x. PMID: 19236435.