No-Transfusion Surgery in Liver Transplantation Pays Dividends

OKLAHOMA CITY, Sept. 19 -- A strategy for transfusion-free liver transplantation, developed for Jehovah's Witness patients, reduced overall blood use when applied to all patients, researchers here reported.

In a study comparing transplants in 33 transfusion and 239 transfusion-free patients, the mean number of transfusions of intraoperative packed red blood cells and fresh frozen plasma was significantly lower for those treated with bloodless strategies compared with those given transfusions, according to a report in the September issue of the Archives of Surgery.

For packed red blood cells, the mean number of units was 8.8 units versus 6.0 (P=.03), and for fresh frozen plasma, it was 7.7 versus 4.9 (P=.004), said Nicolas Jabbour, M.D., formerly of the University of Southern California in Los Angeles and now of the INTEGRIS Baptist Medical Center here, and colleagues.

Platelet use did not seem to be affected, and the preop and postop use of packed red blood cells, fresh frozen plasma, and platelet transfusions between the two groups was not statistically different, the researchers added.

In their study, the investigators evaluated the impact on standard patients of the Transfusion-Free Medicine and Surgery Program developed for Jehovah's Witness patients in 2000. From January 1997 through December 2004, 216 patients (79.4%) received deceased-donor grafts, and 56 (20.6%) were given living-donor transplants.

Thirty-three patients treated before 2000 (prior to the start of the transfusion-free program) received liver transplantation without blood-saving or salvaging techniques, and 239 had intraoperative cell salvage and acute normovolemic hemodilution.

In the hemodilution procedure, the patient's blood is removed and replaced with non-blood products (5% albumin and crystalloid solution) whenever feasible, the authors said. The patient's blood is later reinfused during the operation as needed or routinely after liver implantation.

The patients in the transfusion-free group tended to be sicker, the researchers reported. They had significantly higher mean levels of endstage liver disease (MELD score above 25), and yet they used fewer blood products compared with the transfusion patients (P=.001).

Primary diagnoses included hepatitis C cirrhosis, hepatitis B cirrhosis, autoimmune hepatitis, primary biliary cirrhosis, and primary sclerosing cholangitis.

"In liver transplantation, the colossal intraoperative blood loss that necessitates massive blood transfusion is not unusual, putting patient and graft at risk and challenging the surgeon," Dr. Jabbour said. "The MELD score has pushed many centers to perform transplantations in much sicker patients than was done before 2002.This occurrence is seen in our own series, in which more than 30% of our patients had MELD scores higher than 30."

Discussing the pros and cons of the technique, the researchers said that intraoperative cell salvage is an effective method for collecting blood from the operative field, but a drawback is that it salvages only red blood cells and no clotting factors.

On the other hand, they said, acute normovolemic hemodilution preserves the integrity of the red blood cells and clotting factors, ensuring the availability of safe, fresh autologous blood. There are, however, a few contraindications to the hemodilution procedure, including coronary heart disease, significant anemia, and severe pulmonary hypertension.

Transfusion-free surgery is rapidly gaining much needed attention primarily because of concerns surrounding transmission of diseases such as HIV, hepatitis C, and other viral infections, as well as the strain on blood-banks resources, the researchers said.

"Surgeons are the leading consumers of blood products," Dr. Jabbour wrote, "and it is important that we are leaders in promoting transfusion-free techniques."

In conclusion, he wrote, "We propose that the recognized need to minimize the use of blood products be elevated to the same level as antibiotic and deep venous thrombosis prophylaxis."