Impact of Perioperative Massive Transfusion on Long Term Outcomes of Liver Transplantation: a Retrospective Cohort Study

Abstract

Background: Liver transplantation (LT) is associated with a significant risk of intraoperative hemorrhage and massive blood transfusion. However, there are few relevant reports addressing the long-term impacts of massive transfusion (MT) on liver transplantation recipients. Aim: To assess the effects of MT on the short and long-term outcomes of adult liver transplantation recipients. Methods: We included adult patients who underwent liver transplantation at West China Hospital from January 2011 to February 2015. MT was defined as red blood cell (RBC) transfusion of ≥10 units within 48 hours since the application of LT. Preoperative, intraoperative and postoperative information were collected for data analyzing. We used one-to-one propensity-matching to create pairs. Kaplan-Meier survival analysis was used to compare long-term outcomes of LT recipients between the MT and non-MT groups. Univariate and multivariate logistic regression analyses were performed to evaluate the risk factors associated with MT in LT. Results: Finally, a total of 227 patients were included in our study. After propensity score matching, 59 patients were categorized into the MT and 59 patients in non-MT groups. Compared with the non-MT group, the MT group had a higher 30-day mortality (15.3% vs 0, p=0.006), and a higher incidence of postoperative complications, including postoperative pulmonary infection, abdominal hemorrhage, pleural effusion and severe acute kidney injury. Furthermore, MT group had prolonged postoperative ventilation support (42 vs 25 h, p=0.007) and prolonged durations of ICU (12.9 vs 9.5 d, p<0.001) stay. Multivariate COX regression indicated that massive transfusion (OR: 2.393, 95% CI: 1.164-4.923, p=0.018) and acute rejection (OR: 7.295, 95% CI: 2.108-25.246, p=0.02) were significant risk factors affecting long-term survivals of LT patients. The 1-year and 3-year survival rates patients in MT group were 82.5% and 67.3%, respectively, while those of non-MT group were 93.9% and 90.5%, respectively. The MT group exhibited a lower long-term survival rate than the non-MT group (HR: 2.393, 95% CI: 1.164-4.923, p<0.001). Finally, the multivariate logistic regression revealed that preoperative hemoglobin <118 g/L (OR: 5.062, 95% CI: 2.292-11.181, p<0.001) and intraoperative blood loss ≥1100 ml (OR: 3.212, 95% CI: 1.586-6.506, p = 0.001) were the independent risk factor of MT in patients undergoing LT. Conclusion: Patients receiving MT in perioperative periods of LT had worse short-term and long-term outcomes than the non-MT patients. Massive transfusion and acute rejection were significant risk factors affecting long-term survivals of LT patients, and intraoperative blood loss of over 1100 ml was the independent risk factor of MT in patients undergoing LT. The results may offer valuable information on perioperative management in LT recipients who experience high risk of MT.

Transfused Red Blood Cell Characteristics and Kidney Transplant Outcomes Among Patients Receiving Early Posttransplant Transfusion

“…However, the deleterious association of the transfusion starts with the first transfusion episode (1 or 2 RBC units). In previous studies, this association only appeared after the third RBC unit . The difference may either be related to a smaller number of patients or different transfusion practices in these studies.…”

“…Moreover, the same association of storage duration was observed in patients who had a single episode of RBCT. Although most transfusions (72%) concerned 1 or 2 RBC units, we and others reported that the harmful association of the transfusion was proportional to the number RBC unit transfused . The association between the need for a massive transfusion and severe posttransplant complications is obvious.…”

“…In previous studies, this association only appeared after the third RBC unit. 7,45 The difference may either be related to a smaller number of patients or different transfusion practices in these studies. The association of time elapsed between transplant and transfusion is also probably influenced by differences in the context and indication of transfusion.…”

“…Although most transfusions (72%) concerned 1 or 2 RBC units, we and others reported that the harmful association of the transfusion was proportional to the number RBC unit transfused. 7,[43][44][45][46] The association between the need for a massive transfusion and severe posttransplant complications is obvious. However, the deleterious association of the transfusion starts with the first transfusion episode (1 or 2 RBC units).…”

Advancing Prediction of Risk of Intraoperative Massive Blood Transfusion in Liver Transplantation With Machine Learning Models. A Multicenter Retrospective Study

“…Studies have shown that the need for intraoperative blood transfusion is associated with an increased risk of death after liver transplantation and it is identified as the most important predictor of patient survival (Rana et al, 2013;Cleland et al, 2016;Viguera et al, 2021). A cohort study found that patients who received MT during the perioperative period of liver transplantation had a worse long-term prognosis than non-MT patients, with higher 30-day mortality and complication rates (Tan et al, 2021). Besides, the economic pressure and disease transmission risk brought by MT will further increase.…”