Asian Journal of Transfusion Science
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Intraoperative blood loss and blood transfusion requirement among liver transplant recipients: A national single-center experience 2020

1 Department of Pathology, Hospital Selayang, Selangor, Ministry of Health, Malaysia
2 Department of Hepatobiliary, Hospital Selayang, Selangor, Ministry of Health, Malaysia
3 Department of Hepatology, Hospital Selayang, Selangor, Ministry of Health, Malaysia
4 Department of Anaesthesiology and Intensive Care Unit, Hospital Selayang, Selangor, Ministry of Health, Malaysia

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Date of Submission25-Mar-2021
Date of Decision04-Oct-2021
Date of Acceptance29-Aug-2021
Date of Web Publication26-Sep-2022


BACKGROUND: Liver transplantation (LT) is a complicated surgical procedure with high risk for massive intraoperative blood loss due to pre-existing coagulopathy, portosystemic shunts with collateral circulations, and splenomegaly. The transfusion service will direct most of their resources toward LT programs with great impact on cost. The purpose of this study was to evaluate single center transfusion strategies and to identify the risk factors associated with the intraoperative blood loss and blood transfusion.
METHODS: The study includes 18 patients who underwent LT at Hospital Selayang between January 2020 and December 2020. Retrospective analysis of data included preoperative assessment of coagulopathy, intraoperative blood loss, and blood component transfusion
RESULTS: The mean age in the study group was 36.4 ± 12.68 years. The mean intraoperative blood loss was 4450 ± 1646 ml requiring 4.17 ± 3.3 packed red blood cell (PRBC) units, 7.56 ± 5.5 platelet units, and 9.50 ± 6.0 fresh-frozen plasma units. The independent risk factor for high blood loss (HBL) group was lower preoperative platelet count and it is statistically significant (P = 0.024). The HBL group is associated with higher usage of PRBC (P = 0.024) and platelet units (P = 0.031) and it is statistically significant. The length of stay (LOS) in intensive care unit (ICU) averaging 8.6 ± 4.95 days, and there is no significant differences comparing the HBL and LBL group (P = 0.552). The mortality <90 days for all recipients was 22.2%.
CONCLUSION: The preoperative platelet count for is the most important factor associated with HBL in LT procedure. The usage of PRBC and platelet units was statistically higher in the HBL group. Comparing HBL and LBL patients, there is no difference in terms of the LOS in ICU postoperatively. A larger sample size would be needed in view of relatively small sample size.

Keywords: Blood transfusion requirement among liver transplant recipients, intraoperative blood loss, liver transplant

How to cite this URL:
Yusop MF, Tahir NM, Azim SM, Kamaruzaman AA, Hata NR, Kugaan A, Osman MF, Yazid TN, Mokhtar S, Omar H, Amir AS. Intraoperative blood loss and blood transfusion requirement among liver transplant recipients: A national single-center experience 2020. Asian J Transfus Sci [Epub ahead of print] [cited 2023 Mar 24]. Available from:

   Introduction Top

Liver transplant surgery makes unusual demands on the blood bank. The total use of packed red blood cells (PRBC) in this group of patients (both intra and perioperative) accounted for about 15% of all transfusion needs in the institution. It is about 4.7% of the 130,000 units of blood distributed annually to all hospitals served by the Central Blood Bank of Pittsburgh.[1]

Patients with liver cirrhosis have impaired coagulation profile mainly due to low synthesis of procoagulant factors by the liver.[2] New evidences suggest that hemostasis in liver transplant is “re-balanced” by the elevation of FVIII and depletion of anticoagulants (Protein S, Protein C, and Antithrombin III).[3] Since the first successful liver transplant in year 1967, blood and its components has been massively transfused during surgery to correct coagulation abnormalities. Fresh-frozen plasma (FFP) has also been used for volemic resuscitation during liver transplantation (LT). Massive blood transfusion has led to an increased risk of postoperative transfusion-related complications.[4]

More than one-half of these transfusions occurred intraoperatively. This is a fact that clearly indicates the need for logistic planning by the blood bank in support of these procedures. Liver transplants occur within short notice. The maximal time between donor organ harvest and transplantation is <12 h, often considerably less. Because of their technical difficulties, these procedures take from 6 to 24 h to perform and are often done at night or on weekends. All these factors tend to stress the transfusion service's capability to support these patients.[1]

Latest trends inclined toward restrictive transfusion strategies in all major abdominal surgery including liver transplant. Although recent guidelines suggest more evidenced-based approach based on a complex evaluation of hemostasis, there are still significant differences of practice between transplant centers. Hence, these are based on individual approach to liver transplant and clinical experience by treating physicians.[5]

In our experience, a key to successful transfusion support in LT is to maintain good communication between the transplant team and the transfusion service. The transfusion service must be alerted immediately when an organ becomes available and the recipient is selected. This permits accumulation of red cell and other transfusion products of the proper type and in the necessary amount. The occurrence of unanticipated bleeding or technical problems should be conveyed immediately to the transfusion service so that sufficient quantities of blood and its component can be prepared in advance.[1]

   Methods Top


The purpose of this study was to evaluate a single center transfusion strategy and to identify risk factors associated with high blood loss (HBL) and low blood loss (LBL). Furthermore, it is to evaluate the predictors of blood transfusion requirements and also the outcome of patients in liver transplant.

Data collection

A retrospective cross-sectional study was conducted between January 2020 and 31 December 2020 at Hospital Selayang. All patients who underwent liver transplant during this period were included in the study (n = 18).

The patients' data were collected from the electronic patient information system and filled up in appropriate pro forma. Preoperative data include demographic characteristics, etiology of liver disease, ABO blood group, preoperative Hb (g/dL), and platelet count (1 × 109). Intraoperative data were the duration of surgery (min), estimated blood loss (EBL) (ml), and blood product transfusion. Postoperative data collected were the postoperative Hb (g/dL), Length of stay (LOS) in intensive care unit (ICU), and mortality of <90 days.

Blood transfusion

HBL was defined as blood loss above 5000 ml while low blood loss (LBL) was defined as blood loss < 5000 ml. Blood loss was quantified by measuring direct loss (suction from operatory field and number of gauzes used). Transfusion was triggered by diffuse coagulopathy bleeding and was decided according to local protocol. PRBC were administered to maintain hemoglobin (Hb) level above 8.0 g/dL or/and hematocrit above 30%, FFP was administered to maintain INR around 2.5–3.0, platelet transfusion was administered by liver anesthesiologist according to their own threshold and cryoprecipitate was transfused to maintain fibrinogen above 1 g/L. Intraoperative salvage of blood was used in most of the LT surgeries.

Statistical analysis

Data are presented as mean ± standard deviation of the mean, range (min, max) and otherwise percentage. Data distribution was examined to ensure proper statistical analysis. Demographic and physiological characteristics for the two groups were compared using the Student t-test for continuous data and Mann − Whitney Test for nonparametric data. The Chi-square test and Fischer exact test were used to analyze subgroup differences. Statistical significance was considered at P < 0.05. Statistical analysis was performed using the SPSS software 26.0 (SPSS, Chicago, IL, USA).

   Results Top

Demographic and pretransplant data are presented in [Table 1]. The mean age for the study was 36.4 ± 12.68 years with the range from 15 to 60 years old. About 17% (n = 3) of patients underwent living-related liver transplant while 83% (n = 15) underwent cadaveric liver transplant. As for the age (P = 0.303) and gender (P = 0.319), they were shown not to be statistically significant for HBL category.
Table 1: Demographic and pretransplant data

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Preoperative low platelet count was shown to be an independent predictor for HBL. It is statistically significant with P = 0.024. Meanwhile, for preoperative Hb level (P = 0.437) and INR (P = 0.722) were not shown to be significant predictor for HBL.

The intraoperative data are presented in [Table 2]. The mean duration of surgery was 562 ± 125 min, with the shortest time being 384 min and the longest time being 822 min. The duration of surgery does not show any statistical significant with the blood loss (P = 0.507). The mean EBL was 4450 ± 1646 ml, which ranged from 2000 ml to 8000 ml in liver transplant surgery performed.
Table 2: Intraoperative data

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The mean transfusion requirements were as follows: PRBC averages 4.17 ± 3.3 units ranging from 0 to 14 units, platelet averages 7.56 ± 5.5 units ranging from 0 to 20 units, FFP averages 9.50 ± 6.0 ranging from 0 to 20 units and cryoprecipiate averages 4.44 ± 5.6 ranging from 0 to 20 units. PRBCs (P = 0.024) and platelets (P = 0.031) were the independent variable which were significantly associated with HBL. Meanwhile, FFP (P = 0.110) and cryoprecipitate (P = 0.436) were not significantly associated with HBL among liver transplant recipients. One patient with EBL of about 2500 ml was not transfused with any blood products.

The mean EBL in all patients was 4450 ± 1646 ml. The mean HBL was 5833 ± 935 ml while the mean LBL was 3067 ± 760 among all LT surgeries.

The postoperative data are presented in [Table 3]. The average postoperative Hb level was 9.5 ± 0.90 g/dL in all liver transplant cases. Comparing the postoperative Hb level between HBL group and LBL group, it does not show any statistical significance (P = 0.800). Fourteen patients (77.8%) have survived from after liver transplant surgery for >90 days. Comparing between HBL and LBL group of patients, it does not show any statistical significance (P = 0.288) in terms of the mortality.
Table 3: Postoperative data

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   Discussion Top

Despite recent advances in anesthesiology and surgery which has led to the decreased blood loss in liver transplant surgery, this procedure is still associated with high risk of massive blood loss and requires massive transfusion. The rebalanced approach to hemostasis in chronic liver failure offered new perspective on FFP transfusion during liver transplant. Despite that, transfusion of the blood products remains at physicians' or surgeons' discretion.[5]

The transfusion protocol used by anesthesiologist in our transplant center has been adapted from published guidelines and tailored from case-to-case basis. Nevertheless, the same controversies remain regarding the PRBC transfusion. This is due to the fact that there are scattered evidence supporting one transfusion practice over another. There are conflicting studies in supporting Hb level above 7 g/dL in patients with cardiovascular disease.[6] Nevertheless, we stayed with the current practice in maintaining Hb level above 8 g/dL and hematocrit above 30%.[7] This is evidenced in the pretransplant Hb level of 11.1 ± 2.43 g/dL in all cases here in hospital Selayang. Most study agree that in liver transplant procedure especially involving cirrhotic patients, the platelet count above 50 × 109/L remains a safe level for the procedure.[8] Our current practice varies from individual anesthetist for the platelet level. The mean platelet level for all liver transplant procedures was 144.1 ± 147.9/μL, which ranged from minimum of 33 to maximum of 628.

The blood and its component transfusion requirement in our study group was comparable to other literatures. We reported a mean of 4.17 ± 3.3 PRBC units used, 7.56 ± 5.5 platelet units used, 9.50 ± 6.0 FFP units used and 4.44 ± 5.6 cryoprecipitate units used. Tomescu et al. reported a mean of 6.93 ± 6.25 PRBC and platelet units used, 18.44 ± 12.39 FFP units used and 3.53 ± 4.27 cryoprecipitate units used in all liver transplant procedures.[9] In our study, the number of PRBC and platelet used were higher and statistically significant (P = 0.024 and P = 0.031) in HBL group. However, the number of FFP and cryoprecipitate used were not associated with the type of blood loss. This is in contrast with the other study done by Tomescu et al. who reported there were significant increase in all blood products transfusion in the HBL group (P < 0.001).[9] On top of that, our results show there is no difference regarding blood loss and between patients receiving from living related donor or from cadaveric donors (P = 0.500). This is in line with Pirat et al. who did not detect any significant differences in blood loss between those two groups.[10]

Our results show that the LOS in ICU postoperatively was 8.6 ± 4.95 days, ranged from 2 to 19 days. In terms of LOS, it is not statistically significant comparing the HBL and LBL group of patients (P = 0.552). The mean LOS posttransplant surgery is comparable to Tomescu et al. with 9.71 ± 8.4 days. However, Tomescu et al. reported the longer LOS and it is statistically significant in the HBL group (P = 0.004).[9] On top of that, the survival rate within 1 year is about 77.8%, which is comparable to most of studies in liver transplant surgery.[11] Comparing the HBL and LBL group, the mortality rate is not statistically not significant (P = 0.288).

   Conclusion Top

We found a number of significant differences between liver transplant patients in terms of the types of blood loss, primarily the preoperative platelet level being the important predictor. The number of PRBC and platelet units transfused was higher and was statistically significant in HBL group. In Hospital Selayang, postliver transplant patients' survival rate within 1 year is comparable to other centers. However, our data are very small, and hence, a larger sample size would be needed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Butler P, Israel L, Nusbacher J, Jenkins DE Jr., Starzl TE. Blood transfusion in liver transplantation. Transfusion 1985;25:120-3.  Back to cited text no. 1
Mannucci PM, Franchi F, Dioguardi N. Correction of abnormal coagulation in chronic liver disease by combined use of fresh-frozen plasma and prothrombin complex concentrates. Lancet 1976;2:542-5.  Back to cited text no. 2
Lisman T, Porte RJ. Rebalanced hemostasis in patients with liver disease: Evidence and clinical consequences. Blood 2010;116:878-85.  Back to cited text no. 3
Ramos E, Dalmau A, Sabate A, Lama C, Llado L, Figueras J, 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;9:1320-7.  Back to cited text no. 4
Ozier Y, Pessione F, Samain E, Courtois F, French Study Group on Blood Transfusion in Liver Transplantation. Institutional variability in transfusion practice for liver transplantation. Anesth Analg 2003;97:671-9.  Back to cited text no. 5
Hébert PC, Yetisir E, Martin C, Blajchman MA, Wells G, Marshall J, et al. Is a low transfusion threshold safe in critically ill patients with cardiovascular diseases? Crit Care Med 2001;29:227-34.  Back to cited text no. 6
McCluskey SA, Karkouti K, Wijeysundera DN, Kakizawa K, Ghannam M, Hamdy A, et al. Derivation of a risk index for the prediction of massive blood transfusion in liver transplantation. Liver Transpl 2006;12:1584-93.  Back to cited text no. 7
Estcourt LJ, Birchall J, Allard S, Bassey SJ, Hersey P, Kerr JP, et al. Guidelines for the use of platelet transfusions. Br J Haematol 2017;176:365-94.  Back to cited text no. 8
Tomescu D, Popescu M, Droc G, Fota R, Ungureanu D, Brasoveanu V. Intraoperative blood loss and blood transfusion during liver transplantation. A national single center experience. J Rom Anest Terap Int 2014;21:27-34.  Back to cited text no. 9
Pirat A, Sargin D, Torgay A, Arslan G. Identification of preoperative predictors of intraoperative blood transfusion requirement in orthotopic liver transplantation. Transplant Proc 2002;34:2153-5.  Back to cited text no. 10
Gil E, Kim JM, Jeon K, Park H, Kang D, Cho J, et al. Recipient age and mortality after liver transplantation: A population-based cohort study. Transplantation 2018;102:2025-32.  Back to cited text no. 11

Correspondence Address:
Mohd Faeiz Yusop,
Department of Pathology, Hospital Selayang, Ministry of Health
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ajts.ajts_38_21


  [Table 1], [Table 2], [Table 3]


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