Asian Journal of Transfusion Science
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Mean peroperative blood transfusion requirement in living donor liver transplant recipients

 Hematology Department and Blood Bank, Blood Transfusion Services, Shifa International Hospital; Department of Hepatobiliary and Liver Transplant, Shifa International Hospital, Islamabad, Pakistan

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Date of Submission02-Feb-2020
Date of Decision06-Sep-2020
Date of Acceptance14-May-2022
Date of Web Publication12-Dec-2022


CONTEXT: Excessive bleeding in living donor liver transplantation is a foremost confrontation for transplant surgeons globally. Despite improvement in technical aspects, patient care, graft allocation, and use of blood-sparing policies, excessive blood loss still occurs. Blood transfusion services play a crucial role in providing both quantitative and qualitative support.
AIMS: This study is aimed at estimating the average transfusion requirement in terms of packed red cells (PRCs), fresh-frozen plasma (FFP), platelet concentrates, and cryoprecipitates in liver transplant recipients and analyzing predictors in our local circumstances. This would provide a guideline for anticipating the required blood component for centers intending to undertake this challenging task.
SETTINGS AND DESIGN: Descriptive cross-sectional study was conducted at Blood Transfusion Services and Department of Hepatobiliary and Liver Transplant, Shifa International Hospital, Islamabad.
SUBJECTS AND METHODS: Intraoperative utilization of blood components in 148 living donor liver transplant recipients was analysed using SPSS (IBM Statistical product and service solution version 20.0 (SPSS, Chicago, IL, USA).
RESULTS: The mean perioperative blood loss was 2845 ± 265 ml requiring a mean transfusion of 3. 43 ± 2.8 PRCs, 3.54 ± 5.0 units of FFP, 7.94 ± 7.6 units platelet, and 5.56 ± 7.4 units of cryoprecipitates.
CONCLUSIONS: Anticipation of mean blood loss and transfusion requirement along with close collaboration between the transplant team and blood transfusion services can help better streamlining the resources to provide adequate and timely services.

Keywords: Blood transfusion, end-stage liver disease, living donor liver transplant

How to cite this URL:
Shumail S, Junaid A. Mean peroperative blood transfusion requirement in living donor liver transplant recipients. Asian J Transfus Sci [Epub ahead of print] [cited 2023 Jan 28]. Available from:

   Introduction Top

Orthotopic liver transplantation has surfaced as the prime therapeutic option for patients diagnosed with end-stage liver disease.[1] Infection with hepatitis C virus (HCV) is the primary cause of end-stage liver disease in Pakistan supplanted by hepatitis B virus (HBV) infection, infection with both HBV and HCV, and HBV and hepatitis D virus (HDV) superinfection. Other causes include alcoholic liver disease, Wilson's disease, primary biliary cirrhosis, and hemochromatosis.[2]

Antecedent aberrations of the hemostatic system, inherent coagulopathic characteristics, portal hypertension, splenomegaly, portal vein thrombosis, prior abdominal surgery, and meagre functional retrieval of new liver contribute to increased blood loss and the necessity for transfusion. Upgraded surgical and anesthetic management over the last decade has contributed much to decrease perioperative blood loss and blood component transfusion.[3]

The chances of graft survival, immediate, and long-term consequences after liver transplant surgery are influenced by massive blood loss and increased transfusion therapy.[4],[5]

The transfusion requirements in living donor liver transplant (LDLT) procedures have not yet been reported in this part of the world. Our study will establish a baseline qualitative and quantitative guideline for such life-saving procedures.

   Subjects and Methods Top

This retrospective study on LDLT surgery cases was performed at the Blood Transfusion Services and Department of Hepatobiliary and Liver transplant, Shifa International Hospital, Islamabad, for a period of 18 months starting from February 1, 2016, to July 30, 2017, after the approval of the Hospital's Ethical Committee.

Patient's data were acquired from medical record files including the recipient's age, gender, weight, preoperative diagnosis, and Model for End-Stage Liver Disease (MELD)/Child–Turcotte–Pugh (CTP) score. Preoperative laboratory results of the tests, including hemoglobin (Hb), hematocrit (Hct), platelet count, total leukocyte count, activated partial thromboplastin time, international normalized ratio (INR), and total bilirubin, were recorded. The blood component usage, including packed red cells (PRCs), fresh-frozen plasma (FFP), cryoprecipitates, and platelets during the intraoperative period of every liver transplant surgery, was obtained from blood bank records.

One unit was attributed to 250 ml of PRC, 200 ml of FFP, 50 ml of platelets, and 15 ml of cryoprecipitates. Transfusion triggers were as: Hb <8 g/dL for PRC, >2 INR for FFP, <50,000/μL for platelets, and fibrinogen <100 mg/dl for cryoprecipitates.

Data analysis procedure

Descriptive statistics, i.e., mean and standard deviation (SD) for blood loss and mean per-operative blood transfusion in terms of blood components used, were calculated for PRCs, FFP, platelet concentrates, and cryoprecipitates. The frequency and percentage were calculated for gender, disease etiology, and high and low blood loss group. A t-test was applied to calculate the significance of different predictors.

   Results Top

Demographic profile

Out of 148 patients in the study population, 120 (81%) were male and 28 (19%) were female. Cumulative mean age was 43.0 years ± 14.3 SD.

Utilization of allogenic blood components

During the intraoperative period, 88.5% (n = 131) of the cases utilized red cell components with a median number of 3 and with a wide range (range 1–19). [Table 1] delineates the transfusion pattern. The mean perioperative transfusion requirement for red cell concentrate was 3.43 units ± 2.8 SD with a minimum of 1 and a maximum of 19 units.
Table 1: Utilization of allogenic blood components (n=148)

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Similarly, during the intraoperative period, 56% (n = 83) of the cases received a transfusion of FFP with a median number of 2, and the remaining 44% (n = 65) cases did not utilize even a single unit of FFP. The mean perioperative transfusion requirement for FFP was 3.54 units ± 5.0 SD with a minimum of 2 and a maximum of 30 units.

There were 69% (n = 102) of the cases who required intraoperative platelets transfusion with a median number of 8 and with a wide range (range 1–30). Thirty-one percentage (n = 46) of cases did not utilize even a single unit of platelets. The mean perioperative transfusion requirement for platelets was 7.94 units ± 7.6 SD.

For cryoprecipitates, the mean perioperative transfusion requirement was 5.56 units ± 7.4 SD. Forty-nine percentage (n = 73) of the cases utilized cryoprecipitates with the median number of 0 and with a wide range (range 5–39). Fifty-one percentage (n = 75) did not require cryoprecipitates per-operatively.

There were a total of 12 cases (8.1%) who did not utilize even a single unit of allogeneic blood components (bloodless liver transplantation).

High blood loss and transfusion

Blood loss of above 5000 ml was taken as high blood loss (HBL). The quantification of blood loss, given in [Table 2], was done by measuring direct blood loss (suction from operative field and weight of the soaked gauzes).[6]
Table 2: Blood loss during transplantation

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Pretransplant etiological profile

Majority of the patients (52.8%) in the HBL group were carrying a diagnosis of HCV, followed by hepatocellular carcinoma (HCC) (15.6%). Infection with HBV and HDV, acute liver failure, and cryptogenic liver disease accounted for 10.5% of cases each in HBL.

Pretransplant scores of disease severity

Regarding pretransplant scores of disease severity, MELD score is not an independent predictor of blood loss (P = 0.60).

Preoperative hematological profile

[Table 3] shows that preoperative hematological profile is not a significant predictor of increased blood loss.
Table 3: Preoperative hematological profile

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Intraoperative data

The duration of surgery is the significant parameter for increased blood loss (P = 0.01).

The average duration of surgery in the HBL group was 10.8 ± 1.9, whereas in the low blood loss group, it was 9.5 ± 2.1. Cold and warm ischemia time and graft versus body weight ratio were not significant parameters.

   Discussion Top

The requirement for blood transfusion in liver transplant surgery has dramatically reduced over the last decade, but the role of blood transfusion services is still indispensable. Good coordination and teamwork between liver transplant and blood transfusion services are crucial for the smooth working of the transplant program.

The median utilization of PRCs in 1990 was 10–12 units, and further, the decline was documented in the subsequent years.[7] This decline has been attained due to improved anesthetic and surgical techniques, better graft preservation, and organ allocation. The surgical technique employed is hepatic resection using intermittent vascular inflow occlusion which lower central venous pressure during surgery. These techniques improve morbidity and mortality.[8] [Table 4] gives comparative analysis of blood utilization and transfusion predictors.
Table 4: Comparative analysis of blood utilization

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Jabbour et al.[13] in a study of liver transplant on 27 Jehovah's witnesses' patients documented that preoperative blood augmentation and acute normovolemic hemodilution are effective strategies to decrease operative blood loss. This is an important step toward transfusion-free surgical practices.

In a review Darwish[14] described in Jehovah's witnesses' patients that by utilization of preoperative and intraoperative techniques which decrease surgical blood loss and oxygen consumption, and increase oxygen delivery, liver transplant can be performed without any transfusion requirement.

According to Spence and Maurer,[15] patients with chronic active hepatitis require excessive blood as they have more advanced disease than patients with primary biliary cirrhosis. Cywinski et al.[16] in a retrospective study showed that HCC is negative predictor for massive blood transfusion. In our study, the majority of the patients (52.8%) in HBL group were carrying a diagnosis of HCV, whereas only 15.6% part were contributed by HCC, which is contrary finding as compared to the study of Cywinski et al.

CTP and Model for End-Stage Disease (MELD) are the models for the assessment of the severity of the liver disease. Different studies have been done to determine the association of severity of liver disease with perioperative blood loss, but the results are controversial. Findlay and Rettke,[17] Massicotte et al.,[3] and Roullet et al.[18] in their studies concluded that MELD score is not an independent predictor of blood loss and transfusion requirement. Our results are consistent with their results of MELD score, not being a significant predictor of increased transfusion requirement. Contrary to these results, McCluskey et al.[19] devised that two of the variables which are used to calculate the MELD score, i.e., INR and preoperative creatinine are independent predictors of bleeding, although the MELD score itself is less predictive. In consistence to this conclusion, Mangus et al.,[20] Frasco et al.,[9] and Cywinski et al.[16] reported that high MELD score is one of the risk factors which is statistically significant predictor of increased bleeding and transfusion requirements.

In our study preoperative, Hct did not turn out to be an indicator of increased transfusion requirement. Conversely Steib et al.[21] reported that preoperative low Hb was one of the three preoperative risk factors predictive of increased blood loss. According to Massicotte et al.,[22] indicator for the need for transfusion was low preoperative Hb. Despite this fact, the cutoff threshold for Hb has not been clearly reported yet. However, the investigators inferred that an initial low Hb below 10 g/dL would predict increased transfusion.

Regarding coagulation profile Cywinski et al.[16] in a retrospective study showed that pretransplant higher INR and lower platelet counts are statistically significant predictors of higher intraoperative blood product utilization. These findings are not supported by our data.

   Conclusions Top

Our study shows mean per-operative blood component transfusion requirements at the first LDLT center in Pakistan with state-of-the-art facility for organ transplantation. In addition to the documentation of mean values, predictors of transfusion were also evaluated. Our study revealed that the duration of the operation is the main factor contributing to increased blood loss and increased transfusion volume, highlighting the significance of continued small volume losses during uncomplicated liver transplant procedures. Our results do not support the observations of few earlier studies that hematological, biochemical, and etiological parameters are the predictor of increased transfusion requirement. We suggest that transfusion needs for liver transplant recipients should be individualized for each patient based on the intraoperative conditions including surgical and patient features.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Morell B, Dufour JF. Liver transplantation – When and for whom it should be performed. Ther Umsch 2011;68:707-13.  Back to cited text no. 1
Ullah F, Khan S, Afridi AK, Rahman SU. Frequency of different causes of cirrhosis liver in local population. Gomal J Med Sci 2012;10:178-81.  Back to cited text no. 2
Massicotte L, Denault AY, Beaulieu D, Thibeault L, Hevesi Z, Nozza A, et al. Transfusion rate for 500 consecutive liver transplantations: Experience of one liver transplantation center. Transplantation 2012;93:1276-81.  Back to cited text no. 3
Ghaffaripour S, Mahmoudi H, Khosravi MB, Sahmeddini MA, EqHbal H, Sattari H, et al. Preoperative factors as predictors of blood products transfusion requirements in orthotopic liver transplantation. Prog Transplant 2011;21:254-9.  Back to cited text no. 4
Gurusamy KS, Pissanou T, Pikhart H, Vaughan J, Burroughs AK, Davidson BR. Methods to decrease blood loss and transfusion requirements for liver transplantation. Cochrane Database Syst Rev 2011;2011:CD009052.  Back to cited text no. 5
Tomescue D, Popescu M, Droc G, Fota R, Ungureanu D, Brasoveanu V. Intraoperative blood loss and blood transfusion during liver transplantation. A national single centre experience. J Rom Anest Int 2014;21:27-34.  Back to cited text no. 6
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. 7
Chen H, Merchant NB, Didolker MS. Hepatic resection using intermittent vascular inflow occlusion and low central venous pressure anaesthesia improves morbidity and mortality. J Gastrointest Surg 2000;4:162-7.  Back to cited text no. 8
Frasco PE, Poterack KA, Hentz JG, Mulligan DC. A comparison of transfusion requirements between living donation and cadaveric donation liver transplantation: Relationship to model of end-stage liver disease score and baseline coagulation status. Anesth Analg 2005;101:30-7.  Back to cited text no. 9
Makroo RN, Walia RS, Aneja S, Bhatia A, Chowdhry M. Preoperative predictors of blood component transfusion in living donor liver transplantation. Asian J Transfus Sci 2013;7:140-6.  Back to cited text no. 10
[PUBMED]  [Full text]  
Pandey P, Tiwari AK, Sharma J, Srivastava D, Dixit S, Raina V. Perioperative use of allogenic blood components in live-related donor orthotopic liver transplantation: A cross sectional study. Asian J Transfus Sci 2013;7:68-72.  Back to cited text no. 11
[PUBMED]  [Full text]  
Massicotte L, Sassine MP, Lenis S, Roy A. Transfusion predictors in liver transplant. Anesth Analg 2004;98:1245-51.  Back to cited text no. 12
Jabbour N, Gagandeep S, Mateo R, Sher L, Genyk Y, Selby R. Transfusion free surgery: Single institution experience of 27 consecutive liver transplantation in Jehova's witnesses. J Am Coll Surg 2005;3:412-7.  Back to cited text no. 13
Darwish A. Live transplant in Jehova's witnesses patients. Curr Opin Organ Transplant. 2011;16:326-30.  Back to cited text no. 14
Spence RK, Maurer J. Transfusion requirements in liver transplantation-e medicine updated. 2006.  Back to cited text no. 15
Cywinski JB, Alster JM, Miller C, Vogt DP, Parker BM. Prediction of intraoperative transfusion requirements during orthotopic liver transplantation and the influence on postoperative patient survival. Anesth Analg 2014;118:428-37.  Back to cited text no. 16
Findlay JY, Rettke SR. Poor prediction of blood transfusion requirements in adult liver transplantations from preoperative variables. J Clin Anesth 2000;12:319-23.  Back to cited text no. 17
Roullet S, Biais M, Millas E, Revel P, Quinart A, Sztark F. Risk factors for bleeding and transfusion during orthotopic liver transplantation. Ann Fr Anesth Reanim 2011;30:349-52.  Back to cited text no. 18
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. 19
Mangus RS, Kinsella SB, Nobari MM, Fridell JA, Vianna RM, Ward ES, et al. Predictors of blood product use in orthotopic liver transplantation using the piggyback hepatectomy technique. Transplant Proc 2007;39:3207-13.  Back to cited text no. 20
Steib A, Freys G, Lehmann C, Meyer C, Mahoudeau G. Intraoperative blood losses and transfusion requirements during adult liver transplantation remain difficult to predict. Can J Anaesth 2001;48:1075-9.  Back to cited text no. 21
Massicotte L, Capitanio U, Beaulieu D, Roy JD, Roy A, Karakiewicz PI. Independent validation of a model predicting the need for packed red blood cell transfusion at liver transplantation. Transplantation 2009;88:386-91.  Back to cited text no. 22

Correspondence Address:
Shabana Shumail,
Hematology Department and Blood Bank, Shifa International Hospital Ltd., Sector H8/4, Islamabad
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ajts.AJTS_14_20


  [Table 1], [Table 2], [Table 3], [Table 4]


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