Liver transplantation without the use of blood products
H. C. Ramos, S. Todo, Y. Kang, E. Felekouras, H. R. Doyle and T. E. Starzl
Department of Surgery, University of Pittsburgh, School of Medicine. Pa.
OBJECTIVES: To examine the techniques and the outcome of liver
transplantation with maximal conservation of blood products and to analyze
the potential benefits or drawbacks of blood conservation and salvage
techniques. DESIGN: Case series survey. SETTING: Tertiary care, major
university teaching hospital. PATIENTS AND METHODS: Four patients with
religious objections to blood transfusions who were selected on the basis
of restrictive criteria that would lower their risk for fatal hemorrhage,
including coagulopathy, a thrombosed splanchnic venous system requiring
extensive reconstruction, active bleeding and associated medical
complications. All patients were pretreated with erythropoietin to increase
production of red blood cells. All operations were performed at the same
institution, with a 36-month follow-up. INTERVENTIONS: Orthotopic liver
transplantation that used blood salvage, plateletpheresis, and
autotransfusion and the withholding of the use of human blood products with
the exception of albumin. MAIN OUTCOME MEASURES: Survival and postoperative
complications, with the effectiveness of erythropoietin and
plateletpheresis as secondary measures. RESULTS: All patients are alive at
36 months after orthotopic liver transplantation. One patient, a minor (13
years of age), was transfused per a state court ruling. Erythropoietin
increased the production of red blood cells as shown by a mean increase in
hematocrit levels of 0.08. Platelet-pheresis allowed autologous,
platelet-rich plasma to be available for use after allograft reperfusion.
Three major complications were resolved or corrected without sequelae. Only
one patient developed postoperative hemorrhage, which was corrected
surgically. The mean charge for bloodless surgery was $174,000 for the
three patients with United Network for Organ Sharing (UNOS) status 3
priority for transplantation. This result was statistically significant
when these patients were compared with all the patients with UNOS status 3
priority during the same period who met the same restrictive guidelines (P
< .05). Only 19 of 1009 orthotopic liver transplantations performed at
our institution were similar according to the UNOS status and the
fulfillment of the guidelines. The mean charge for these comparison
patients was $327,000, 3.8% of which was related to transfusions.
CONCLUSIONS: Orthotopic liver transplantation without the use of blood
products is possible. Blood conservation techniques do not increase
morbidity or mortality and can result in fewer transfusion-related,
in-hospital charges.
