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May 1994

Liver Transplantation Without the Use of Blood Products

Author Affiliations

From the Departments of Surgery (Drs Ramos, Todo, Felekouras, Doyle, and Starzl) and Anesthesiology/Critical Care Medicine (Dr Kang), Pittsburgh Transplantation Institute, University of Pittsburgh (Pa) School of Medicine.

Arch Surg. 1994;129(5):528-533. doi:10.1001/archsurg.1994.01420290074011

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. Plateletpheresis 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 similiar 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.(Arch Surg. 1994;129:528-533)

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