Factors associated with blood transfusion in donor hepatectomy: results from 2344 donors at a large single center. Transplantation. 2013;96:1000-1007. [PMID: 23985722 DOI: 10.1097/tp.0b013e3182a41937]

Perioperative management of living donor liver transplantation: Part 2 - Donors

Living donor liver transplantation was first developed to mitigate the limited access to deceased donor organs in Asia in the 1990s. This alternative liver transplantation method has become a widely practiced and established transplantation option for adult patients suffering with end-stage liver disease, and it has successfully helped address the shortage of deceased donors. The Society for the Advancement of Transplant Anesthesia and the Korean Society of Transplantation Anesthesiologists jointly reviewed published studies on the perioperative management of adult live liver donors undergoing donor hemi-hepatectomy. The goal of the review is to offer transplant anesthesiologists and critical care physicians a comprehensive overview of the perioperative management of adult live donors. We featured the current status, donor selection process, outcomes and complications, surgical procedure, anesthetic management, Enhanced Recovery After Surgery protocols, avoidance of blood transfusion, and considerations for emergency donation. Recent surgical advances, including laparoscopic donor hemi-hepatectomy and robotic laparoscopic donor surgery, are also addressed.

Use of minor donors for living donor liver transplantation and associated ethical issues

Background

Living liver donation by minors is regarded as justifiable only if minors possess the capacity to consent to donation and the procedure is in their best interests. This study analyzed the incidence of and reasons for living donor liver transplantation (LDLT) by minor donors in Korea, and discussed ethical issues regarding liver donation by minors.

Methods

The databases of the Korean Network for Organ Sharing (KONOS) and Asan Medical Center (AMC) from 2010 to 2019 were retrospectively reviewed to determine the incidence of LDLT by minor donors.

Results

From 2010 to 2019, 590 (4.1%) of 14,243 liver donors in the KONOS database and 276 (7.5%) of 3,401 liver donors in the AMC database were minors. The proportions of minor donors in the KONOS and AMC databases were highest in 2012, at 4.1% and 12.6%, respectively, and lowest in 2019, at 1.1% and 3.0%, respectively. Because most LDLT recipients had relatively low model for end-stage liver disease scores and hepatocellular carcinoma, they were unlikely candidates for deceased-donor liver transplantation and were highly likely to drop out of LDLT if they waited for 1-2 years. The donor-recipient relationship of minor donors in the AMC database was first-degree in 256 (92.8%) and second- or third-degree in 20 (7.2%).

Conclusions

Liver donation by minors is limitedly acceptable only when the minor proves informed, well-considered, and autonomous consent to the procedure and the procedure is in the minor's best interests. We suggest that minors be allowed to donate only to first-degree family members.

The Association between Prognostic Nutritional Index (PNI) and Intraoperative Transfusion in Patients Undergoing Hepatectomy for Hepatocellular Carcinoma: A Retrospective Cohort Study

BACKGROUND

PNI is significantly associated with surgical outcomes; however, the association between PNI and intraoperative transfusions is unknown.

METHODS

This study retrospectively analyzed 1065 patients who underwent hepatectomy. We divided patients into two groups according to the PNI (<44 and >44) and compared their transfusion rates and surgical outcomes. We performed multivariate logistic and Cox regression analysis to determine risk factors for transfusion and the 5-year survival. Additionally, we found the net reclassification index (NRI) to validate the discriminatory power of PNI.

RESULTS

The PNI <44 group had higher transfusion rates (adjusted odds ratio [OR]: 2.20, 95%CI: 1.06-4.60, p = 0.035) and poor surgical outcomes, such as post hepatectomy liver failure (adjusted [OR]: 3.02, 95%CI: 1.87-4.87, p < 0.001), and low 5-year survival (adjusted OR: 1.68, 95%CI: 1.17-2.24, p < 0.001). On multivariate analysis, PNI <44, age, hemoglobin, operation time, synthetic colloid use, and laparoscopic surgery were risk factors for intraoperative transfusion. On Cox regression analysis, PNI <44, MELD score, TNM staging, synthetic colloid use, and transfusion were associated with poorer 5-year survival. NRI analysis showed significant improvement in the predictive power of PNI for transfusion (p = 0.002) and 5-year survival (p = 0.004).

CONCLUSIONS

Preoperative PNI <44 was significantly associated with higher transfusion rates and surgical outcomes.

Predictors of Red Blood Cell Transfusion in Bimaxillary Orthognathic Surgery: A Retrospective Study

Background: Orthognathic surgery requires red blood cell (RBC) transfusions more frequently than other oral and maxillofacial surgeries. The purpose of this study was to identify reliable predictors for RBC transfusion during bimaxillary orthognathic surgery (BOS). Methods: This retrospective study reviewed 1,616 electronic medical records of patients who underwent BOS during a 5-year period at Seoul National University Dental Hospital. The perioperative variable data were collected from electronic medical records and analyzed by dividing patients into the two groups (non-transfusion and transfusion group). Results: Of the 1,616 patients, 1,311 patients were excluded. The remaining 305 patients were divided into non-transfusion (NTF, n = 256) and transfusion (TF, n = 49) groups. Univariate logistic regression analysis revealed that age, body mass index, the presence of several adjunctive surgeries (including genioplasty, extraction, and mandibular angle reduction), preoperative hemoglobin (Hb) and prothrombin time, surgical time, amount of fluid infusion and blood loss, and mean pulse rate during surgery were significant factors predicting RBC transfusion. Multivariate logistic regression analysis revealed that preoperative Hb and blood loss amount during surgery were significantly related to RBC transfusion in BOS patients. Conclusion: Since blood loss amounts could not be measured preoperatively, we found that the independent predictor associated with RBC transfusion during BOS was a low preoperative Hb level.

Preoperative Autologous Blood Collection in Adult Living Liver Donors: Are We Wasting Donor Blood and Increasing Exposure to Risk?

BACKGROUND

Despite waning indications in the general population for preoperative autologous blood donation (PABD), it is a procedure that continues to be offered to healthy living liver donor (LLD). In this study, we sought to understand the impact of PABD on the LLD population.

METHODS

We retrospectively reviewed charts of one institution's LLDs over a 2-year period. Per institutional protocol, all accepted LLDs donated 1 unit of autologous blood before living donor hepatectomy.

RESULTS

Sixty-six LLDs underwent PABD and 59 of these donors underwent living donor hepatectomy. In this cohort, there was a significant 1.2 g/dL drop in hemoglobin (HB) from baseline (before PABD) to the evening before surgery. Mean (standard deviation [SD]) procedure estimated blood loss was 260 mL (±100), mean (SD) resected graft weight was 592 g (±174). No allogeneic blood was transfused. Forty-two percent of LLD received autologous transfusion. Mean (SD) pretransfusion HB of transfused LLDs was 11.7 g/dL (±1.2). All LLDs had negative antibody screens. Sixty-three percent of donated autologous units were discarded.

CONCLUSIONS

Preoperative autologous blood donation in our population is associated with decreased preoperative HB, increased exposure of healthy LLD to unnecessary transfusion-related risks and high rates of discarded blood product. We encourage further investigation and reconsideration of the practice of PABD and autologous transfusion in LLDs.

Comparison of postoperative coagulation profiles and outcome for sugammadex versus pyridostigmine in 992 living donors after living-donor hepatectomy

Donor safety is the major concern in living donor liver transplantation, although hepatic resection may be associated with postoperative coagulopathy. Recently, the use of sugammadex has been gradually increased, but sugammadex is known to prolong prothrombin time (PT) and activated partial thromboplastin time (aPTT). We compared the postoperative coagulation profiles and outcomes of sugammadex versus pyridostigmine group in donors receiving living donor hepatectomy.Consecutive donor hepatectomy performed between September 2013 and August 2016 was retrospectively analyzed. For reversal of rocuronium-induced neuromuscular blockade, donors received sugammadex 4 mg/kg or pyridostigmine 0.25 mg/kg. The primary end-points were laboratory findings (PT, aPTT, hemoglobin, platelet count) and clinically evaluated postoperative bleeding (relaparotomy for bleeding, cumulative volume collected in drains). Secondary outcomes were anesthesia time, postoperative hospital day.Of 992 donors, 383 treated with sugammadex and 609 treated with pyridostigmine for the reversal of neuromuscular blockade. There were no significant differences between both groups for drop in hemoglobin and platelet, prolongation in PT, aPTT, and the amount of 24-h drain volume. Bleeding events within 24 h were reported in 2 (0.3%) for pyridostigmine group and 0 (0%) for sugammadex group (P = .262). Anesthesia time was significantly longer in pyridostigmine group than that in sugammadex group (438.8 ± 71.4 vs. 421.3 ± 62.3, P < .001). Postoperative hospital stay was significantly longer in pyridostigmine group than that in sugammadex group (P = .002).Sugammadex 4 mg/kg was not associated with increased bleeding tendency, but associated with reduced anesthesia time and hospital stay. Therefore, sugammadex may be safely used and will decrease morbidity in donor undergoing living-donor hepatectomy.

Central Venous Pressure Drop After Hypovolemic Phlebotomy is a Strong Independent Predictor of Intraoperative Blood Loss During Liver Resection

BACKGROUND

Intraoperative hypovolemic phlebotomy (HP) has been suggested to reduce central venous pressure (CVP) before hepatectomy. This study aimed to analyze the impact of CVP drop after HP on intraoperative blood loss and postoperative renal function.

METHODS

A retrospective review of a prospective database including 100 consecutive patients (43 males and 57 females; mean age, 65 years; range 23-89 years) undergoing liver resection with HP was performed. The primary outcome variable was estimated blood loss (EBL), and the secondary outcome was postoperative serum creatinin (Scr). A multivariate linear regression analysis was performed to identify predictors of intraoperative blood loss.

RESULTS

The median CVP before blood salvage was 8 mmHg (range 4-30 mmHg). The median volume of hypovolemic phlebotomy was 400 ml (range 200-1000 ml). After HP, CVP decreased to a median of 3 mmHg (range -2 to 16 mmHg), resulting in a median CVP drop of 5.5 mmHg (range 2-14 mmHg). The median EBL during liver resection was 165 ml (range 0-800 ml). The median preoperative serum creatinin (Scr) was 0.82 g/dl (range 0.5-1.74 g/dl), and the postoperative Scr on day 1 was 0.74 g/dl (range 0.44-1.68 g/dl). The CVP drop was associated with EBL (P < 0.001). There was no significant impact of CVP drop on postoperative Scr.

CONCLUSION

A CVP drop after HP is a strong independent predictor of EBL during liver resection. The authors advocate the routine use of HP to reduce perioperative blood loss and transfusion rates in liver surgery. As a predictive tool, CVP drop might help surgeons decide whether a laparoscopic approach is safe.

Risk factors for intraoperative massive transfusion in pediatric liver transplantation: a multivariate analysis

Background: Pediatric liver transplantation (LT) is strongly associated with increased intraoperative blood transfusion requirement and postoperative morbidity and mortality. In the present study, we aimed to assess the risk factors associated with massive transfusion in pediatric LT, and examined the effect of massive transfusion on the postoperative outcomes. Methods: We enrolled pediatric patients who underwent LT between December 1994 and June 2015. Massive transfusion was defined as the administration of red blood cells ≥100% of the total blood volume during LT. The cases of pediatric LT were assigned to the massive transfusion or no-massive transfusion (administration of red blood cells <100% of the total blood volume during LT) group. Univariate and multivariate logistic regression analyses were performed to evaluate the risk factors associated with massive transfusion in pediatric LT. Kaplan-Meier survival analysis, with the log rank test, was used to compare graft and patient survival within 6 months after pediatric LT between the 2 groups. Results: The total number of LT was 112 (45.0%) and 137 (55.0%) in the no-massive transfusion and massive transfusion groups, respectively. Multivariate logistic regression analysis indicated that high white blood cell (WBC) count, low platelet count, and cadaveric donors were significant predictive factors of massive transfusion during pediatric LT. The graft failure rate within 6 months in the massive transfusion group tended to be higher than that in the no-massive transfusion group (6.6% vs. 1.8%, P = 0.068). However, the patient mortality rate within 6 months did not differ significantly between the massive transfusion and no-massive transfusion groups (7.3% vs. 7.1%, P = 0.964). Conclusion: Massive transfusion during pediatric LT is significantly associated with a high WBC count, low platelet count, and cadaveric donor. This finding can provide a better understanding of perioperative blood transfusion management in pediatric LT recipients.

Effect of Hydroxyethyl Starch on Acute Kidney Injury After Living Donor Hepatectomy

BACKGROUND

Concerns about the adverse effects of hydroxyethyl starch (HES) on renal function have been raised in recent studies involving critically ill patients. We aimed to evaluate the effect of HES on acute kidney injury (AKI) after living donor right hepatectomy.

METHODS

We performed a 1:3 propensity score matching analysis of the medical records of 1641 living donors who underwent a donor right hepatectomy. They were divided into the control group (n = 60), who received only crystalloids, and the colloid group (n = 1,581), who received HES 130/0.4 and crystalloids. Postoperative AKI was determined by AKI Network (AKIN) and Risk, Injury, Failure, Loss, End-stage (RIFLE) criteria.

RESULTS

A 1:3 propensity score matching was performed in 206 donors, 54 donors in the control group and 152 donors in the colloid group. For the matched colloid group, the median amount of 7.65 mL/kg (interquartile range, 6.64-9.20) of colloid and 58.19 mL/kg (interquartile range, 45.63-71.51) of crystalloid were given. The median amount of administered crystalloid in the control group was 56.48 mL/kg (interquartile range, 47.94-76.12) after propensity score matching. The incidences of AKI were not different between the control and colloid groups (P = .460 by AKIN criteria; P = .999 by RIFLE criteria).

CONCLUSION

Intraoperative administration of HES may not be associated with AKI after living donor hepatectomy. This result can provide useful information on perioperative fluid management in living liver donors.

The learning curves in living donor hemiliver graft procurement using small upper midline incision

The learning curve for performing living donor hemiliver procurement (LDHP) via small upper midline incision (UMI) has not been determined. Living donors (n=101) who underwent LDHP via UMI were included to investigate the learning curve using cumulative sum analysis. The cumulative sum analysis showed that nine cases for right lobe (case #23) and 19 cases for left lobe (case #32 in the whole series) are needed for stable and acceptable surgical outcomes in LDHP via UMI. The established phase (n=69, since case #33) had a significantly shorter operative time, a smaller incision size, and less blood loss than the previous learning phase (n=32, serial case number up to the last 19th left lobe case). Multivariate analysis showed that the learning phase, high body mass index ≥25 kg/m² , and left lobe graft procurement are the factors associated with surgical events including operative blood loss ≥400 mL, operative time ≥300 minutes, or surgical complications ≥Clavien-Dindo grade II. There is an obvious learning curve in performing LDHP via UMI, and 32 cases including both 19 cases for left lobe and nine cases for right lobe are needed for having stable and acceptable surgical outcomes.

Intraoperative factors associated with delayed recovery of liver function after hepatectomy: analysis of 1969 living donors

BACKGROUND

The safety of healthy living donors who are undergoing hepatic resection is a primary concern. We aimed to identify intraoperative anaesthetic and surgical factors associated with delayed recovery of liver function after hepatectomy in living donors.

METHODS

We retrospectively analysed 1969 living donors who underwent hepatectomy for living donor liver transplantation. Delayed recovery of hepatic function was defined by increases in international normalised ratio of prothrombin time and concomitant hyperbilirubinaemia on or after post-operative day 5. Univariate and multivariate logistic regression analyses were performed to determine the factors associated with delayed recovery of hepatic function after living donor hepatectomy.

RESULTS

Delayed recovery of liver function after donor hepatectomy was observed in 213 (10.8%) donors. Univariate logistic regression analysis showed that sevoflurane anaesthesia, synthetic colloid, donor age, body mass index, fatty change and remnant liver volume were significant factors for prediction of delayed recovery of hepatic function. Multivariate logistic regression analysis showed that independent factors significantly associated with delayed recovery of liver function after donor hepatectomy were sevoflurane anaesthesia (odds ratio = 3.514, P < 0.001), synthetic colloid (odds ratio = 1.045, P = 0.033), donor age (odds ratio = 0.970, P = 0.003), female gender (odds ratio = 1.512, P = 0.014) and remnant liver volume (odds ratio = 0.963, P < 0.001).

CONCLUSIONS

Anaesthesia with sevoflurane was an independent factor in predicting delayed recovery of hepatic function after donor hepatectomy. Although synthetic colloid may be associated with delayed recovery of hepatic function after donor hepatectomy, further study is required. These results can provide useful information on perioperative management of living liver donors.

High Stroke Volume Variation Method by Mannitol Administration Can Decrease Blood Loss During Donor Hepatectomy

Optimal fluid management to reduce blood loss during donor hepatectomy is important for maximizing donor safety. Mannitol can induce osmotic diuresis, helping prevent increased intravascular volume status. We therefore evaluated the effect of high stroke volume variation (SVV) method by mannitol administration and fluid restriction on blood loss during donor hepatectomy.In this prospective study, 64 donors scheduled for donor right hepatectomy were included and allocated into 2 groups. In group A, the SVV value of each patient was maintained at 10% to 20% during hepatic resection with 0.5 g/kg mannitol administration and fluid restriction at a rate of 2 to 4 mL/kg/h. In group B, the SVV value was maintained at <10% by fluid administration at a rate of 6 to 10 mL/kg/h without diuretic administration during surgery. Intraoperative blood loss was estimated by the loss of red cell mass. Surgeon satisfaction scores and postoperative outcomes, including acute kidney injury, abnormal chest radiographic findings, and hospital stay duration, were also assessed.SVV during hepatectomy was significantly higher in group A than in group B (11.0 ± 1.7 vs 6.5 ± 1.1, P < 0.001). The red cell mass loss was significantly lower in group A than in group B (145.4 ± 107.6 vs 307.9 ± 110.7 mL, P < 0.001). Surgeon satisfaction scores were higher in group A than in group B (2.8 ± 0.5 vs 2.0 ± 0.6, P < 0.001). The incidence of acute kidney injury, abnormal chest radiographic findings, and duration of hospital stay did not significantly differ between the 2 groups.Maintenance of high SVV by mannitol administration is effective and safe for reducing blood loss during donor hepatectomy.

Fluid management in living donor hepatectomy: Recent issues and perspectives

The importance of the safety of healthy living liver donors is widely recognized during donor hepatectomy which is associated with blood loss, transfusion, and subsequent post-operative morbidity. Although the low central venous pressure (CVP) technique can still be effective, it may not be advantageous concerning the safety of healthy donors undergoing hepatectomy. Emerging evidence suggests that stroke volume variation (SVV), a simple and useful index for fluid responsiveness and preload status in various clinical situations, can be applied as a guide for fluid management to reduce blood loss during living donor hepatectomy. Synthetic colloid solutions are also associated with serious adverse events such as the use of renal replacement therapy and transfusion in critically ill or septic patients. However, it is uncertain whether the intra-operative use of colloid solution is associated with similarly adverse effects in patients undergoing living donor hepatectomy. In this review article we discuss the recent issues regarding the low CVP technique and the high SVV method, i.e., maintaining 10%-20% of SVV, for fluid management in order to reduce blood loss during living donor hepatectomy. In addition, we briefly discuss the effects of intra-operative colloid or crystalloid administration for surgical rather than septic or critically ill patients.

Effect of stroke volume variation-directed fluid management on blood loss during living-donor right hepatectomy: a randomised controlled study

Reducing blood loss is beneficial in living liver donor hepatectomy. Although it has been suggested that maintaining a low central venous pressure is important, it is known that low stroke volume variation may be associated with increased blood loss. Therefore, we compared the effect on blood loss of 40 patients randomly assigned to a high stroke volume variation group (maintaining 10-20% of stroke volume variation) vs 38 patients in a control group (maintaining < 10% stroke volume variation) during living-donor right hepatectomy. Mean (SD) blood loss during donor hepatectomy was significantly lower in the high stroke volume variation group than in the control group: 476 (131) ml vs 836 (341) ml, respectively (p < 0.001). Blood pressure and peri-operative laboratory values did not differ between the two groups. However, in the high stroke volume variation group, central venous pressure values were also significantly lower. We were unable to disentangle the effects of stroke volume variation and central venous pressure, but our results confirm that the two together appear beneficial.