Intraoperative red blood cell transfusion in liver transplantation: influence on patient outcome, prediction of requirements, and measures to reduce them.

Objectives of this study are to quantify the need for blood transfusion during liver transplantation (LT) and confirm the importance of intraoperative blood transfusion as an independent prognostic factor for postoperative outcome. Furthermore, we try to detect useful variables for the preoperative identification of patients likely to require transfusion of packed red blood cell units (PRCUs) and identify measures to reduce transfusion needs. Data were collected prospectively between September 1998 and November 2000. One hundred twenty-two LTs were included in the study. Forty-two patients (34%) did not require transfusion of PRCUs. In multivariate analysis, transfusion of more than three PRCUs was found to be the only significant variable associated with prolonged hospital stay. In addition, excluding perioperative deaths, PRCU transfusion, using a cutoff value of six units, was the only variable to reach statistical significance (P =.008; risk ratio, 4.93; 95% confidence interval, 15 to 15.9) to predict survival in a multivariate analysis that also included Child's class and United Network for Organ Sharing (UNOS) classification. Moreover, only preoperative hemoglobin (Hb) level was found to significantly predict the need for transfusion of one or more PCRUs. Finally, only UNOS classification and placement of an intraoperative portacaval shunt were found to be statistically significant to predict the need to transfuse more than six PRCUs. We found the requirement of even a moderate number of blood transfusions is associated with longer hospital stay, and transfusion of more than six PRCUs is associated with diminished survival. Preoperative normalization of Hb levels and placement of an intraoperative portacaval shunt can diminish the number of blood transfusions during LT.

Influence of endothelin-1 on hemodynamics during liver transplantation with and without temporary portocaval shunt: results of a clinical randomized study.

Aims of this study are to analyze the influence of endothelin-1 (ET-1) on hemodynamic evolution during liver transplantation (LT) and study the role of a temporary portacaval shunt in ET-1 synthesis. Forty LTs in patients with cirrhosis were studied. Two groups were analyzed: the first group had a temporary portacaval shunt during the anhepatic phase, and the second group did not. Portal and systemic ET-1 levels were measured at several times. At the end of the anhepatic phase, systemic (16.1 +/- 6.5 pg/mL) and portal (19.2 +/- 7 pg/mL) ET-1 levels increased, whereas they decreased after reperfusion (systemic, 11.8 +/- 7.1 pg/mL; portal, 13.2 +/- 6.8 pg/mL). Portal flow at the beginning of LT correlated with systemic ET-1 levels (R2 = 0.3; P =.004). A temporary portacaval shunt reduced portal pressure during the anhepatic phase, but did not modify ET-1 levels. Patients with reperfusion syndrome had greater systemic ET-1 levels in the anhepatic phase (19.1 +/- 6.9 v 15.1 +/- 6.1 pg/mL; P =.07). Although there is a relationship between ET-1 levels and portal flow and reperfusion syndrome, no clear clinical effect on hemodynamics could be shown. Creation of a portacaval shunt made no change in ET-1 levels.

Análisis de 500 trasplantes hepáticos en el Hospital de Bellvitge / Analysis of 500 liver transplantations in the Bellvitge Hospital, Spain

Fundamento: Se presenta la experiencia del programa de trasplante hepático del Hospital de Bellvitge en 500 trasplantes realizados durante 15 años, con el objetivo de poner de manifiesto los cambios que se han producido y exponer los resultados a largo plazo de esta terapéutica. Pacientes y método: Se consideraron y compararon 5 grupos de 100 trasplantes consecutivos (I-V). Resultados: Las indicaciones más frecuentes fueron el hepatocarcinoma (23 por ciento), la cirrosis alcohólica (22,8 por ciento) y la hepatopatía crónica por virus C (18,8 por ciento). En 59 pacientes se llevaron a cabo 65 retrasplantes (13 por ciento), cuyas indicaciones más frecuentes fueron la trombosis arterial (13 pacientes) y el fallo primario del injerto (10 pacientes). En 19 enfermos se realizó un trasplante combinado hepatorrenal. La causa más frecuente de muerte del donante en el grupo I fueron los traumatismos craneales (80 por ciento), mientras que en el grupo V fue la enfermedad vascular (52 por ciento). Otras diferencias significativas entre estos grupos se observan en la proporción de pacientes en estadio 2 y 3 de la clasificación UNOS (el 45 frente al 19 por ciento), en el consumo de hemoderivados (29,6 [26] frente a 4,6 [5,3] concentrados de hematíes), en la frecuencia de reintervenciones por hemoperitoneo (el 22 frente al 5 por ciento), en la estancia en UCI (13 [13] frente a 7,4 [11] días) y en el hospital 40 [52] frente a 23,7 [17] días), y en la incidencia de rechazo (el 46 frente al 20 por ciento) y de fallo primario del injerto (el 9 frente al 3 por ciento). Sin embargo, la prevalencia de infección (el 48 frente al 54,5 por ciento) y la incidencia de complicaciones biliares (el 26 frente al 20 por ciento) no han presentado variaciones significativas. La supervivencia actuarial de los pacientes trasplantados desde 1990 es del 83 y del 70 por ciento al año y a los 5 años, respectivamente. Conclusiones: Se observa una mejoría notable y progresiva de los resultados del trasplante hepático. Sin embargo, los tumores de novo, la recidiva de la hepatitis por virus C y el rechazo crónico pueden limitar los resultados a largo plazo. (AU)