• blood transfusion
• liver transplantation
• living donor liver transplantation
• risk factors
• survival

• Chronic liver disease
• Hepatic encephalopathy
• Hypotension
• Liver transplantation
• Neuronal cell loss
• Upper gastrointestinal bleeding

• Humans
• Hypotension/physiopathology
• Hypotension/etiology
• Hepatic Encephalopathy/etiology
• Hepatic Encephalopathy/physiopathology
• Animals
• Cognitive Dysfunction/etiology
• Cognitive Dysfunction/physiopathology
• Brain Injuries/physiopathology
• Brain Injuries/complications
• Liver Diseases/physiopathology
• Liver Diseases/pathology
• Liver Diseases/complications
• Liver Diseases/etiology
• Chronic Disease
• Liver Cirrhosis/physiopathology
• Liver Cirrhosis/complications

• Blood loss
• Blood transfusion
• Fibrinogen level
• Orthotopic liver transplantation
• Postoperative outcomes

• Humans
• Liver Transplantation/adverse effects
• Liver Transplantation/methods
• Blood Transfusion
• Erythrocyte Transfusion/adverse effects
• Fibrinogen
• End Stage Liver Disease

• Liver transplantation
• Massive transfusion
• Patient survival
• Predictive index
• Supervivencia de paciente
• Transfusion
• Transfusión
• Transfusión masiva
• Trasplante hepático
• Índice predictive

• Humans
• Liver Transplantation/adverse effects
• Liver Transplantation/methods
• Creatinine
• Blood Transfusion
• Risk Factors
• Hemoglobins

• end stage liver disease
• graft outcomes
• hemoglobin
• liver transplantation
• prognosis
• survival analysis

• Humans
• Erythrocyte Transfusion
• Liver Transplantation
• End Stage Liver Disease/surgery
• Retrospective Studies
• Severity of Illness Index

• Q2217521

• HIF-1α signalling pathway
• autologous blood transfusion
• autophagy
• hepatocellular carcinoma

• PWZxq2022-5 Key Disciplines Group Construction Project of Pudong Health Bureau of Shanghai
• 82170225 National Natural Science Foundation of China

• anesthesiology
• blood banks
• blood coagulation
• liver transplantation
• transfusion medicine

• donation after brain death
• donation after circulatory death
• hepatic arterial complications
• ischemic cholangiopathy
• patient-centered outcome
• survival

Intraoperative blood salvage autotransfusion(IBSA) has been widely used in a variety of surgeries, but the use of IBSA in hepatocellular carcinoma (HCC) patients undergoing liver transplantation (LT) is controversial. Numerous studies have reported that IBSA used during LT for HCC is not associated with adverse oncologic outcomes. This systematic review and meta-analysis aims to estimate the clinical prognosis of IBSA for patients with H+CC undergoing LT.

MEDLINE, Embase, Web of Science, and Cochrane Library were searched for articles describing IBSA in HCC patients undergoing LT from the date of inception until May 1, 2022, and a meta-analysis was performed. Study heterogeneity was assessed by I² test. Publication bias was evaluated by funnel plots, Egger’s and Begg’s test.

12 studies enrolling a total of 2253 cases (1374 IBSA and 879 non-IBSA cases) are included in this meta-analysis. The recurrence rate(RR) at 5-year(OR=0.75; 95%CI, 0.59-0.95; P=0.02) and 7-year(OR=0.65; 95%CI, 0.55-0.97; P=0.03) in the IBSA group is slightly lower than non-IBSA group. There are no significant differences in the 1-year RR(OR=0.77; 95% CI, 0.56-1.06; P=0.10), 3-years RR (OR=0.79; 95% CI, 0.62-1.01; P=0.06),1-year overall survival outcome(OS) (OR=0.90; 95% CI, 0.63-1.28; P=0.57), 3-year OS(OR=1.16; 95% CI, 0.83-1.62; P=0.38), 5-year OS(OR=1.04; 95% CI, 0.76-1.40; P=0.82),1-year disease-free survival rate(DFS) (OR=0.80; 95%CI, 0.49-1.30; P=0.36), 3-year DFS(OR=0.99; 95%CI, 0.64-1.55; P=0.98), and 5-year DFS(OR=0.88; 95%CI, 0.60-1.28; P=0.50). Subgroup analysis shows a difference in the use of leukocyte depletion filters group of 5-year RR(OR=0.73; 95%CI, 0.55-0.96; P=0.03). No significant differences are found in other subgroups.

IBSA provides comparable survival outcomes relative to allogeneic blood transfusion and does not increase the tumor recurrence for HCC patients after LT.

https://www.crd.york.ac.uk/prospero/, identifier CRD42022295479.

• liver transplantation
• hepatocellular carcinoma (hcc)
• intraoperative blood salvage (ibs)

• Carcinoma, Hepatocellular/surgery
• Humans
• Liver Neoplasms/surgery
• Liver Transplantation
• Neoplasm Recurrence, Local
• Operative Blood Salvage
• Retrospective Studies

• bleeding
• causal inference
• liver transplantation
• phlebotomy
• red blood cell transfusion

• hepatocellular carcinoma
• intraoperative blood salvage
• liver transplantation
• recurrence
• survival

In this study, we aimed to investigate the effect of using autologous blood recovery systems on transfusion-related complications in patients undergoing lung transplantation and cardiovascular surgeries.

Between May 2016 and May 2019, a total of 104 patients (90 males, 14 females; mean age: 59.3±16.4 years; range, 12 to 89 years) in whom cell-saver and autologous blood recovery systems were used during lung transplantation or cardiovascular surgeries were retrospectively analyzed. The patients were divided into two groups as Group 1 (n=61) consisting of patients who received autologous blood transfusion and as Group 2 (n=43) consisting of patients who did not. Data including demographic and clinical characteristics of the patients, operation data, and postoperative complications were recorded.

The total amount of transfused blood/blood product was found to be significantly higher in Group 1 (p=0.018). However, transfusionrelated complications were found to be higher in Group 2 (p=0.0261). There was no significant difference in the length of hospital stay between the groups.

Autologous blood transfusion may prevent the development of transfusion-related complications by reducing the amount of allogenic transfusion in major surgical procedures. In our study, the autologous blood transfusion was used in critical patients with major bleeding and, therefore, the total amount of transfused blood/blood product was higher in these patients. Nevertheless, lower complication rates in this patient group emphasize the importance of autologous blood transfusion.

• Autotransfusion
• cardiovascular surgery
• hemorrhage
• operation
• thoracic surgery
• transfusion

• Blood Transfusion
• Brain Death
• Death
• End Stage Liver Disease/surgery
• Graft Survival
• Humans
• Liver Transplantation/adverse effects
• Retrospective Studies
• Severity of Illness Index
• Tissue Donors

Intraoperative massive bleeding is associated with high rates of mortality and anesthetic management of massive bleeding is challenging because it is necessary to achieve volume resuscitation and electrolyte correction simultaneously during massive transfusion. We report a case of life-threatening bleeding of more than 80,000 mL during liver transplantation in which real-time QTc monitoring was useful for an extremely large amount of calcium administration for treatment of hypocalcemia. A 47-year-old female with a giant liver due to polycystic liver disease was scheduled to undergo liver transplantation. During surgery, life-threatening massive bleeding occurred. The maximum rate of blood loss was approximately 15,000 mL/hr and the total amount of estimated blood loss was 81,600 mL. It was extremely difficult to maintain blood pressure and a risk of cardiac arrest continued due to hypotension. In addition, even though administration of insulin and calcium was performed, electrolyte disturbances of hyperkalemia and hypocalcemia with prolongation of QTc interval occurred. At that time, we visually noticed that the QT interval was shortened in response to bolus calcium administration, and we used the change of real-time QTc interval as a supportive indicator for calcium correction. This monitoring allowed for us to administer calcium at an unusually high rate, by which progression of hypocalcemia was prevented. Levels of hemoglobin and coagulation factors were preserved both by restriction of crystalloid infusion and by a massive transfusion protocol. The patient was extubated without pulmonary edema or cardiac overload and was finally discharged without any sequelae. Intensive and cooperative management for massive transfusion and electrolyte correction using QTc monitoring was considered to be a key for successful management.

Enhanced recovery after surgery (ERAS) has been shown to facilitate discharge, decrease length of stay, improve outcomes and reduce costs. We used this concept to design a comprehensive fast-track pathway (OR-to-discharge) before starting our liver transplant activity and then applied this protocol prospectively to every patient undergoing liver transplantation at our institution, monitoring the results periodically. We now report our first six years results.

Prospective cohort study of all the liver transplants performed at our institution for the first six years. Balanced general anesthesia, fluid restriction, thromboelastometry, inferior vena cava preservation and temporary portocaval shunt were strategies common to all cases. Standard immunosuppression administered included steroids, tacrolimus (delayed in the setting of renal impairment, with basiliximab induction added) and mycophenolate mofetil. Tacrolimus dosing was adjusted using a Bayesian estimation methodology. Oral intake and ambulation were started early.

A total of 240 transplants were performed in 236 patients (191♂/45♀) over 74 months, mean age 56.3±9.6 years, raw MELD score 15.5±7.7. Predominant etiologies were alcohol (n = 136) and HCV (n = 82), with hepatocellular carcinoma present in 129 (54.7%). Nine patients received combined liver and kidney transplants. The mean operating time was 315±64 min with cold ischemia times of 279±88 min. Thirty-one patients (13.1%) were transfused in the OR (2.4±1.2 units of PRBC). Extubation was immediate (< 30 min) in all but four patients. Median ICU length of stay was 12.7 hours, and median post-transplant hospital stay was 4 days (2-76) with 30 patients (13.8%) going home by day 2, 87 (39.9%) by day 3, and 133 (61%) by day 4, defining our fast-track group. Thirty-day-readmission rate (34.9%) was significantly lower (28.6% vs. 44.7% p=0.015) in the fast-track group. Patient survival was 86.8% at 1 year and 78.6% at five years.

Fast-Tracking of Liver Transplant patients is feasible and can be applied as the standard of care

• Aged
• Bayes Theorem
• Enhanced Recovery After Surgery
• Humans
• Length of Stay
• Liver Transplantation
• Middle Aged
• Prospective Studies

• SHapley Additive exPlanations
• liver transplantation
• machine learning
• prediction model
• red blood cell transfusion

• Adolescent
• Adult
• Aged
• Body Mass Index
• Female
• Hepatectomy/methods
• Humans
• Liver Transplantation/methods
• Male
• Middle Aged
• Operative Time
• Young Adult

Hepatectomies promote considerable amount of blood loss and the need to administrate blood products, which are directly linked to higher morbimortality rates. The blood-conserving hepatectomy (BCH) is a modification of the selective vascular occlusion technique. It could be a surgical maneuver in order to avoid or to reduce the blood products utilization in the perioperative period.

To evaluate in rats the BCH effects on the hematocrit (HT) variation, hemoglobin serum concentration (HB), and on liver regeneration.

Twelve Wistar rats were divided into two groups: control (n=6) and intervention (n=6). The ones in the control group had their livers partially removed according to the Higgins and Anderson technique, while the rats in the treatment group were submitted to BCH technique. HT and HB levels were measured at day D0, D1 and D7. The rate between the liver and rat weights was calculated in D0 and D7. Liver regeneration was quantitatively and qualitatively evaluated.

The HT and HB levels were lower in the control group as of D1 onwards, reaching an 18% gap at D7 (p=0.01 and p=0.008, respectively); BCH resulted in the preservation of HT and HB levels to the intervention group rats. BCH did not alter liver regeneration in rats.

The BCH led to beneficial effects over the postoperative HT and serum HB levels with no setbacks to liver regeneration. These data are the necessary proof of evidence for translational research into the surgical practice.

A) Unresected liver; B) liver appearance after the partial hepatectomy (1=vena cava; 2=portal vein; 3=hepatic vein; 4=biliary drainage; 5=hepatic artery)

Jehovah’s Witnesses represent a tremendous clinical challenge when indicated to liver transplantation because they refuse blood transfusion on religious grounds and the procedure is historically associated with potential massive peri-operative blood loss. We herein describe a peri-operative management pathway with strategies toward a transfusion-free environment with the aim not only of offering liver transplant to selected Jehovah’s Witnesses patients but also, ultimately, of translating this practice to all general surgical procedures.

This is a retrospective review of prospective medical records of JW patients who underwent LT at our Institution. The peri-operative multimodal strategy to liver transplantation in Jehovah’s Witnesses includes a pre-operative red cell mass optimization package and the intra-operative use of normovolemic haemodilution, veno-venous bypass and low central venous pressure.

In a 9-year period, 13 Jehovah’s Witness patients received liver transplantation at our centre representing the largest liver transplant program from deceased donors in Jehovah’s Witnesses patients reported so far. No patient received blood bank products but 3 had fibrinogen concentrate and one tranexamic acid to correct ongoing hyper-fibrinolysis. There were 4 cases of acute kidney injury (one required extracorporeal renal replacement treatment) and one patient needed vasoactive medications to support blood pressure for the first 2 postoperative days. Two patients underwent re-laparotomy. Finally, of the 13 recipients, 12 were alive at the 1 year follow-up interview and 1 died due to septic complications.

Our experience confirms that liver transplantation in selected Jehovah’s Witnesses patients can be feasible and safe provided that it is carried out at a very experienced centre and according to a multidisciplinary approach.

• Bloodless medicine and surgery programs; strategies
• Jehovah witnesses
• Liver transplantation
• Transfusion-alternative

• Hepatocellular carcinoma
• Propensity score
• Repeat liver resection
• Salvage liver transplantation
• Survival analysis
• Tumour recurrence

Despite improvements in techniques and management of liver transplant patients, numerous perioperative complications that contribute to perioperative mortality remain. Models to predict intraoperative massive blood transfusion, prolonged mechanical ventilation, or in-hospital mortality in liver transplant recipients have not been identified. In this study we aim to identify preoperative factors associated with the above mentioned complications.

A retrospective observational analysis was conducted on data collected from 124 orthotopic liver transplants performed at a single institution between 2014 and 2017. A multivariable logistic regression using backwards elimination was performed for three defined outcomes (massive transfusion ≥ 10 units packed red blood cells (PRBC), prolonged mechanical ventilation > 24 h, and in-hospital mortality) to identify associations with preoperative characteristics.

Statistically significant (P < 0.05) associations with massive transfusion ≥ 10 units PRBC were hepatocellular carcinoma and preoperative transfusion of PRBC. Significant associations with prolonged mechanical ventilation > 24 h were hepatitis C, alcoholic hepatitis, elevated preoperative alanine aminotransferase, and hepatorenal syndrome. Male gender was protective for requiring prolonged mechanical ventilation. End-stage renal disease and hepatitis B were significantly associated with increased in-hospital mortality.

This study identified risk factors associated with common perioperative complications of liver transplantation. These factors may assist practitioners in risk stratification and may form the basis for further investigations of potential interventions to mitigate these risks.

• Blood transfusion
• Carcinoma, hepatocellular
• Hepatitis C
• Liver cirrhosis
• Liver transplantation
• Mechanical ventilation

• Cardiovascular adverse events
• Cirrhotic cardiomyopathy
• Hemodynamic impairment
• Post-liver transplant complications
• Vasomotor tone abnormalities

• blood loss
• cost effective
• liver transplantation
• mobile laboratory
• point of care testing

• Orthotopic liver transplant
• Quality improvement
• Transfusion practice

Introduction: Bleeding occurs frequently in liver surgery. Unbalance between tissue plasminogen activator (t-PA) and plasminogen activator inhibitor-1 (PAI-1) concentrations might increase bleeding. Our aim was to analyze perioperative fibrinolytic changes during liver surgery.

Materials and Methods: We evaluated 15 patients for inclusion into a prospective pilot study of liver surgery. We assessed fibrinolysis by plasma PAI-1 and t-PA: before surgery (T1), before Pringle maneuver (PM;T2), at the end of surgery (T3) and 24 h postoperatively (T4), and registered demographic and laboratory data, extent and duration of surgery, hemodynamic parameters, blood loss, and transfused volumes of blood products. Data presented as mean ± SD. Significance at P < 0.05.

Results: After exclusion of six patients only undergoing biopsies, we included six women and three men aged 49.1 ± 19.6 years; two patients with liver metastases of colorectal cancer and hepatocellular carcinoma, respectively, two with focal nodular hyperplasia, two with hepatic hemangioma, and one with angiomyolipoma. Six patients underwent PM. PAI-1 plasma concentration (n = 9) rose from 6.25 ± 2.25 at T1 through 17.30 ± 14.59 ng/ml at T2 and 28.74 ± 20.4 (p = 0.007) and 22.5 ± 16.0 ng/ml (p = 0.04), respectively, at T3 and T4. Correspondingly, t-PA plasma concentration (n = 9) increased from 4.76 ± 3.08 ng/ml at T1 through 8.00 ± 5.10 ng/ml (p = 0.012) at T2 and decreased to 4.25 ± 2.29 ng/ml and 3.04 ± 3.09 at T3 and T4, respectively. Plasma t-PA level at T2 was significantly different from those at T1, T3, and T4 (p < 0.004). In PM patients, t-PA levels increased from T1, peaked at T2 (p = 0.001), and subsequently decreased at T3 and T4 (p = 0.011 and p = 0.037), respectively. Mean blood loss was 1,377.7 ± 1,062.8 ml; seven patients received blood products. Patients with higher PAI-1 levels at T3 received more fresh frozen plasma (r = 0.79; p = 0.01) and red blood cells (r = 0.88; p = 0.002).

Conclusions: During liver surgery, fibrinolysis increased, as evidenced by rises in plasma PAI-1and t-PA, especially after start of surgery and following PM. Transfused volumes of blood products correlated with higher plasma concentrations of PAI-1. Confirming this tendency requires a larger cohort of patients.

• PAI-1
• fibrinolysis
• liver surgery
• plasminogen activator inhibitor type 1
• t-PA
• tissue plasminogen activator

• blood transfusion
• hepatocellular carcinoma
• liver transplantation
• outcomes
• survival

• Adult
• Blood Transfusion
• Carcinoma, Hepatocellular/mortality
• Carcinoma, Hepatocellular/pathology
• Carcinoma, Hepatocellular/surgery
• Disease-Free Survival
• Female
• Humans
• Intraoperative Care
• Liver Neoplasms
• Liver Transplantation/adverse effects
• Male
• Middle Aged
• Postoperative Complications/epidemiology
• Retrospective Studies
• Survival Rate
• Treatment Outcome

• Acute Kidney Injury
• Adolescent Idiopathic Scoliosis
• Autologous Blood Transfusion
• Cell Saver
• Level IV
• Pigment-Induced Acute Tubular Necrosis

• Acute Kidney Injury/etiology
• Adolescent
• Blood Transfusion, Autologous/adverse effects
• Blood Transfusion, Autologous/methods
• Humans
• Male
• Operative Blood Salvage/adverse effects
• Postoperative Complications/etiology
• Scoliosis/surgery
• Spinal Fusion/adverse effects
• Spinal Fusion/methods

• Blood conservation
• Coagulopathy
• Organ transplantation
• ROTEM
• Thromboelastography
• Transfusion

• Blood Coagulation
• Blood Coagulation Disorders/therapy
• Blood Transfusion/statistics & numerical data
• Decision Making
• Hemorrhage/etiology
• Humans
• Organ Transplantation
• Perioperative Period
• Thrombelastography/methods
• Transfusion Medicine

To investigate the relationship between baseline platelet count, clauss fibrinogen, maximum amplitude (MA) on thromboelastography, and blood loss in orthotopic liver transplantation (OLT).

A retrospective analysis of our OLT Database (2006-2015) was performed. Baseline haematological indices and intraoperative blood transfusion requirements, as a combination of cell salvage return and estimation of 300 mls/unit of allogenic blood, was noted as a surrogate for intraoperative bleeding. Two groups: Excessive transfusion (> 1200 mL returned) and No excessive transfusion (< 1200 mL returned) were analysed. All data analyses were conducted using IBM SPSS Statistics version 23.

Of 322 OLT patients, 77 were excluded due to fulminant disease; redo transplant or baseline haemoglobin (Hb) of < 80 g/L. One hundred and fourteen (46.3%) were classified into the excessive transfusion group, 132 (53.7%) in the no excessive transfusion group. Mean age and gender distribution were similar in both groups. Baseline Hb (P ≤ 0.001), platelet count (P = 0.005), clauss fibrinogen (P = 0.004) and heparinase MA (P = 0.001) were all statistically significantly different. Univariate logistic regression with a cut-off of platelets < 50 × 10⁹/L as the predictor and Haemorrhage as the outcome showed an odds ratio of 1.393 (95%CI: 0.758-2.563; P = 0.286). Review of receiver operating characteristic curves showed an area under the curve (AUC) for platelet count of 0.604 (95%CI: 0.534-0.675; P = 0.005) as compared with AUC for fibrinogen level, 0.678 (95%CI: 0.612-0.744; P ≤ 0.001). A multivariate logistic regression shows United Kingdom model for End Stage Liver Disease (P = 0.006), Hb (P = 0.022) and Fibrinogen (P = 0.026) to be statistically significant, whereas Platelet count was not statistically significant.

Platelet count alone does not predict excessive transfusion. Additional investigations, e.g., clauss fibrinogen and viscoelastic tests, provide more robust assessment of bleeding-risk in thrombocytopenia and cirrhosis.

• Thrombocytopenia
• Cirrhosis
• Haemostasis
• Fibrinogen
• Liver transplantation

Adult-to-adult living donor liver transplantation (LDLT) is widely accepted today with good outcomes and safety reported worldwide for both donor and recipient. Nonetheless, it remained a highly demanding technical and complex surgery if undertaken. The last two decades have seen an increased in adult-to-adult LDLT following our first report of right lobe LDLT in overcoming graft size limitation in adults. In this article, we discussed the operative techniques and challenges of adult right lobe LDLT incorporating the middle hepatic vein, which is practiced in our center for the recipient operation. The various issues and challenges faced by the transplant surgeon in ensuring good recipient outcome are explored and discussed here as well. Hence, it is important to understand that a successful recipient operation is dependent of multifactorial events starting at the preoperative stage of planning, understanding the intraoperative technical challenges and the physiology of flow modulation that goes hand-in-hand with the operation. Therefore, one needs to arm oneself with all the possible knowledge in overcoming these technical challenges and the ability to be flexible and adaptable during LDLT by tailoring the needs of each patient individually.

• Living donor liver transplantation
• operative techniques
• right lobe liver transplantation

• hemorrhage
• pediatric liver transplantation
• predictive factors
• surgery
• transfusion

From its inception the success of liver transplantation has been associated with massive blood loss. Massive transfusion is classically defined as > 10 units of red blood cells within 24 h, but describing transfusion rates over a shorter period of time may reduce the potential for survival bias. Both massive haemorrhage and transfusion are associated with increased risk of mortality and morbidity (need for dialysis/surgical site infection) following liver transplantation although causality is difficult to prove due to the observational design of most trials. The blood loss associated with liver transplantation is multifactorial. Portal hypertension secondary to cirrhosis results in extensive collateral circulation, which can bleed during hepatectomy particular if portal pressures are increased. Avoiding volume loading and maintenance of a low central venous pressure together with the use of vasopressors have been shown to reduce blood loss and transfusion during liver transplantation, but may increase the risk of renal impairment post-operatively. Coagulation defects may be present pre-transplant, but haemostasis is often re-balanced due to a deficit in both pro- and anti-coagulation factors. Further derangement of haemostasis may develop in the anhepatic and neohepatic phases due to absent hepatic metabolic function, hyperfibrinolysis and platelet sequestration in the donor liver. Point-of-care tests of coagulation such as the viscoelastic tests rotation thromboelastometry/thromboelastometry allow and more accurate and rapid assessment of these derangements in coagulation and guide the use of factor replacement and antifibrinolytics. Transfusion protocols guided by these tests have been shown to reduce transfusion rates compared with conventional coagulation tests, but have not shown improvements in mortality or morbidity. Pre-operative factors associated with massive transfusion include previous surgery, re-do transplantation, the aetiology and severity of liver disease. Intra-operatively the use of piggy-back technique and avoiding veno-veno bypass has been shown to reduced blood loss.

• Liver transplantation
• Massive transfusion
• Coagulopathy

• Children
• Coagulation
• Liver disease
• Point of care coagulation
• Thrombosis
• Transfusion
• Transplantation

• Age Factors
• Anticoagulants/adverse effects
• Anticoagulants/therapeutic use
• Blood Coagulation/drug effects
• Blood Coagulation Tests
• Blood Loss, Surgical/prevention & control
• Blood Transfusion/standards
• Child
• Child Development
• Child, Preschool
• End Stage Liver Disease/blood
• End Stage Liver Disease/complications
• End Stage Liver Disease/diagnosis
• End Stage Liver Disease/surgery
• Humans
• Infant
• Infant, Newborn
• Liver Transplantation/adverse effects
• Liver Transplantation/standards
• Point-of-Care Testing
• Postoperative Hemorrhage/blood
• Postoperative Hemorrhage/etiology
• Postoperative Hemorrhage/prevention & control
• Practice Guidelines as Topic
• Predictive Value of Tests
• Risk Factors
• Thrombosis/blood
• Thrombosis/etiology
• Thrombosis/prevention & control
• Transfusion Reaction
• Treatment Outcome

Liver transplantation (LT) was historically associated with massive blood loss and transfusion. Over the past two decades transfusion requirements have reduced dramatically and increasingly transfusion-free transplantation is a reality. Both bleeding and transfusion are associated with adverse outcomes in LT. Minimising bleeding and reducing unnecessary transfusions are therefore key goals in the perioperative period. As the understanding of the causes of bleeding has evolved so too have techniques to minimize or reduce the impact of blood loss. Surgical “piggyback” techniques, anaesthetic low central venous pressure and haemodilution strategies and the use of autologous cell salvage, point of care monitoring and targeted correction of coagulopathy, particularly through use of factor concentrates, have all contributed to declining reliance on allogenic blood products. Pre-emptive management of preoperative anaemia and adoption of more restrictive transfusion thresholds is increasingly common as patient blood management (PBM) gains momentum. Despite progress, increasing use of marginal grafts and transplantation of sicker recipients will continue to present new challenges in bleeding and transfusion management. Variation in practice across different centres and within the literature demonstrates the current lack of clear transfusion guidance. In this article we summarise the causes and predictors of bleeding and present the evidence for a variety of PBM strategies in LT.

• Liver transplantation
• Transfusion
• Blood conservation
• Patient blood management
• Coagulation

Several studies have investigated the effect of intraoperative blood loss (IBL) on recurrence of tumors. However, the independent effect of IBL on oncological outcome after liver transplantation (LT) for hepatocellular carcinoma (HCC) is unclear.

A total of 479 patients who underwent LT for HCC from January 2001 to December 2012 at our institution were enrolled in this retrospective study. Kaplan–Meier and Cox regression methods were used to assess the recurrence rate, as well as its risk factors. Stratified analysis was performed to further examine the effect of IBL on HCC recurrence according to different characteristics of tumors. We also investigated the independent risk factors for excessive IBL using logistic regression analysis.

The median follow-up was 28 months (range, 1–131 months). Kaplan–Meier analysis with the log-rank test according to IBL at per liter intervals showed that IBL > 4 L was significantly associated with a higher recurrence rate (P < 0.001). Multivariate analysis identified that IBL > 4 L (P < 0.001; hazard ratio [HR] = 2.32, 95 % confidence interval [CI] = 1.60–3.36) was an independent risk factor for post-LT HCC recurrence, as well as age < 60 years, exceeding Milan criteria, α-fetoprotein levels > 400 ng/mL, and micro- and macrovascular invasion. IBL > 4 L (P < 0.001; HR = 2.45, 95 % CI = 1.64–3.66) was also independently associated with early (within 1 year) recurrence after LT. Furthermore, a significant correlation between IBL > 4 L and vascular invasion (P = 0.019) was found. IBL > 4 L was independently associated with HCC recurrence for patients with vascular invasion, but not for patients without vascular invasion. Finally, we found that the presence of ascites, model for end-stage liver disease score, and operation time were independent risk factors for IBL > 4 L.

Excessive IBL is an independent predictor of HCC recurrence after LT, especially in patients with vascular invasion.

• Blood coagulation
• Coagulación sanguínea
• Haemostasis.
• Hemostasia.
• Liver transplantation
• Transfusion
• Transfusión
• Trasplante de hígado

• Blood-loss
• Liver-transplantation
• Measurement techniques—coagulation
• Mobile laboratory
• Point of care testing