LIVER-TRANSPLANTATION WITHOUT THE USE OF BLOOD PRODUCTS

Objectives: To examine the techniques and the outcome of liver transpl antation with maximal conservation of blood products and to analyze th e potential benefits or drawbacks of blood conservation and salvage te chniques. Design: Case series survey. Setting: Tertiary care, major un iversity teaching hospital. Patients and Methods: Four patients with r eligious objections to blood transfusions who were selected on the bas is of restrictive criteria that would lower their risk for fatal hemor rhage, including coagulopathy, a thrombosed splanchnic venous system r equiring extensive reconstruction, active bleeding, and associated med ical complications. All patients were pretreated with erythropoietin t o increase production of red blood cells. All operations were performe d at the same institution, with a 36-month follow-up. Interventions: O rthotopic liver transplantation that used blood salvage, plateletphere sis, and autotransfusion and the withholding of the use of human blood products with the exception of albumin. Main Outcome Measures: Surviv al and postoperative complications, with the effectiveness of erythrop oietin and plateletpheresis as secondary measures. Results: All patien ts are alive at 36 months after orthotopic liver transplantation. One patient, a minor (13 years of age), was transfused per a state court r uling. Erythropoietin increased the production of red blood cells as s hown by a mean increase in hematocrit levels of 0.08. Plateletpheresis allowed autologous, platelet-rich plasma to be available for use afte r allograft reperfusion. Three major complications were resolved or co rrected without sequelae. Only one patient developed postoperative hem orrhage, which was corrected surgically. The mean charge for bloodless surgery was $174 000 for the three patients with United Network for O rgan 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 wh o met the same restrictive guidelines (P<.05). Only 19 of 1009 orthoto pic liver transplantations performed at our institution were similiar according to the UNOS status and the fulfillment of the guidelines. Th e mean charge for these comparison patients was $327 000, 3.8% of whic h was related to transfusions. Conclusions: Orthotopic liver transplan tation without the use of blood products is possible. Blood conservati on techniques do not increase morbidity or mortality and can result in fewer transfusion-related in-hospital charges.