Blood product-independent liver transplantation

Since the first human liver transplantation by Thomas E. Starzl in 1963 thi s operation has been considered among the most difficult ones. One of the f actors influencing outcome of the graft, patient survival, and cost of the procedure is the amount of blood products being used during liver transplan tation. Between 1981 and 1985 the average use of blood products per patient during liver transplantation at the University Hospital of Pittsburgh, PA, was 25 units of red blood cells (RBCs), 24 units of fresh frozen plasma (F FP), 9 units of cryoprecipitates and 20 units of platelets. In some difficu lt cases several hundred units of blood products were required to treat one single patient. Thus keeping up with the requirements of liver transplanta tion can be a very demanding task for any blood bank. Although massive bloo d transfusion may still occasionally be required, the use of blood products during liver transplantation has declined in recent years due to several f actors. We recently presented our own experience of blood requirements duri ng liver transplantation. At the University Hospital of Bern median blood r eplacement has decreased from 9 RBCs per patient between 1991 and 1993 to a median of 3 RBCs per patient in the period from 1995 to 1998. Three patien ts out of 75 (4%) who had liver transplantation at our institution between 1991 and 1998 did not receive any perioperative blood products. Furthermore , 13 (17%) received no RBCs, 5 (7%) had no FFP, and 23 (30%) received no pl atelet-rich plasma. This review discusses the pathophysiology of patients w ith terminal chronic liver insufficiency with regard to their hematologic a nd cardiovascular condition during the intraoperative phases of orthotopic liver transplantation. The risk of giving blood products to these patients, the possible predictors of increased intraoperative blood loss, and some o f the available options to limit the use of blood products are addressed.