Duration of red blood cell storage and outcomes following orthotopic liver transplantation

Abstract

Liver transplantation may be complicated by massive intraoperative bleeding, and red blood cell (RBC) transfusions may be required. The storage duration or age of transfused RBCs has been shown to affect the morbidity and mortality of critically ill, trauma, and cardiac surgery patients. Here we investigate the effect of RBC age on the outcomes of liver transplant patients. Five hundred thirty-one patients underwent orthotopic liver transplantation between January 1, 2000 and August 15, 2010. The patient demographics, the Model for End-Stage Liver Disease-sodium (MELD-Na) score, and the number and age of RBC units were evaluated with univariate and multivariate models of outcomes, which included mortality rates 2 years after transplantation, postoperative infections, and organ rejection. In a univariate analysis, the number of RBC units (but not the RBC age) was associated with increased 2-year mortality, an increased risk of infection, and a decreased risk of organ rejection. Only the number of RBC units was associated with increased 2-year mortality in a multivariate Cox regression model. The mortality risk was decreased by two-thirds for patients who received <10 U of RBCs versus those who received 10 U (hazard ratio ¼ 0.33, 95% confidence interval ¼ 0.16-0.69, P ¼ 0.003). The number of transfused RBC units was not associated with the risk of infection or organ rejection in a multivariate logistic regression model. In conclusion, the RBC age is not associated with infection, organ rejection, or death in liver transplant patients. Patients who receive more blood have an increased risk of death. In a multivariate model, the MELD-Na score was not associated with increased mortality, and this is consistent with previous studies demonstrating that the MELD-Na score is a poor predictor of long-term survival after transplantation. Liver Transpl 18:475-481, 2012. V C 2012 AASLD.Received July 27, 2011; accepted December 23, 2011.More than 5700 orthotopic liver transplants were performed in the United States in 2010. 1 Liver transplantation may be complicated by massive intraoperative bleeding; this requires the transfusion of large amounts of blood products and places a heavy demand on limited blood bank supplies. 2 Advances in surgical and anesthetic techniques have decreased blood product usage, 3-6 but there remains great institutional variability in blood transfusion practices. 7 Retrospective studies have shown an association between red blood cell (RBC) transfusions and adverse outcomes in critically ill, 8,9 trauma, 10,11 and cardiac surgery patients 12 and in patients undergoing liver transplantation. [13][14][15][16][17] In a multivariate analysis of 155 liver transplants, Wiederkehr et al. 18 reported that only a high Model for End-Stage Liver Disease score and the amount of transfused packed RBCs were predictive of poorer patient survival. De Morais et al. 19 reported that the accumulated transfusion of blood products, including packed RBCs, was associated with greater 5-year mortality after liver transpl...

The effects of storage of red blood cells on the development of postoperative infections after noncardiac surgery

“…The median [interquartile range] storage time of and 15 [11][12][13][14][15][16][17][18][19][20] days in fresh blood and in old blood groups, respectively. The occurrence of postoperative infection did not differ between groups (fresh blood 22% vs. old blood 25%; relative risk [RR], 1.17; confidence interval [CI], 0.71-1.93), although wound infections occurred more frequently in old blood (15% vs. 5%; RR, 3.09; CI,).…”

“…There were no other differences in the secondary outcomes between groups in the ITT analysis. In the AT analysis, hospital LOS was longer in the old blood group than in the fresh blood group (11 [7][8][9][10][11][12][13][14][15][16][17][18][19][20] vs. 9 [6][7][8][9][10][11][12][13][14][15][16]; difference in means, -3.62; CI, -7.6 to -0.6; Table 4). …”

“…Among the different subgroups of infection, only wound infections were more frequent in patients receiving RBCs more than 21 days old 28 The clinical relevance of this change was studied in different patient populations. 6,10,[12][13][14][15][29][30][31] Recently, the effects of RBC storage duration have been evaluated in patients undergoing cardiac surgery and the rate of postoperative infections ranged from 4% to 15%. 10,12,29 In one study, Koch and colleagues 10 found that in patients receiving RBC transfusions during cardiac surgery, those treated with fresh blood (stored for 14 days) had a reduced occurrence of sepsis (2.8% vs. 4.0%, p 5 0.01) and renal failure (1.6% vs. 2.7%, p 5 0.003) than those receiving old blood, although differences in the baseline characteristics between the two groups could affect the ability to interpret the results.…”

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“…[16][17][18] Several investigations have reported that massive intraoperative allogeneic red blood cell transfusions have a negative effect on liver transplant recipient outcomes. [19][20][21] Ramos and associates 22 confirmed that massive red blood cell transfusions are associated with longer hospital stays, and decreased postoperative survival for liver transplant recipients. Benson and associates 23 suggest that red blood cells transfusion contributes to postoperative infections in a dose-dependent manner.…”

Characterisation of dendritic cell immune profile in models of transfusion

“…Studies demonstrated increased rates of mortality [22][23][24][25][26][27][28], morbidity [29], MOD [22,27,30] and infection [22,31,32] in trauma, cardiac surgery, cardiovascular and ICU patients receiving blood stored for two weeks or more. On the other hand, several other studies were unable to demonstrate that the storage duration of blood components utilised have contributed to adverse patient outcomes [24,[33][34][35][36][37][38][39].…”