Requirements for transfusion and postoperative outcomes in orthotopic liver transplantation: A meta-analysis on aprotinin

Liu, Cunming; Chen, Jing; Wang, Xuehao

doi:10.3748/wjg.14.1425

Cited by 11 publications

(10 citation statements)

References 34 publications

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“…In contrast to other groups, we have shown no increase in red blood cell or other blood component transfusion requirements since the withdrawal of APRO from our routine practice . A recent Cochrane systematic review also showed that APRO, recombinant factor VIIa, and TEG may potentially reduce blood loss and transfusion requirements, but there was no difference in transfusion requirements when APRO and tranexamic acid were compared .…”

Section: Discussioncontrasting

confidence: 68%

“…Since the late 1980s, aprotinin (APRO), a serine protease an inhibitor of plasmin and, at higher doses, kallikrein, have been used at many institutions to reduce the incidence of bleeding caused by fibrinolysis during OLT . The first multicenter, randomized study by Porte et al showed that the intraoperative use of APRO in patients undergoing OLT significantly reduced blood transfusion requirements, and other groups have reported similar findings …”

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confidence: 98%

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No increase in blood transfusions during liver transplantation since the withdrawal of aprotinin

et al. 2014

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The aims of this study were to determine whether the withdrawal of aprotinin (APRO) led to an increased bleeding risk in patients undergoing orthotopic liver transplantation (OLT). A retrospective analysis compared consecutive patients undergoing OLT and treated with aprotinin (APRO group; n 5 100) with a group in which aprotinin was not used (no-APRO group; n 5 100). Propensity score matching was then performed for each group to identify 2 matched cohorts. Patients were matched by their primary diagnoses and Model for End-Stage Liver Disease scores. This resulted in 2 matched cohorts with 55 patients in each group. None of the patients in the APRO group had significant fibrinolysis. In the no-APRO group, 23.6% of the patients developed fibrinolysis (P < 0.003). Tranexamic acid was used in 61.5% of the patients (n 5 8) in the no-APRO group in whom lysis was present, and this resolved the fibrinolysis in all but 1 of these patients. There were no differences in red blood cell, fresh frozen plasma, platelet concentrate, or cryoprecipitate transfusions between the 2 groups. In conclusion, we have shown a significant increase in the prevalence of fibrinolysis during OLT since the withdrawal of APRO. However, there has been no increase in transfusion requirements. Liver Transpl 20:584-590, 2014. V C 2014 AASLD.

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Section: Discussioncontrasting

confidence: 68%

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confidence: 98%

No increase in blood transfusions during liver transplantation since the withdrawal of aprotinin

et al. 2014

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“…First, they have the potential to require large amounts of blood products. In a meta‐analysis of 4 studies comparing transfusion requirements during liver transplantation, the mean number of transfused RBC units ranged from 2 to 14, and the mean number of fresh frozen plasma units ranged from 1 to 28 31. Second, they could potentially benefit from the immunosuppression that may accompany RBCs that have been stored for longer periods of time.…”

Section: Discussionmentioning

confidence: 99%

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

et al. 2012

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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...

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“…was withdrawn from the market amid concerns over excess mortality in 2007 but it is available once more, following a revoked suspension in 2012 by the European Medicines Agency [90,91] . A meta-analysis of 7 studies in LT demonstrated significantly lower RBC and FFP requirements patients who received aprotinin compared with controls but no differences in terms of reoperation rates, thrombotic events or mortality [92] . Tranexamic acid and epsilon aminocaproic acid (EACA) are lysine analogues that adhere to lysine binding sites on plasminogen preventing its conversion to plasmin.…”

Section: Antifibrinolyticsmentioning

confidence: 99%

Reducing transfusion requirements in liver transplantation

Donohue

Mallett

2015

WJT

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Liver transplantation (LT) was historically associated with massive blood loss and transfusion. Over the past two decades transfusion requirements have reduced dramatically and increasingly transfusionfree 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. Core tip: Liver transplantation (LT) was historically associated with massive blood loss. Many factors have contributed to the decline in bleeding and transfusion in the past two decades including refinement of surgical techniques, anaesthetic management and the use of point of care guided goal-directed haemostatic therapies. Increasing awareness of the adverse associations of allogenic transfusion has driven the quest for transfusion-free transplantation. Increasing use of marginal grafts and transplantation of sicker recipients will continue to challenge perioperative care and transfusion practice. Inter-institutional variability suggests a current lack of clear guidance and limited application of the principles of patient blood management to LT.

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Requirements for transfusion and postoperative outcomes in orthotopic liver transplantation: A meta-analysis on aprotinin

Cited by 11 publications

References 34 publications

No increase in blood transfusions during liver transplantation since the withdrawal of aprotinin

No increase in blood transfusions during liver transplantation since the withdrawal of aprotinin

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

Reducing transfusion requirements in liver transplantation

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