Validation of predictive models identifying patients at risk for massive transfusion during liver transplantation and their potential impact on blood bank resource utilization

Abstract

Background: Intraoperative massive transfusion (MT) is common during liver transplantation (LT). A predictive model of MT has the potential to improve use of blood bank resources. Study Design and Methods: Development and validation cohorts were identified among deceased-donor LT recipients from 2010 to 2016. A multivariable model of MT generated from the development cohort was validated with the validation cohort and refined using both cohorts. The combined cohort also validated the previously reported McCluskey risk index (McRI). A simple modified risk index (ModRI) was then created from the combined cohort. Finally, a method to translate model predictions to a population-specific blood allocation strategy was described and demonstrated for the study population. Results: Of the 403 patients, 60 (29.6%) in the development and 51 (25.5%) in the validation cohort met the definition for MT. The ModRI, derived from variables incorporated into multivariable model, ranged from 0 to 5, where 1 point each was assigned for hemoglobin level of less than 10 g/dL, platelet count of less than 100 × 10 9 /dL, thromboelastography R interval of more than 6 minutes, simultaneous liver and kidney transplant and retransplantation, and a ModRI of more than 2 defined recipients at risk for MT. The multivariable model, McRI, and ModRI demonstrated good discrimination (c statistic

Impact of Perioperative Massive Transfusion on Long Term Outcomes of Liver Transplantation: a Retrospective Cohort Study

“…Patients with ESLD are often accompanied by coagulation dysfunction and fibrinolysis dysfunction, which mainly due to the reduction of coagulation factors and platelet, the deficiency of platelet function and the hyperfibrinolysis 22 - 24 . Several studies have concluded that preoperative anemia is associated with massive blood transfusion, our study confirmed these findings and further defined the degree of anemia 2 , 24 . Preoperative coagulation disorders increase the risk of hemorrhage, then massive hemorrhage will aggravate existing anemia and increase the requirements of blood transfusion.…”

“…As an established intervention for patients with end-stage liver disease (ESLD), liver transplantation (LT) is associated with a significant risk of massive hemorrhage and massive blood transfusion 1 , 2 . Owing to advances in surgical technique and anesthetic management, blood loss and blood product requirement has significantly decreased during LT over the past decade.…”

Blood products and liver transplantation: A strategy to balance optimal preparation with effective blood stewardship

“…Consequently, a wide spectrum of patient and operative characteristics have been described to portend increased operative bleeding, though no consensus risk factors have been clearly delineated across multiple centers 31–36 . Despite these consternations, there have been several reported predictive models for identifying patients at risk for high blood product utilization, though the majority are restricted to RBC use alone, and are complex, thus limiting their bedside utility 19–22 . McCluskey et al, however, did develop an applicable preoperative risk index derived from seven binary variables that were subsequently validated and modified to five binary factors by Pustavoitau et al 20,21 While successful in developing applicable risk indices, both studies were restricted to RBC transfusion requirements and did not extend their predictive modeling to FFP or Plt utilization.…”

Coagulopathy and hemostasis management in patients undergoing liver transplantation: Defining a dynamic spectrum across phases of care

“…Preemptive transfusion to reverse hemostasis defects is not recommended in the absence of nonsurgical bleeding, although laboratory testing may predict intraoperative bleeding and inform intraoperative management. [ 61 ] Although limited by evidence, our expert panel recommends a preoperative hemoglobin of 7 or greater prior to surgery. [ 62 ] Preoperative hypofibrinogenemia (≤200 mg/dl) has been associated with increased red blood cell (RBC) transfusions, although a randomized controlled trial that transfused fibrinogen concentrate to >290 mg/dl preoperatively showed no benefit.…”

“…Perioperatively, multiple clinical factors impact dynamic changes in the coagulation cascade within hours, including donor and recipient factors as well as surgical and anesthesia management considerations that collectively require a multidisciplinary approach perioperatively bank resource use, there are no data to support using VET to initiate preemptive transfusion therapies. [61,66]…”