Retrospective Cohort Study
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Mar 28, 2021; 27(12): 1161-1181
Published online Mar 28, 2021. doi: 10.3748/wjg.v27.i12.1161
Perioperative blood transfusion decreases long-term survival in pediatric living donor liver transplantation
Karina Gordon, Estela Regina Ramos Figueira, Joel Avancini Rocha-Filho, Luiz Antonio Mondadori, Eduardo Henrique Giroud Joaquim, Joao Seda-Neto, Eduardo Antunes da Fonseca, Renata Pereira Sustovitch Pugliese, Agustin Moscoso Vintimilla, Jose Otavio Costa Auler Jr, Maria Jose Carvalho Carmona, Luiz Augusto Carneiro D'Alburquerque
Karina Gordon, Joel Avancini Rocha-Filho, Jose Otavio Costa Auler Jr, Maria Jose Carvalho Carmona, Division of Anesthesiology, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo 05403-000, Brazil
Karina Gordon, Luiz Antonio Mondadori, Eduardo Henrique Giroud Joaquim, Department of Anesthesiology, AC Camargo Cancer Center, São Paulo 01509-010, Brazil
Estela Regina Ramos Figueira, Department of Gastroenterology, Discipline of Liver and Gastrointestinal Transplantation, Laboratory of Medical Investigations LIM37 Hospital das Clinicas, University of São Paulo School of Medicine, São Paulo 05402-000, Brazil
Joao Seda-Neto, Eduardo Antunes da Fonseca, Renata Pereira Sustovitch Pugliese, Department of Liver Transplantation, AC Camargo Cancer Center, São Paulo 01525-901, Brazil
Agustin Moscoso Vintimilla, Luiz Augusto Carneiro D'Alburquerque, Department of Gastroenterology, Division of Liver and Gastrointestinal Transplant, Hospital das Clinicas, University of São Paulo School of Medicine, São Paulo 05402-000, Brazil
Author contributions: Gordon K, Figueira ERR, Rocha-Filho JA, Mondadori LA, Joaquim EHG, Seda-Neto J, da Fonseca EA, Pugliese RPS, Vintimilla AM, Carmona MJC, Auler Jr JOC, and D'Alburquerque LAC contributed equally to this work; Gordon K, Figueira ERR, and Rocha-Filho JA designed the research study; Gordon K, Figueira ERR, and Mondadori LA performed the research; Gordon K, Figueira ERR, Rocha-Filho JA, and Mondadori LA analyzed the data and wrote the manuscript; Gordon K, Joaquim EHG, Seda-Neto J, da Fonseca EA, Pugliese RPS, Vintimilla AM, Carmona MJC, Auler Jr JOC, and D'Alburquerque LAC made critical revisions related to important intelectual content of manuscript; all authors have read and approved the final version of the manuscript.
Institutional review board statement: The study was reviewed and approved by the ACCamargo Cancer Center Institutional Review Board, No. 103.402; the University of Sao Paulo School of Medicine Institutional Review Board, No. 243/12.
Informed consent statement: Informed consent statements are not required.
Conflict-of-interest statement: The authors declare that they have no conflicts of interest relevant to the manuscript submitted to World Journal of Gastroenterology.
Data sharing statement: No additional data are available.
STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Karina Gordon, MD, PhD, Academic Research, Attending Doctor, Staff Physician, Division of Anesthesiology, Hospital das Clínicas, University of São Paulo School of Medicine, Av. Dr. Eneas de Carvalho Aguiar, 155 8th Floor, São Paulo 05403-000, Brazil. gordonkarina00@gmail.com
Received: December 18, 2020
Peer-review started: December 18, 2020
First decision: January 10, 2021
Revised: January 20, 2021
Accepted: March 13, 2021
Article in press: March 13, 2021
Published online: March 28, 2021
Processing time: 96 Days and 12.3 Hours
ARTICLE HIGHLIGHTS
Research background

Pediatric living donor liver transplantation (PLDLT) is a multidisciplinary procedure of high complexity and potential risk of bleeding. The association between transfusion and short- and long-term postoperative complications is poorly established especially in small children. Blood transfusion is frequently indicated in the perioperative period of liver transplant, though there is little robust evidence of associated postoperative complications. Given the good survival results, in the past decade, it is now necessary to identify risk factors for complications in order to improve the long-term evolution.

Research motivation

To study in depth the short- and long-term evolution of this specific group of highly fragile pediatric patients, in order to improve the proficiency acquired in 20 years of working with PLDLT, and to be able to share knowledge.

Research objectives

This study assessed whether perioperative transfusion is associated with early and late postoperative complications and mortality in small patients undergoing PLDLT.

Research methods

Postoperative complications along 10 years of follow up were graduated with Clavien-Dindo modified classification in order to assess relationship between blood transfusion and postoperative complications. Multiple logistic regression analysis identified risk factors for major postoperative complications. Perioperative red blood cells volume was identified as a single risk factor and a receiver operating characteristic curve identified a cutoff point of 27.5 mL/kg. Cox regression analyses identified independent risk factors for mortality. Overall patient and graft survival analyses was performed using Kaplan–Meier survival curves, which were compared using the log-rank test and a P < 0.05 was considered statistically significant.

Research results

In terms of red blood cells (RBC) transfusion volume, there was a significantly higher rate of 30 d reoperation (26.3% × 8.7%, P < 0.001) and 30 d mortality rate (6.6% × 0.0%, P < 0.001) in the high-volume transfusion (HTr) vs low-volume transfusion (LTr), respectively. Early liver transplantation (LT)-specific complications include primary non-function, biliary complications, vascular thrombosis, and retransplantation that were not related to a higher perioperative transfusion volume. Over 10 years of follow-up, with respect to RBC transfusion volume, there was a significantly higher rate of reoperation (36.5% × 12.6%, P < 0.001) and mortality (25.5% × 7.8%, P < 0.001), respectively, in the HTr compared to the LTr. Perioperative RBC volume > 27.5 mL/kg and preoperative estimated glomerular filtration rate were identified as independent risk factors for mortality over 10 years of follow-up after LT. The patient survival rates were significantly lower in the HTr than in the LTr at 1, 5, and 10 years post-LT: 82.7% vs 97.7%, 73.9% vs 93.8%, and 72.6% vs 90.9%, respectively. Likewise, the graft survival rates were significantly lower in the HTr than in the LTr at 1, 5, and 10 years post-LT: 79.5% vs 97.7%, 67.2% vs 92.3%, and 67.2% vs 87%, respectively.

Research conclusions

A perioperative RBC transfusion volume > 27.5 mL/kg is associated with not only increased rates of infectious, cardiovascular, respiratory, and neoplastic complications but also decreased frequency of rejection episodes. Furthermore, a perioperative volume of RBC transfusion higher than 27.5 mL is an independent risk factor for mortality, and is directly related to reduced patient and graft survival in PLDLT.

Research perspectives

The detailed analysis of this study allows the construction of strategy protocols to reduce the need for transfusion of patients undergoing PLDLT improving short- and long-term outcome.