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Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Transplant. Dec 24, 2015; 5(4): 165-182
Published online Dec 24, 2015. doi: 10.5500/wjt.v5.i4.165
Reducing transfusion requirements in liver transplantation
Ciara I Donohue, Susan V Mallett
Ciara I Donohue, Susan V Mallett, Royal Free Perioperative Research Group (RoFPoR), Department of Anaesthesia, Royal Free London NHS Trust, London NW3 2QG, United Kingdom
Author contributions: Donohue CI and Mallett SV contributed equally to this manuscript.
Conflict-of-interest statement: The authors declare no conflict of interest.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (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/
Correspondence to: Ciara I Donohue, MBChB, BSc, FRCA, Anaesthetic Registrar, Royal Free Perioperative Research Group (RoFPoR), Department of Anaesthesia, Royal Free London NHS Trust, Pond Street, Hampstead, London NW3 2QG, United Kingdom. ciara.donohue@nhs.net
Telephone: +44-207-7945000
Received: June 29, 2015
Peer-review started: July 1, 2015
First decision: August 4, 2015
Revised: October 21, 2015
Accepted: November 23, 2015
Article in press: November 25, 2015
Published online: December 24, 2015
Processing time: 177 Days and 3.2 Hours
Abstract

Liver transplantation (LT) was historically associated with massive blood loss and transfusion. Over the past two decades transfusion requirements have reduced dramatically and increasingly transfusion-free 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.

Keywords: Liver transplantation; Transfusion; Blood conservation; Patient blood management; Coagulation

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.