Massive haemorrhage in liver transplantation: Consequences, prediction and management

Table 1 Studies evaluating red blood cell transfusion requirements and prediction variables in adult liver transplantation

Ref.	No. of patients	Population	Data methodology	Outcomes	Final model prediction variables	Performance of model
Motschman et al[63]	83	OLT	Retrospective univariate and multivariate	RBC transfusion requirement	History of previous GI bleed, Previous RUQ surgery
Deakin et al[64]	300	OLT	Retrospective univariate and stepwise multivariate	≥ 7 units RBC	Urea levels and platelet count	Specificity 62%
						Sensitivity 68%
Findlay et al[65]	583	OLT	Retrospective univariate and multiple linear regression analysis	RBC transfusion requirement	Age, creatinine and bilirubin	R = 0.22
Steib et al[66]	410	OLT	Retrospective univarite and stepwise multivariate analysis	High blood loss ≥ 12 units RBC	Preoperative Hb, previous abdominal surgery, preoperative FDP	Sensitivity 18% Specificity 98%
Pirat et al[67]	40	OLT	Bivariate and multiple linear regression	RBC transfusion requirement	Preoperative albumin	R = 0.48
Ramos et al[44]	122	OLT	Univariate and multivariate regression	> 6 units RBC	UNOS class and placement of caval shunt
Massicotte et al[68]	206	OLT	Retrospective univariate and multivariate logistic regression	> 4 units RBC	Starting INR, platelet count and duration of surgery
Yuasa et al[69]	635	LDLT (adult and pediatric)	Univariate	Arbitrary high blood loss quartile (344 ± 272 mL/kg)	Univariate = age < 1 yr, Hct < 30%, T-Bil > 20 mg/dL, BUN > 30 mg/dL. Dx Pre-op atresia, Re transplantation
McCluskey et al[42]	460	OLT	Multivariate regression. Risk index internally validated	> 6 units RBC in 24 h	Age > 40, Hb < 10 g/dL, NR 1.21-1.99 and > 2, platelet < 70, creatinine > 110 mmol/L female and > 120 mmol/L males, albumin < 28 h/L and redo transplant	C statistic model = 0.79
Mangus et al[70]	526	OLT “piggy back”	Univariate and multivariate regression	RBC transfusion requirements	Pre-op Hb MELD score, Initial CVP
Massicotte et al[71]	505	OLT	Nomogram risk model based on multivariate regression analysis		FFP transfusion. High starting Hb and phlebotomy protective for blood loss	Bootstrapped AUC prediction model = 89.8%
Araújo et al[72]	758	OLT	Retrospective univariate and multivariate regression	RBC requirements	PT, Hb, age, liver malignancy	R = 0.30
Bang et al[73]	555	LDLT	Multivariate regression	Intraoperative blood loss > 1000 mL	MELD, albumin, ascites and previous abdominal surgery
Roullet et al[74]	148	OLT	Univariate and multivariate regression	> 8 units RBC and loss of > 1 blood volume	Preoperative Hb and Child-Pugh A protective for blood loss > 1 blood volume
Esmat Gamil et al[43]	286	OLT	Univariate and multivariate logistic regression	> 6 units RBC	INR > 1.6, Ascites
Li et al[60]	181	LDLT	Univariate and multivariate regression	> 6 units RBC	Platelet count < 70 × 109/L, Hb < 100 g/L, fibrinogen < 1.5 g/L and previous abdominal surgery
Wu et al[75]	522	LDLT	Univariate and multivariate regression	Re-exploration for hemostasis	> 10 mL/kg FFP transfusion
Varotti et al[76]	219	OLT	Univariate and multivariate regression	RBC transfusion requirements	MELD
[77]	291	OLT (no malignancy or re-transplant)	Multivariate logistic regression	RBC transfusion requirements	Baseline Hb and Fibrinogen
De Santis et al[78]	166	OLT “piggy back”	Univariate and multivariate regression	Blood product requirements	Child-Pugh, preoperative Hb and INR, graft ischemia time
Cywinski et al[79]	804	OLT	Multivariate regression Bootstrapping for prediction model	RBC and cell saver requirement, > 20 and > 30 RBC units usage	MELD and preoperative platelet count	RBC + CS > 20 units c = 0.70 (RBC + CS > 30 units c = 0.67

OLT: Orthotopic liver transplantation; LDLT: Living donor liver transplantation; RBC: Red blood cells; GI: Gastrointestinal; RUQ: Right upper quadrant; UNOS: United Network for Organ Sharing; INR: International normalized ratio for prothrombin activity; FFP: Fresh frozen plasma; Hct: Hematocrit; Hb: Hemoglobin; PT: Prothrombin time; MELD: Model for End-Stage Liver Disease; CVP: Central venous pressure; AUC: Area under the curves.