http://www.medpagetoday.com/Surgery/...rgery/tb1/1808
No-Transfusion Liver Graft in Surgical Tour de Force
By Neil Osterweil, Senior Associate Editor, MedPage Today Reviewed by
Zalman S. Agus, MD; Emeritus Professor at the University of Pennsylvania School of Medicine.
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MedPage Today Action Points- Explain to patients who ask that although these preoperative and intraoperative techniques were developed for use in Jehovah's Witnesses they may have much broader application and lead to a reduction in the need for transfusion.
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Review
LOS ANGELES, Sept. 26-A surgical team here has performed 27 consecutive transfusion-free liver transplants on Jehovah's Witnesses, whose religion forbids the use of donated blood products.
Twenty-five of the patients were alive and doing well at the time the study was reported, wrote Nicolas Jabbour, M.D., and colleagues at the division of hepatobiliary/pancreatic surgery and transplantation surgery at the University of Southern California here.
"The associated coagulopathy, anemia, malnutrition, and severe portal hypertension have made this procedure more daunting and the use of blood products almost universal," Dr. Jabbour and colleagues reported in the Sept. issue of the
Journal of the American College of Surgeons.
"Using conventional surgical standards, it would be a clinical improbability to perform liver transplantation with success in Jehovah's Witness patients," the authors wrote.
The authors reported on a series of Jehovah's Witness patients (24 adults and three children) scheduled to receive liver grafts at their institution.
Nineteen of the procedures used living-donor tissues, and eight used cadaver donors.
Prior to surgery, all patients received erythropoietin in conjunction with iron sulfate and folic acid to increase red cell mass and decrease portal hypertension. Erythropoietin was given at a dose of 20,000 U subcutaneously twice a week, or 40,000 U once a week for the preoperative period. Erythropoietin was suspended and serial monitoring continued if the hematocrit reached 45 g/dL.
Despite anemia in patients with decompensating cirrhosis, the targeted hematocrit in the majority of our patients was achieved within 2 months, the surgeons noted.
At the time of anesthesia induction, all living donor patients and six of eight deceased-donor recipients underwent acute normovolemic hemodilution. The remaining two patients had a low preoperative hematocrit and could not tolerate removal of blood for hemodilution.
The operation was then conducted with the patients under conditions of moderate anemia. A cell saver was used intraoperatively in all surgeries, and acute normovolemic hemodilution and salvaged blood were returned as needed during bleeding or on completion of transplantation.
Following surgery, patients were managed with regular steroid induction, followed by maintenance therapy with Prograf (tacrolimus) and prednisone, with or without the addition of CellCept (mycophenolate mofetil).
All 19 patients who received living donor tissue had successful engraftment and survived. There were two deaths among the eight patients who received cadaveric transplants. This group had higher preoperative liver-disease severity scores at study outset, the investigators wrote.
Both deaths were in patients with concomitant liver and kidney dysfunction. One patient had hepatorenal syndrome and the other had polycystic kidney disease. In both patients, the bone marrow was relatively refractory to erythropoietin therapy; and the coagulopathy was more difficult to control in the absence of blood products in the face of kidney failure despite the use of desmopressin acetate and factor VIIa, the authors wrote.
The remaining 25 patients were all alive and doing well with a mean follow-up of 965 days (range 266 to 1,979 days) in the living donor group and 624 days (119 to 1,132 days) in the deceased donor group.
"Preoperative blood augmentation and acute normovolemic hemodilution provide a safe cushion against operative blood loss," Dr. Jabbour and colleagues wrote. "Elective living-donor liver transplantation allows full implementation of a transfusion-free strategy in the setting of early hepatic failure, portal hypertension, and anemia."
"This feat," they added, "is an important step toward global standardization of transfusion-free surgical practice and an important response to widespread blood shortages and transfusion risks."
Primary source:
Journal of the American College of Surgeons
Source reference:
J Am Coll Surg 2005;201:412-417
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No-Transfusion Liver Graft in Surgical Tour de Force
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