Live donor liver transplantation without blood products: strategies developed for Jehovah's Witnesses offer broad application.
OBJECTIVE
Developing strategies for transfusion-free live donor liver transplantation in Jehovah's Witness patients.


BACKGROUND
Liver transplantation is the standard of care for patients with end-stage liver disease. A disproportionate increase in transplant candidates and an allocation policy restructuring, favoring patients with advanced disease, have led to longer waiting time and increased medical acuity for transplant recipients. Consequently, Jehovah's Witness patients, who refuse blood product transfusion, are usually excluded from liver transplantation. We combined blood augmentation and conservation practices with live donor liver transplantation (LDLT) to accomplish successful LDLT in Jehovah's Witness patients without blood products. Our algorithm provides broad possibilities for blood conservation for all surgical patients.


METHODS
From September 1998 until June 2001, 38 LDLTs were performed at Keck USC School of Medicine: 8 in Jehovah's Witness patients (transfusion-free group) and 30 in non-Jehovah's Witness patients (transfusion-eligible group). All transfusion-free patients underwent preoperative blood augmentation with erythropoietin, intraoperative cell salvage, and acute normovolemic hemodilution. These techniques were used in only 7%, 80%, and 10%, respectively, in transfusion-eligible patients. Perioperative clinical data and outcomes were retrospectively reviewed. Data from both groups were statistically analyzed.


RESULTS
Preoperative liver disease severity was similar in both groups; however, transfusion-free patients had significantly higher hematocrit levels following erythropoietin augmentation. Operative time, blood loss, and postoperative hematocrits were similar in both groups. No blood products were used in transfusion-free patients while 80% of transfusion-eligible patients received a median of 4.5+/- 3.5 units of packed red cell. ICU and total hospital stay were similar in both groups. The survival rate was 100% in transfusion-free patients and 90% in transfusion-eligible patients.


CONCLUSIONS
Timely LDLT can be done successfully without blood product transfusion in selected patients. Preoperative preparation, intraoperative cell salvage, and acute normovolemic hemodilution are essential. These techniques may be widely applied to all patients for several surgical procedures. Chronic blood product shortages, as well as the known and unknown risk of blood products, should serve as the driving force for development of transfusion-free technology.
Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA. njabbour@surgery.usc.edu
Nicolas
N
Jabbour
Singh
S
Gagandeep
Rodrigo
R
Mateo
Linda
L
Sher
Earl
E
Strum
John
J
Donovan
Jeffrey
J
Kahn
Christian G
CG
Peyre
Randy
R
Henderson
Tse-Ling
TL
Fong
Rick
R
Selby
Yuri
Y
Genyk
D001803:Blood Transfusion / Q000592:standards* / Q000639:trends; D016022:Case-Control Studies; D005260:Female; D005500:Follow-Up Studies; D006085:Graft Survival; D006801:Humans; D033221:Jehovah's Witnesses; D017093:Liver Failure / Q000175:diagnosis / Q000601:surgery; D016031:Liver Transplantation / Q000592:standards* / Q000639:trends; D019520:Living Donors; D008297:Male; D011182:Postoperative Care; D011300:Preoperative Care / Q000379:methods; D011336:Probability; D012016:Reference Values; D012068:Religion and Medicine; D012189:Retrospective Studies; D018570:Risk Assessment; D016896:Treatment Outcome