title: Excessive intraoperative blood loss independently predicts recurrence of hepatocellular carcinoma after liver transplantation.
abstract: BACKGROUND
  Several studies have investigated the effect of intraoperative blood loss (IBL) on recurrence of tumors. However, the independent effect of IBL on oncological outcome after liver transplantation (LT) for hepatocellular carcinoma (HCC) is unclear.
  
  
  METHODS
  A total of 479 patients who underwent LT for HCC from January 2001 to December 2012 at our institution were enrolled in this retrospective study. Kaplan-Meier and Cox regression methods were used to assess the recurrence rate, as well as its risk factors. Stratified analysis was performed to further examine the effect of IBL on HCC recurrence according to different characteristics of tumors. We also investigated the independent risk factors for excessive IBL using logistic regression analysis.
  
  
  RESULTS
  The median follow-up was 28 months (range, 1-131 months). Kaplan-Meier analysis with the log-rank test according to IBL at per liter intervals showed that IBL > 4 L was significantly associated with a higher recurrence rate (P < 0.001). Multivariate analysis identified that IBL > 4 L (P < 0.001; hazard ratio [HR] = 2.32, 95 % confidence interval [CI] = 1.60-3.36) was an independent risk factor for post-LT HCC recurrence, as well as age < 60 years, exceeding Milan criteria, α-fetoprotein levels > 400 ng/mL, and micro- and macrovascular invasion. IBL > 4 L (P < 0.001; HR = 2.45, 95 % CI = 1.64-3.66) was also independently associated with early (within 1 year) recurrence after LT. Furthermore, a significant correlation between IBL > 4 L and vascular invasion (P = 0.019) was found. IBL > 4 L was independently associated with HCC recurrence for patients with vascular invasion, but not for patients without vascular invasion. Finally, we found that the presence of ascites, model for end-stage liver disease score, and operation time were independent risk factors for IBL > 4 L.
  
  
  CONCLUSIONS
  Excessive IBL is an independent predictor of HCC recurrence after LT, especially in patients with vascular invasion.
authors.affiliation: Department of Liver Surgery and Organ Transplantation Institute of Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, China. doctorliubing@163.com.
authors.forename: Bing
authors.initials: B
authors.lastname: Liu
authors.affiliation: Department of Liver Surgery and Organ Transplantation Institute of Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, China. flyteng5635@vip.sina.com.
authors.forename: Fei
authors.initials: F
authors.lastname: Teng
authors.affiliation: Department of Liver Surgery and Organ Transplantation Institute of Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, China. fuhong@medmail.com.cn.
authors.forename: Hong
authors.initials: H
authors.lastname: Fu
authors.affiliation: Department of Liver Surgery and Organ Transplantation Institute of Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, China. gwyuan7502@aliyun.com.
authors.forename: Wen-Yuan
authors.initials: WY
authors.lastname: Guo
authors.affiliation: Department of Liver Surgery and Organ Transplantation Institute of Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, China. shixiaominmail@sina.com.
authors.forename: Xiao-Min
authors.initials: XM
authors.lastname: Shi
authors.affiliation: Department of Liver Surgery and Organ Transplantation Institute of Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, China. nzj@21cn.com.
authors.forename: Zhi-Jia
authors.initials: ZJ
authors.lastname: Ni
authors.affiliation: Department of Liver Surgery and Organ Transplantation Institute of Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, China. shieldgun@sina.com.
authors.forename: Xiao-Gang
authors.initials: XG
authors.lastname: Gao
authors.affiliation: Department of Liver Surgery and Organ Transplantation Institute of Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, China. reck_mj@hotmail.com.
authors.forename: Jun
authors.initials: J
authors.lastname: Ma
authors.affiliation: Department of Liver Surgery and Organ Transplantation Institute of Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, China. zhirenf@vip.sina.com.
authors.forename: Zhi-Ren
authors.initials: ZR
authors.lastname: Fu
authors.affiliation: Department of Liver Surgery and Organ Transplantation Institute of Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, China. dingguoshanmail@163.com.
authors.forename: Guo-Shan
authors.initials: GS
authors.lastname: Ding
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D016063:Blood Loss, Surgical / Q000706:statistics & numerical data*; D006528:Carcinoma, Hepatocellular / Q000473:pathology / Q000601:surgery*; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008113:Liver Neoplasms / Q000473:pathology / Q000601:surgery*; D016031:Liver Transplantation / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D009361:Neoplasm Invasiveness; D009364:Neoplasm Recurrence, Local / Q000209:etiology*; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012307:Risk Factors; D000509:alpha-Fetoproteins / Q000032:analysis
chemical_list: D000509:alpha-Fetoproteins