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©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
Perioperative blood transfusion decreases long-term survival in pediatric living donor liver transplantation
Karina Gordon, Estela Regina Ramos Figueira, Joel Avancini Rocha-Filho, Luiz Antonio Mondadori, Eduardo Henrique Giroud Joaquim, Joao Seda-Neto, Eduardo Antunes da Fonseca, Renata Pereira Sustovitch Pugliese, Agustin Moscoso Vintimilla, Jose Otavio Costa Auler Jr, Maria Jose Carvalho Carmona, Luiz Augusto Carneiro D'Alburquerque
Karina Gordon, Joel Avancini Rocha-Filho, Jose Otavio Costa Auler Jr, Maria Jose Carvalho Carmona, Division of Anesthesiology, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo 05403-000, Brazil
Karina Gordon, Luiz Antonio Mondadori, Eduardo Henrique Giroud Joaquim, Department of Anesthesiology, AC Camargo Cancer Center, São Paulo 01509-010, Brazil
Estela Regina Ramos Figueira, Department of Gastroenterology, Discipline of Liver and Gastrointestinal Transplantation, Laboratory of Medical Investigations LIM37 Hospital das Clinicas, University of São Paulo School of Medicine, São Paulo 05402-000, Brazil
Joao Seda-Neto, Eduardo Antunes da Fonseca, Renata Pereira Sustovitch Pugliese, Department of Liver Transplantation, AC Camargo Cancer Center, São Paulo 01525-901, Brazil
Agustin Moscoso Vintimilla, Luiz Augusto Carneiro D'Alburquerque, Department of Gastroenterology, Division of Liver and Gastrointestinal Transplant, Hospital das Clinicas, University of São Paulo School of Medicine, São Paulo 05402-000, Brazil
Author contributions: Gordon K, Figueira ERR, Rocha-Filho JA, Mondadori LA, Joaquim EHG, Seda-Neto J, da Fonseca EA, Pugliese RPS, Vintimilla AM, Carmona MJC, Auler Jr JOC, and D'Alburquerque LAC contributed equally to this work; Gordon K, Figueira ERR, and Rocha-Filho JA designed the research study; Gordon K, Figueira ERR, and Mondadori LA performed the research; Gordon K, Figueira ERR, Rocha-Filho JA, and Mondadori LA analyzed the data and wrote the manuscript; Gordon K, Joaquim EHG, Seda-Neto J, da Fonseca EA, Pugliese RPS, Vintimilla AM, Carmona MJC, Auler Jr JOC, and D'Alburquerque LAC made critical revisions related to important intelectual content of manuscript; all authors have read and approved the final version of the manuscript.
Institutional review board statement: The study was reviewed and approved by the ACCamargo Cancer Center Institutional Review Board, No. 103.402; the University of Sao Paulo School of Medicine Institutional Review Board, No. 243/12.
Informed consent statement: Informed consent statements are not required.
Conflict-of-interest statement: The authors declare that they have no conflicts of interest relevant to the manuscript submitted to World Journal of Gastroenterology.
Data sharing statement: No additional data are available.
STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (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/ Corresponding author: Karina Gordon, MD, PhD, Academic Research, Attending Doctor, Staff Physician, Division of Anesthesiology, Hospital das Clínicas, University of São Paulo School of Medicine, Av. Dr. Eneas de Carvalho Aguiar, 155 8th Floor, São Paulo 05403-000, Brazil. gordonkarina00@gmail.com
Received: December 18, 2020
Peer-review started: December 18, 2020
First decision: January 10, 2021
Revised: January 20, 2021
Accepted: March 13, 2021
Article in press: March 13, 2021
Published online: March 28, 2021
BACKGROUND
The impact of perioperative blood transfusion on short- and long-term outcomes in pediatric living donor liver transplantation (PLDLT) must still be ascertained, mainly among young children. Clinical and surgical postoperative complications related to perioperative blood transfusion are well described up to three months after adult liver transplantation.
AIM
To determine whether transfusion is associated with early and late postoperative complications and mortality in small patients undergoing PLDLT.
METHODS
We evaluated the effects of perioperative transfusion on postoperative complications in recipients up to 20 kg of body weight, submitted to PLDLT. A total of 240 patients were retrospectively allocated into two groups according to postoperative complications: Minor complications (n = 109) and major complications (n = 131). Multiple logistic regression analysis identified the volume of perioperative packed red blood cells (RBC) transfusion as the only independent risk factor for major postoperative complications. The receiver operating characteristic curve was drawn to identify the optimal volume of the perioperative RBC transfusion related to the presence of major postoperative complications, defining a cutoff point of 27.5 mL/kg. Subsequently, patients were reallocated to a low-volume transfusion group (LTr; n = 103, RBC ≤ 27.5 mL/kg) and a high-volume transfusion group (HTr; n = 137, RBC > 27.5 mL/kg) so that the outcome could be analyzed.
RESULTS
High-volume transfusion was associated with an increased number of major complications and mortality during hospitalization up to a 10-year follow-up period. During a short-term period, the HTr showed an increase in major infectious, cardiovascular, respiratory, and bleeding complications, with a decrease in rejection complications compared to the LTr. Over a long-term period, the HTr showed an increase in major infectious, cardiovascular, respiratory, and minor neoplastic complications, with a decrease in rejection complications. Additionally, Cox hazard regression found that high-volume RBC transfusion increased the mortality risk by 3.031-fold compared to low-volume transfusion. The Kaplan-Meier survival curves of the studied groups were compared using log-rank tests and the analysis showed significantly decreased graft survival, but with no impact in patient survival related to major complications. On the other hand, there was a significant decrease in both graft and patient survival, with high-volume RBC transfusion.
CONCLUSION
Transfusion of RBC volume higher than 27.5 mL/kg during the perioperative period is associated with a significant increase in short- and long-term postoperative morbidity and mortality after PLDLT.
Core Tip: This study aimed to assess whether perioperative transfusion is associated with early and late postoperative complications and mortality in small patients undergoing pediatric living donor liver transplantation (PLDLT). The volume of perioperative packed red blood cell (RBC) transfusion was the only independent risk factor for major postoperative complications. The perioperative volume of RBC > 27.5 mL/kg was an independent risk factor for mortality, increasing the risk by 3.031-fold, and was directly related to reduced patient and graft survival. In conclusion, not even massive transfusion, in the perioperative period, was associated with a significant increase in short- and long-term postoperative morbimortality after PLDLT.
