To the Editor:-One-year survival after orthotopic liver transplantation (OLT) has improved to approximately 85–90%, with improvements in operative technique, anesthetic management, and patient selection. Despite these improvements, perioperative mortality is still a significant threat. A variety of contributory factors are plausible, including Childs score, preoperative UNOS status, quality of the donor organ, and comorbid conditions. We hypothesized that all of these factors, as reflected in blood requirements during the intraoperative portion of OLT, would correlate with 72-h perioperative mortality. Although clinical intuition suggests that the degree of blood loss will correlate with ultimate outcome for OLT recipients, this issue has not been examined.

Records of adult OLT recipients at three institutions (University of Maryland Hospital, Stanford University Hospital, and Johns Hopkins Hospital) were retrospectively reviewed. A total of 300 patients received OLTs from Jly 1993, to February 1998. Intraoperative erythrocyte requirements, including cell-saver units, were totaled. The patients were then stratified according to the categories: less than 20 U, 21–40 U, 41–60 U, 61–80 U, and more than 80 U. The 72-h postoperative mortality was determined for each category. The OLT procedure was performed in the traditional fashion with caval occlusion and excision. Venovenous bypass was used in a selective fashion as determined by the patient's hemodynamic response to a 2-min trial of portal and caval clamping.

The majority of patients (73%) received less than 20 U of blood during OLT (Figure 1). Fifteen percent of patients received 21–40 U of blood. Perioperative mortality increased in a highly significant fashion among the five categories of blood usage (P < 0.0001, chi-square test). Among patients who received less than 20 U, perioperative mortality was only 0.5%; in contrast, in those who received 61–80 U and more than 80 U, mortality was 70% and 86%, respectively. The LD50 for blood administration was approximately 58 U of blood.

Figure 1. Histogram of OLT recipients and number of units of blood transfused intraoperatively, and a superimposed 72-h perioperative mortality curve. 

Figure 1. Histogram of OLT recipients and number of units of blood transfused intraoperatively, and a superimposed 72-h perioperative mortality curve. 

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Our analysis does not address the precise factors that contribute to early postoperative mortality after OLT. Although there are certainly a multitude of factors (preoperative, intraoperative, and postoperative) that have an effect on survival, our data suggest that intraoperative blood usage during OLT may reflect the sum total of donor and recipient factors that may contribute to patient mortality.

Rebecca A. Schroeder, M.D.

Assistant Professor of Anesthesia

Lynt B. Johnson, M.D.

Associate Professor of Surgery

Jeffrey S. Plotkin, M.D.

Assistant Professor of Anesthesia

Paul C. Kuo, M.D.

Professor of Surgery; Georgetown University Medical Center; Washington, DC;

Andrew S. Klein, M.D.

Associate Professor of Surgery; Johns Hopkins Hospital; Baltimore, Maryland

(Accepted for publication March 19, 1999.)