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Intraoperative blood loss as a predictor of outcomes in liver transplantation: determining optimal cutoff values for
Ayato Obana1,2, Miho Akabane3, Khalid Mumtaz4
1Comprehensive Transplant Center, Department of Surgery, Ohio State University Wexner Medical Center, Ohio , OH, USA. Ayato.Obana@osumc.edu.
Background:
Liver transplantation (LT) remains the definitive treatment for end-stage liver disease, with intraoperative estimated blood loss (EBL) receiving limited attention despite its potential impact on outcomes. This study investigated the impact of EBL on graft survival (GS) in LT recipients and aimed to identify a clinically optimal EBL cutoff to guide surgical management.
Methods:
This observational cohort study analyzed 914 adult patients who underwent primary orthotopic LT at Ohio State University Wexner Medical Center between January 2016 and December 2023. Intraoperative EBL was calculated by subtracting the volume of salvaged blood from the total volume lost during surgery, then normalized by dividing by the patient's body weight, resulting in adjusted EBL (aEBL). The primary outcome was GS, defined as the time from transplantation to graft failure, re-LT, or death. Kaplan-Meier analysis and Cox regression were used to evaluate GS, and a restricted cubic spline with five knots was applied to determine the optimal aEBL cutoff.
Results:
Multivariate analysis confirmed aEBL as an independent risk factor for 1-year GS (HR:1.01, 95%CI:1.00-1.01, p < 0.001) and 3-year GS (HR:1.01, 95%CI:1.00-1.01, p < 0.001). The optimal aEBL cutoff was established at 25.0 mL/kg. Patients with aEBL < 25.0 mL/kg demonstrated superior GS rates at 90 days (p = 0.03), 1 year (p = 0.007), and 3 years (p = 0.003) compared to those with aEBL ≥ 25.0 mL/kg. Higher MELD-Na scores (OR:1.07, 95%CI:1.05-1.09, p < 0.001) and DCD donor status (OR:1.61, 95%CI:1.13-2.29, p = 0.01) were significant predictors of exceeding this threshold.
Conclusions:
This study establishes aEBL as an independent risk factor for GS in LT recipients and identifies 25.0 mL/kg as a significant cutoff impacting both short-term and long-term outcomes. These findings underscore the importance of tailoring blood loss management to individual patient characteristics, particularly body weight, and suggest a practical approach to enhance outcomes for LT recipients.
