Document Type : Research articles


1 Department of Anesthesia and Intensive Care, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran

2 Department of Biostatistics, School of Health, Mashhad University of Medical Sciences, Mashhad, Iran

3 Organ Transplant Center, Montaserieh Hospital, Mashhad University of Medical Sciences, Mashhad, Iran


Background: Orthotopic liver transplant (LT) is often associated with massive blood loss and significant transfusion requirements. Recent recommendations for resuscitation strategy in massive bleeding include the transfusion of balanced blood products, fresh frozen plasma (FFP), platelets, packed red blood cells (PRBC), and restricted use of crystalloids.
Objectives: To evaluate whether the intraoperative transfusion ratio of fresh frozen plasma to packed red blood cell units (FFP: PRBC ?1:1 versus >1:1) plays a positive role in reducing PRBC transfusion in LT.
Methods: This is a retrospective study of 84 liver transplant recipients who received at least one PRBC unit during the surgery. The patients were grouped into those who received intraoperative FFP: PRBC ratio ?1:1 (low ratio) versus the ratio>1:1 (high ratio). Selected perioperative variables were compared between the two groups.
Results: Patients in the low-ratio versus high-ratio group had lower intraoperative requirements for PRBC (P<0.001). Importantly, in the high-ratio group, the mean postoperative PRBC transfused units were 1.76 times that of the low-ratio group (incidence rate ratio [IRR], 1.76; 95% CI=1.07-2.90). There was a significant difference between the two groups in preoperative body mass index (P=0.047), hemoglobin (P=0.005), and surgical time (P=0.071); moreover, all the variables were higher in the high-ratio group. After adjusting the variables, postoperative PRBC consumption in the low-ratio group was 43% less than that in the high-ratio group (P=0.007).
Conclusion: The intraoperative low-ratio transfusion was associated with a reduced need for total PRBC transfusion in LT.


  1. Hannaman MJ, Hevesi ZG. Anesthesia care for liver transplantation. Transplant Rev (Orlando). 2011;25(1):36-43. doi: 10.1016/j.trre.2010.10.004. [PubMed: 21126662].
  2. Stine JG, Argo CK, Pelletier SJ, Maluf DG, Northup PG. Liver transplant recipients with portal vein thrombosis receiving an organ from a high-risk donor are at an increased risk for graft loss due to hepatic artery thrombosis. Transpl Int. 2016;29(12):1286-95. doi: 10.1111/tri.12855. [PubMed: 27714853].
  3. de Boer MT, Christensen MC, Asmussen M, van der Hilst CS, Hendriks HG, Slooff MJ, et al. The impact of intraoperative transfusion of platelets and red blood cells on survival after liver transplantation. Anesth Analg. 2008;106(1):32-44. doi: 10.1213/01.ane.0000289638.26666.ed. [PubMed: 18165548].
  4. Pereboom IT, de Boer MT, Haagsma EB, Hendriks HG, Lisman T, Porte RJ. Platelet transfusion during liver transplantation is associated with increased postoperative mortality due to
  5. acute lung injury. Anesth Analg. 2009;108(4):1083-91. doi: 10.1213/ane.0b013e3181948a59. [PubMed: 19299765].
  6. Benson AB, Burton Jr JR, Austin GL, Biggins SW, Zimmerman MA, Kam I, et al. Differential effects of plasma and red blood cell transfusions on acute lung injury and infection risk following liver transplantation. Liver Transpl. 2011;17(2):149-58. doi: 10.1002/lt.22212. [PubMed: 21280188].
  7. Ramos E, Dalmau A, Sabate A, Lama C, Llado L, Figueras J, et al. Intraoperative red blood cell transfusion in liver transplantation: influence on patient outcome, prediction of
  8. requirements, and measures to reduce them. Liver Transpl. 2003;9(12):1320-27. doi: 10.1016/jlts.2003.50204. [PubMed: 14625833].
  9. Hogen R, Dhanireddy K, Clark D, Biswas S, DiNorcia J, Brown N, et al. Balanced blood product transfusion during liver transplantation. Clin Transplant. 2018;32(3):e13191. doi: 10.1111/ctr.13191. [PubMed: 29314246].
  10. Pagano MB, Metcalf RA, Hess JR, Reyes J, Perkins JD, Montenovo MI. A high plasma: red blood cell transfusion ratio during liver transplantation is associated with decreased
  11. blood utilization. Vox Sang. 2018;113(3):268-74. doi: 10.1111/vox.12634. [PubMed: 29359471].
  12. Tripodi A, Mannucci PM. The coagulopathy of chronic
  13. liver disease. N Engl J Med. 2011;365(2):147-56. doi: 10.1056/NEJMra1011170. [PubMed: 21751907].
  14. Feng S, Goodrich NP, Bragg‐Gresham JL, Dykstra DM, Punch JD, DebRoy MA, et al. Characteristics associated with liver graft failure: the concept of a donor risk index. Am J Transplant. 2006;6(4):783-90. doi: 10.1111/j.1600-6143.2006.01242.x. [PubMed: 16539636].
  15. Krasnodębski M, Grąt M, Stypułkowski J, Bik E, Wronka KM, Patkowski W, et al. Impact of donor risk index on risk of hepatic artery thrombosis in patients after orthotopic liver transplantation. Transplant Proc. 2018;50(7):2006-8. doi: 10.1016/j.transproceed.2018.02.151. [PubMed: 30177098].
  16. Milani S, Shahroudi A, Morovatdar N, Zirak N, Jafari Farkhod M. Perioperative Changes in Platelet Counts During Adult Liver Transplantation. Exp Clin Transplant. 2021;19(2):137-41. doi: 10.6002/ect.2020.0195. [PubMed: 33605209].
  17. Gamil ME, Pirenne J, Van Malenstein H, Verhaegen M, Desschans B, Monbaliu D, et al. Risk factors for bleeding and clinical implications in patients undergoing liver transplantation. Transplant Proc. 2012;44(9):2857-60. doi: 10.1016/j.transproceed.2012.09.085. [PubMed: 23146542].
  18. LaMattina JC, Foley DP, Fernandez LA, Pirsch JD, Musat AI, D'Alessandro AM, et al. Complications associated with liver transplantation in the obese recipient. Clin Transplant. 2012;26(6):910-8. doi: 10.1111/j.1399-0012.2012.01669.x. [PubMed: 22694047].
  19. Spengler EK, O’Leary JG, Te HS, Rogal S, Pillai AA,
  20. Al-Osaimi A, et al. Liver transplantation in the obese cirrhotic patient. Transplantation. 2017;101(10):2288-96. doi: 10.1097/TP.0000000000001794. [PubMed: 28930104].
  21. Yanaral TU, Karaaslan P. The Impact of Body Mass Index on Intraoperative Blood Loss, Blood Transfusion and Fluid Management in Patients Undergoing Liver Transplantation: A Retrospective Analysis from a Tertiary Referral
  22. Center. Haseki Tıp Bülteni. 2021;59(4):302-7. doi: 10.4274/haseki.galenos.2021.7247.
  23. Bhangui P, Fernandes ESM, Di Benedetto F, Joo DJ, Nadalin S. Current management of portal vein thrombosis in liver transplantation. Int J Surg. 2020;82S:122-7. doi: 10.1016/j.ijsu.2020.04.068. [PubMed: 32387201].
  24. Doenecke A, Tsui TY, Zuelke C, Scherer MN, Schnitzbauer AA, Schlitt HJ, et al. Pre-existent portal vein thrombosis in liver transplantation: influence of pre-operative disease severity. Clin Transplant. 2010;24(1):48-55. doi: 10.1111/j.1399-0012.2009.00977.x. [PubMed: 19236435].
  25. Singal AK, Kamath PS. Model for end-stage liver disease. J Clin Exp Hepatol. 2013;3(1):50-60. doi: 10.1016/j.jceh.2012.11.002. [PubMed: 25755471].