Imagine undergoing a liver transplant, and not losing any blood, at least not enough to require a transfusion. That's what a group of surgeons say they accomplished in a report published earlier this month.1
"Despite the risks associated with transfusion, the medical community continues to view blood as a safe and abundant product," wrote Singh Gagandeep, MD, an assistant professor of Clinical Surgery at the University of Southern Calfornia, and his colleagues. "We provide an effective strategy to accomplish liver transplantation without transfusion."
Testing a Blood-Sparing Approach
The research team described the approach they used in 27 liver transplantations performed between 1999 and 2004 on a group of Jehovah's Witness patients. The religion forbids the use of blood transfusions. Nineteen were living-donor liver transplant procedures and the rest involved deceased donors.
The patients received doses of a drug known as erythropoietin, as well as iron, to build up their red blood cells. Most of the patients also underwent a technique that involves collecting several units of their blood before surgery, and replacing it with the same volume of an intravenous solution. The patient's existing blood supply is thus diluted, and any blood lost during surgery involves very little whole blood. After surgery, the previously collected blood is returned to the patient.2,3 If blood loss during surgery is not excessive, the advantage is that the patient's red cell volume is generally about the same as it was before surgery.
In this study, all patients had their salvaged blood returned to them after surgery was completed.
During surgery, there are techniques the surgeon can use minimize blood loss, such as returning any lost blood to the patient, and maintaining normal fluid levels in the blood to prevent the patient from going into shock, Gagandeep explained. Monitoring coagulation components in the blood and treating this with medication as necessary is also essential, he said.
Positive Outcomes Noted
Of those patients in the study who underwent living donor transplantation, all survived, Gagadeep and his associates reported, in the Journal of the American College of Surgeons. Two who had received livers from deceased donors later died, both of severe kidney dysfunction. "The remaining are all alive and well, with a mean follow-up of 965 days in the living donor group and 624 days in the deceased donor group," wrote the surgeons.
In conclusion, the surgical team wrote that boosting red blood cell numbers and replacing some volume of blood with solution prior to surgery "provide a safe cushion against operative blood loss."
Preventing the need for blood transfusion during surgery helps prevent the risk of disease transmission, even though efforts to make the blood supply as safe as possible have been significant in the past two decades or so, experts say. These include donor screening, blood testing, donor lists, quarantining blood until it is proven safe, and the monitoring of problems and deficiencies in the nation's blood collection process.4 The U.S. Food and Drug Administration (FDA) provides the oversight for this safety net.
However, experts have found that the risks associated with blood transfusion still exist.5,6
Preventing these risks is the aim of non-transfusion based surgery, what the study team calls "an important response to widespread blood shortages and transfusion risks."
1. Jabbour N, Gagandeep S, Mateo R, Sher L, Genyk Y, Selby R. Transfusion free surgery: single institution experience of 27 consecutive liver transplants in Jehovah's Witnesses. J Am Coll Surg 2005 Sep;201(3):412-7.
2. University Hospital. University of Medicine & Dentistry of New Jersey. Terms and Technology. Available at: http://www.theuniversityhospital.com/
bloodless/html/bloodlessterms/glossary.htm. Accessed September 28, 2005.
3. Murray D. Acute normovolemic hemodilution. Eur Spine J 2004 Oct;13 Suppl 1:S72-5. Epub 2004 Jun 10.
4. Food and Drug Administration. Keeping Blood Transfusions Safe: FDA's Multi-Layered Protections for Donated Blood. Available at: http://www.fda.gov/opacom/factsheets/justthefacts/15blood.html. Accessed September 28, 2005.
5. Goodnough LT. Risks of blood transfusion. Crit Care Med 2003 Dec;31(12 Suppl):S678-86.
6. Pomper GJ, Wu Y, Snyder EL. Risks of transfusion-transmitted infections: 2003. Curr Opin Hematol 2003 Nov;10(6):412-8.
John Martin is a long-time health journalist and an editor for Priority Healthcare. His credits include overseeing health news coverage for the website of Fox Television's The Health Network, and articles for the New York Post and other consumer and trade publications.
