Howard F. Taswell

The First 100 Liver Transplantations at the Mayo Clinic

Between March 1985 and June 1987, the first 100 liver transplantations at the Mayo Clinic were performed in 83 patients (primarily adults). The most frequent diagnoses were chronic active hepatitis (in 24 patients), primary sclerosing cholangitis (in 22), and primary biliary cirrhosis (in 20). The median operating time was 406 minutes, and the median usage of erythrocytes was 13.2 units. A venovenous bypass was used in all patients older than 10 years of age. Hepatic artery thrombosis occurred in 10% of the 100 transplants. A choledochocholedochostomy was done in 58 patients and a choledochojejunostomy in 25 patients. Revision of the biliary anastomosis was necessary in 9 of the 83 patients (11%). Rejection, diagnosed by clinical and histologic criteria, occurred in 50 patients (60%) and was treated with a corticosteroid bolus, followed by OKT3 (monoclonal antibody) treatment if necessary. Selective bowel decontamination helped prevent infections; only 16 bacteremias occurred, 1 of which was caused by a gram-negative organism. Fungal infections were rare. Cytomegalovirus infection occurred in 47 patients (57%). Of the 83 patients, 16 required retransplantation, in 11 of whom graft rejection had occurred. One- and 2-year patient survival was 83% and 70%, respectively. Although problems still remain, liver transplantation is a reasonable option for patients with end-stage liver disease.

Intraoperative Autologous Transfusion

Intraoperative autologous transfusion is a technique that was first used almost 2 centuries ago but that has realized its potential only in the past 5 years. A growing national awareness of transfusion-related morbidity, of the need for alternative blood sources, and of improved methods for red blood cell recovery has led to an increased frequency of use of autologous transfusion. Most hospital programs use semicontinuous flow centrifugation or canister technology for the intraoperative salvage and reinfusion of shed blood. This technique is particularly valuable for cardiovascular surgical procedures but has been useful in many other types of surgical procedures as well. Deleterious effects formerly attributed to this technique have been eliminated by methodologic improvements. Concerns about use of autologous transfusion in patients who have an infection or a malignant lesion persist. Most hematologic aberrations are related to massive transfusions and should not be considered a contraindication to the general use of autologous blood.

Hemodynamic and metabolic changes in hepatic transplantation.

In this study, we retrospectively analyzed the intraoperative hemodynamic, laboratory, and coagulation data on the first 83 patients who underwent an initial liver transplantation procedure at our institution. The major hemodynamic changes at the time of reperfusion of the donor liver were significant decreases in arterial blood pressure, systemic vascular resistance, and pulmonary artery temperature and significant increases in cardiac output and pulmonary capillary wedge pressure. The alterations in laboratory values reflected intraoperative therapeutic manipulations. Citrate toxicity is a concern, and the amount of calcium chloride administered reflected the volume of blood transfused. On reperfusion, the fibrinogen concentration decreased and both the prothrombin time and the activated partial thromboplastin time increased. This coagulopathy was also evident in the thromboelastographic values. Aggressive monitoring and prompt intervention are necessary to maintain hemodynamic and metabolic homeostasis in these patients.

Intraoperative Autologous Transfusion: Its Role in Orthotopic Liver Transplantation

In our orthotopic liver transplantation program, intraoperative autologous transfusion was used in 89 of the first 100 procedures. In these 89 cases, intraoperative autologous transfusion provided a mean of 6.2 erythrocyte units per case or 32% of the total intraoperative erythrocyte requirements. The maximal number of erythrocyte units administered to any patient was 36.6 units (and 51% of the erythrocyte requirements). The most rapid rate of reinfusion of intraoperatively salvaged blood (11.8 units/h) occurred during reperfusion. No coagulopathy, infectious sequelae, or other complications were attributable to intraoperative autologous transfusion. In patients with large volumes of blood loss, intraoperative autologous transfusion is cost-effective, apart from the consideration of its medical benefits. Use of intraoperative autologous transfusion in liver transplantation resulted in conservation of erythrocytes and reduction in exposure to homologous blood and blood components.

Evaluation of Preoperative Hematology-Coagulation Screening in Liver Transplantation

We retrospectively reviewed the results of preoperative hematology-coagulation studies in 66 patients who underwent orthotopic liver transplantation-24 with the primary diagnosis of chronic active hepatitis (CAH), 22 with primary sclerosing cholangitis (PSC), and 20 with primary biliary cirrhosis (PBC). The mean prothrombin time was above normal in all three diagnostic groups, patients with CAH having the highest values. The mean activated partial thromboplastin time was normal in patients with PSC or PBC but elevated in those with CAH. Fibrinogen levels were above normal in patients with PBC but decreased in 1 patient (5%) with PSC and 10 (42%) with CAH. Mean platelet counts were below normal in 68% and 55% of patients with PSC and PBC, respectively, but in 96% of those with CAH. The mean Ivy bleeding time was normal in patients with PSC or PBC but prolonged in those with CAH. Patients with PSC or PBC had normal mean activity levels of factors II, V, VII, IX, and X, whereas those with CAH had below normal mean values for factors II and VII. The antithrombin III activity level was normal in patients with PSC or PBC but reduced in those with CAH. Thus, patients with CAH have a greater derangement in results of clotting studies in comparison with those who have PSC or PBC, but the use of blood did not differ among the three diagnostic groups.

Anesthesia approach to hepatic transplantation

Anesthesia support for patients undergoing orthotopic liver transplantation can be complicated because of multiple medical problems in such patients and rapid hemodynamic, metabolic, and coagulation changes intraoperatively. Preoperative assessment should include careful review of the cardiovascular, respiratory, and hematologic systems. Use of isoflurane as the main anesthetic agent will minimize toxicity to the liver. During liver transplantation, hemodynamic monitoring and immediate laboratory studies should be available. In our experience during the first 100 liver transplantations performed at our institution, use of a rapid infusion pump and venovenous bypass has helped normalize hemodynamic and renal function.

Human T-Cell Leukemia Virus Type I (HTLV-I) and Blood Transfusion

Human T-cell leukemia (or T-lymphotropic) virus type I (HTLV-I) is a human exogenous infectious retrovirus of the family Retroviridae. This virus has been associated with adult T-cell leukemia and endemic myelopathies (tropical spastic paraparesis and HTLV-I associated myelopathy). HTLV-I is transmitted by sexual contact, from mother to child, by intravenous drug abuse, and by blood transfusion. The estimated lifetime risk of developing disease in antibody-positive patients is 1 in 80, and a latency period as long as 20 years can intervene. No case of transfusion-transmitted disease has been reported to date. Currently, no testing of blood donors for HTLV-I is required in the United States, and no such test has been approved by the Food and Drug Administration. Because data on the natural history of this virus may take years to accumulate, it is probably wise to begin excluding anti-HTLV-I-positive units from the blood supply in the United States as soon as a licensed test is available.

Blood Bank Support of a Liver Transplantation Program

Successful implementation of a liver transplantation program is dependent on extensive blood bank support. Careful planning, organization, and coordination of the blood bank and other clinical services are necessary. In our first 100 orthotopic liver transplantations, our median intraoperative erythrocyte use was 12.6 units, and 30% of the erythrocytes were provided by intraoperative cell salvage. Thus, the need for homologous blood and the number of donors to whom recipients were exposed were reduced. Use of intraoperative cell salvage and expansion of our erythrocyte inventory through the use of AS-1 preservative helped us meet the demands of the liver transplant program without compromising the availability of blood products for all other surgical and medical patients.

A blood bank consultation service: principles and practice

In the blood bank setting, a close relationship with both clinicians and patients is essential for good medical practice. In July 1982, the Mayo Clinic Blood Bank and Transfusion Services formally organized a consultation service with daily visits to patients of mutual interest to blood bank consultants and clinicians for practice and education. Detailed diaries of this activity were maintained for 12 months, during which time 802 impatient visits were recorded. The most frequent reasons for consultations were clarification or amplification of the clinical history (34.0%), evaluation of transfusion reactions (27.2%), and assessment of serologic problems (18.2%). These consultations resulted in diagnostic, management, and therapeutic recommendations for a wide variety of medical problems. Of the 802 consultations, 23% were conducted at the direct request of clinicians. We believe that a blood bank consultation service is feasible, is enlightening for the blood bank and clinicians, and contributes to patient care.