Intraoperative cryoprecipitate transfusion and its association with the incidence of biliary complications after liver transplantation--a retrospective cohort study

Shuang Liu, Junwei Fan, Xiaoliang Wang, Zijun Gong, Shuyun Wang, Li Huang, Tonghai Xing, Tao Li, Zhihai Peng, Xing Sun, Shuang Liu, Junwei Fan, Xiaoliang Wang, Zijun Gong, Shuyun Wang, Li Huang, Tonghai Xing, Tao Li, Zhihai Peng, Xing Sun

Abstract

Background: Cryoprecipitate is largely used for acquired hypofibrinogenemia in the setting of massive hemorrhage in liver transplantation (LT). However, the influence of intraoperative cryoprecipitate transfusion on biliary complications (BC) after LT has not been studied in detail.

Study design and methods: In a series of 356 adult patients who received their first LT, the causes of BC were retrospectively studied by multivariate logistic regression analysis. The clinical relationship between intraoperative cryoprecipitate transfusion and BC occurrence was studied through a retrospective cohort study in patients. All patients received follow-ups for one year, and, during the follow-up period, the time of BC occurrence and liver biopsies were recorded.

Results: Intraoperative cryoprecipitate transfusion (RR = 3.46, 95% CI [1.72-6.97], P<0.001), cold ischemia time >8 h (RR = 4.24, 95% CI [2.28-7.92], P<0.01), and high-level Child-Pugh ( RR = 1.71, 95% CI [1.11-2.63], P = 0.014) are independent risk factors to predict BC after LT according to time-to-event analysis. One year BC-free survival probability of patients received intraoperative cryoprecipitate transfusions was significantly lower when compared to the group that received no cryoprecipitate(P<0.001). Moreover, BC patients in the cryoprecipitate transfusion group owned different liver pathological feature, pathological micro-thrombus formation and cholestasis were seen more often (41.4% vs 0%, 62.1% vs 12.5%, respectively) than no cryoprecipitate transfusion group.

Conclusion: These findings suggested that intraoperative cryoprecipitate transfusion was associated with BC after LT. The mechanism of BC occurrence might involve micro-thrombus formation and immune rejection.

Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Figure 1. Liver biopsies from BC patients.
Figure 1. Liver biopsies from BC patients.
Representative histopathology images of BC patients liver biopsies, A,C are from No-cryo group and B,D are from Cryo group. In the No-cryo group, the structure of hepatic lobule was integrated, normal hepatic plates were observed, hepatic cells occurred vacuolar degeneration, bile duct epithelium hyperplasia and a few inflammatory cells infiltration, cholestasis was seen (A, C). The integrity of the lobular structure was loss. Intrahepatic bile ducts proliferated significantly, part of the bile duct disappeared. Bile duct epithelial deformation, atrophy, shedding, ?the portal area shows infiltration of lymphocytes, the intrahepatic seen varying degrees of cholestasis, micro-thrombosis was observed in various sized portal area vessels (B, D).
Figure 2. One year BC-free survival curve…
Figure 2. One year BC-free survival curve for live-transplant patients.
One year BC-free survival curve for live-transplant patients according to the Kaplan–Meier method. BC-free survival probability of Patients received intraoperative cryoprecipitate transfusions(red line) was statistically significant lower when compared to the group that received no cryoprecipitate (blue line)(P<0.001).

References

    1. Perrakis A, Fortsch T, Schellerer V, Hohenberger W, Muller V (2010) Biliary tract complications after orthotopic liver transplantation: still the “Achilles heel”? Transplant Proc 42: 4154–4157.
    1. Wojcicki M, Milkiewicz P, Silva M (2008) Biliary tract complications after liver transplantation: a review. Dig Surg 25: 245–257.
    1. Gantxegi A, Caralt M, Bilbao I, Castells L, Lázaro JL, et al. (2011) Evolution of Biliary Complications After Liver Transplantation: A Single European Series. Transplant Proc 43: 745–748.
    1. Heidenhain C, Pratschke J, Puhl G, Neumann U, Pascher A, et al. (2010) Incidence of and risk factors for ischemic-type biliary lesions following orthotopic liver transplantation. Transplant International 23: 14–22.
    1. Chang TI, Ho MC, Wu YM, Lee PH, Hu RH (2011) Biliary complications after liver transplantation: an 18-year single-center experience. J Formos Med Assoc 110: 183–189.
    1. Fusai G, Dhaliwal P, Rolando N, Sabin CA, Patch D, et al. (2006) Incidence and risk factors for the development of prolonged and severe intrahepatic cholestasis after liver transplantation. Liver Transpl 12: 1626–1633.
    1. Dorobantu B, Brasoveanu V, Matei E, Dima S, Giacomoni A, et al. (2010) Biliary complications after liver transplantation–523 consecutive cases in two centers. Hepatogastroenterology 57: 932–938.
    1. Schofield WN, Rubin GL, Dean MG (2003) Appropriateness of platelet, fresh frozen plasma and cryoprecipitate transfusion in New South Wales public hospitals. Med J Aust 178: 117–121.
    1. Alport EC, Callum JL, Nahirniak S, Eurich B, Hume HA (2008) Cryoprecipitate use in 25 Canadian hospitals: commonly used outside of the published guidelines. Transfusion 48: 2122–2127.
    1. Kelly D, Jara P, Rodeck B, Lykavieris P, Burdelski M, et al. (2004) Tacrolimus and steroids versus ciclosporin microemulsion, steroids, and azathioprine in children undergoing liver transplantation: randomised European multicentre trial. Lancet 364: 1054–1061.
    1. Atwal T, Pastrana M, Sandhu B (2012) Post-liver Transplant Biliary Complications. Journal of Clinical and Experimental Hepatology 2: 81–85.
    1. Pereboom IT, de Boer MT, Haagsma EB, Hendriks HG, Lisman T, et al. (2009) Platelet transfusion during liver transplantation is associated with increased postoperative mortality due to acute lung injury. Anesth Analg 108: 1083–1091.
    1. Boin IF, Leonardi MI, Luzo AC, Cardoso AR, Caruy CA, et al. (2008) Intraoperative massive transfusion decreases survival after liver transplantation. Transplant Proc 40: 789–791.
    1. de Boer MT, Christensen MC, Asmussen M, van der Hilst CS, Hendriks HG, et al. (2008) The impact of intraoperative transfusion of platelets and red blood cells on survival after liver transplantation. Anesth Analg 106: 32–44, table of contents.
    1. Benson AB, Burton JR, Austin GL, Biggins SW, Zimmerman MA, et al. (2011) Differential effects of plasma and red blood cell transfusions on acute lung injury and infection risk following liver transplantation. Liver Transpl 17: 149–158.
    1. Pool JG, Gershgold EJ, Pappenhagen AR (1964) HIGH-POTENCY ANTIHAEMOPHILIC FACTOR CONCENTRATE PREPARED FROM CRYOGLOBULIN PRECIPITATE. Nature 203: 312.
    1. Sparrow RL, Greening DW, Simpson RJ (2011) A protocol for the preparation of cryoprecipitate and cryodepleted plasma. Methods Mol Biol 728: 259–265.
    1. George JN, Pickett EB, Heinz R (1986) Platelet membrane microparticles in blood bank fresh frozen plasma and cryoprecipitate. Blood 68: 307–309.
    1. Nieuwland R, Berckmans RJ, Rotteveel-Eijkman RC, Maquelin KN, Roozendaal KJ, et al. (1997) Cell-derived microparticles generated in patients during cardiopulmonary bypass are highly procoagulant. Circulation 96: 3534–3541.
    1. Biro E, Akkerman JW, Hoek FJ, Gorter G, Pronk LM, et al. (2005) The phospholipid composition and cholesterol content of platelet-derived microparticles: a comparison with platelet membrane fractions. J Thromb Haemost 3: 2754–2763.
    1. Sinauridze EI, Kireev DA, Popenko NY, Pichugin AV, Panteleev MA, et al. (2007) Platelet microparticle membranes have 50- to 100-fold higher specific procoagulant activity than activated platelets. Thromb Haemost 97: 425–434.
    1. Callum JL, Karkouti K, Lin Y (2009) Cryoprecipitate: the current state of knowledge. Transfus Med Rev 23: 177–188.
    1. Sprague DL, Elzey BD, Crist SA, Waldschmidt TJ, Jensen RJ, et al. (2008) Platelet-mediated modulation of adaptive immunity: unique delivery of CD154 signal by platelet-derived membrane vesicles. Blood 111: 5028–5036.
    1. Amendments and corrections to the ‘Transfusion Guidelines for neonates and older children’ (BCSH, 2004a); and to the ‘Guidelines for the use of fresh frozen plasma, cryoprecipitate and cryosupernatant’ (BCSH, 2004b). Br J Haematol 136: 514–516.
    1. Levi M, Toh CH, Thachil J, Watson HG (2009) Guidelines for the diagnosis and management of disseminated intravascular coagulation. British Committee for Standards in Haematology. Br J Haematol 145: 24–33.
    1. Practice parameter for the use of fresh-frozen plasma, cryoprecipitate, and platelets. Fresh-Frozen Plasma, Cryoprecipitate, and Platelets Administration Practice Guidelines Development Task Force of the College of American Pathologists. JAMA 271: 777–781.
    1. Tripodi A, Mannucci PM (2011) The coagulopathy of chronic liver disease. N Engl J Med 365: 147–156.
    1. Lim JK (2011) Chronic Liver Failure: Mechanisms and Management, First Edition. Journal of Clinical Gastroenterology 45 914 910.1097/MCG.1090b1013e31822cf31824a31825.
    1. de Vera ME, Lopez-Solis R, Dvorchik I, Campos S, Morris W, et al. (2009) Liver transplantation using donation after cardiac death donors: long-term follow-up from a single center. Am J Transplant 9: 773–781.
    1. Chan EY, Olson LC, Kisthard JA, Perkins JD, Bakthavatsalam R, et al. (2008) Ischemic cholangiopathy following liver transplantation from donation after cardiac death donors. Liver Transpl 14: 604–610.
    1. Foley DP, Fernandez LA, Leverson G, Anderson M, Mezrich J, et al. (2011) Biliary complications after liver transplantation from donation after cardiac death donors: an analysis of risk factors and long-term outcomes from a single center. Ann Surg 253: 817–825.
    1. Welling TH, Heidt DG, Englesbe MJ, Magee JC, Sung RS, et al. (2008) Biliary complications following liver transplantation in the model for end-stage liver disease era: effect of donor, recipient, and technical factors. Liver Transpl 14: 73–80.
    1. Qian Y LCLCFS (2004) RIsk factors for biliary complications after liver transplantation. Archives of Surgery 139: 1101–1105.
    1. Halme L, Hockerstedt K, Lautenschlager I (2003) Cytomegalovirus infection and development of biliary complications after liver transplantation. Transplantation 75: 1853–1858.
    1. Busquets J, Castellote J, Torras J, Fabregat J, Ramos E, et al. (2007) Liver transplantation across Rh blood group barriers increases the risk of biliary complications. J Gastrointest Surg 11: 458–463.
    1. Fujita S, Fujikawa T, Mizuno S, Reed AI, Kim RD, et al. (2007) Is early recurrence of hepatitis C associated with biliary anastomotic stricture after liver transplantation? Transplantation 84: 1631–1635.
    1. Nishida S, Kato T, Levi D, Naveen M, Thierry B, et al. (2002) Effect of protocol Doppler ultrasonography and urgent revascularization on early hepatic artery thrombosis after pediatric liver transplantation. Arch Surg 137: 1279–1283.
    1. Amador A, Charco R, Marti J, Alvarez G, Ferrer J, et al. (2005) Cost/efficacy clinical trial about the use of T-tube in cadaveric donor liver transplant: preliminary results. Transplant Proc 37: 1129–1130.
    1. Sotiropoulos GC, Sgourakis G, Radtke A, Molmenti EP, Goumas K, et al. (2009) Orthotopic Liver Transplantation: T-Tube or Not T-Tube? Systematic Review and Meta-Analysis of Results. Transplantation 87: 1672–1680 1610.1097/TP.1670b1013e3181a1675cf1673f.
    1. Scatton O, Meunier B, Cherqui D, Boillot O, Sauvanet A, et al. (2001) Randomized trial of choledochocholedochostomy with or without a T tube in orthotopic liver transplantation. Ann Surg 233: 432–437.
    1. Fenger-Eriksen C, Lindberg-Larsen M, Christensen AQ, Ingerslev J, Sorensen B (2008) Fibrinogen concentrate substitution therapy in patients with massive haemorrhage and low plasma fibrinogen concentrations. Br J Anaesth 101: 769–773.
    1. Sorensen B, Bevan D (2010) A critical evaluation of cryoprecipitate for replacement of fibrinogen. Br J Haematol 149: 834–843.

Source: PubMed

Szponzorok és közreműködők

Egészségi állapot

Kábítószer-beavatkozások

3
Iratkozz fel