Transfusion requirements in living donor liver
transplantation e Role of laboratory assessment
and Model For End Stage Liv...
Original Article
Transfusion requirements in living donor liver
transplantation e Role of laboratory assessment
and Model ...
separately for each blood component. We also identified those preoperative variables
which significantly influence the in hos...
3. Results
A total of 534 patients underwent LDLT during the period of
study. Out of these, twenty-five cases were excluded...
MELD score, haematocrit and total bilirubin. Similarly, total
platelet transfusions were significantly correlated to preop-...
a recipient’s hepatic, renal and haemostatic status,
respectively.
We observed that our blood component prediction models
...
8. Massicotte L, Sassine M, Lenis S, Roy A. Transfusion
predictors in liver transplant. Anesth Analg.
2004;98:1245e1251.
9...
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Transfusion requirements in living donor liver transplantation e Role of laboratory assessment and Model For End Stage Liver Disease (MELD) score

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Liver transplant surgery is often associated with considerable bleeding. This study was undertaken to analyse the average blood component consumption and the effectiveness of preoperative laboratory assessment and Model For End Stage Liver Disease (MELD) score in the estimation of transfusion requirements in Living Donor Liver Transplantation (LDLT).

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  1. 1. Transfusion requirements in living donor liver transplantation e Role of laboratory assessment and Model For End Stage Liver Disease (MELD) score
  2. 2. Original Article Transfusion requirements in living donor liver transplantation e Role of laboratory assessment and Model For End Stage Liver Disease (MELD) score R.N. Makroo a, *, R. Walia b , A. Bhatia c , M. Chowdhry d a Director, Senior Consultant, Department of Transfusion Medicine, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi, India b DNB Resident, Department of Transfusion Medicine, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi, India c Sr. Registrar, Department of Transfusion Medicine, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi, India d Associate Consultant, Department of Transfusion Medicine, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi, India a r t i c l e i n f o Article history: Received 17 April 2014 Accepted 3 May 2014 Available online xxx Keywords: MELD score Liver transplant Living donor Prediction models a b s t r a c t Introduction and aims: Liver transplant surgery is often associated with considerable bleeding. This study was undertaken to analyse the average blood component consump- tion and the effectiveness of preoperative laboratory assessment and Model For End Stage Liver Disease (MELD) score in the estimation of transfusion requirements in Living Donor Liver Transplantation (LDLT). Material and methods: Univariate and stepwise regression analysis were employed to establish the significance of correlation of the preoperative laboratory variables, including haematocrit, platelet count, INR, total bilirubin, serum creatinine, blood urea and MELD score with the total consumption of Packed Red Cells (PRCs), cryoprecipitates, aphaeresis platelets and Fresh Frozen Plasma (FFP). Stepwise discriminant analysis was used to identify those preoperative factors which have a significant predictive value for the total consumption of each blood component and these results were employed to construct separate prediction models for the utilization of each blood component and the respective R square values were determined. Results: A total of 509 patients were included. On an average, 8.44 units (SD ¼ 6.11) of PRCs, 2.58 units (SD ¼ 2.95) of cryoprecipitates, 0.81 units (SD ¼ 1.16) of aphaeresis platelets and 2074.85 ml (SD ¼ 1240.20) of FFP were consumed per LDLT. The blood component prediction models could be employed to accurately predict the total utilisation of PRCs, cry- oprecipitates, FFP and aphaeresis platelets in 23, 22.6, 17.8 and 20.7 per cent of our patients, respectively. Conclusion: We have been able to identify those preoperative factors which can be employed to predict the consumption of various blood components in living donor liver graft recipients. These variables were further employed to construct prediction models, * Corresponding author. E-mail address: makroo@apollohospitals.com (R.N. Makroo). Available online at www.sciencedirect.com ScienceDirect journal homepage: www.elsevier.com/locate/apme a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1 e6 Please cite this article in press as: Makroo RN, et al., Transfusion requirements in living donor liver transplantation e Role of laboratory assessment and Model For End Stage Liver Disease (MELD) score, Apollo Medicine (2014), http://dx.doi.org/10.1016/ j.apme.2014.05.010 http://dx.doi.org/10.1016/j.apme.2014.05.010 0976-0016/Copyright ª 2014, Indraprastha Medical Corporation Ltd. All rights reserved.
  3. 3. separately for each blood component. We also identified those preoperative variables which significantly influence the in hospital mortality and PLOS in LDLT recipients. Copyright ª 2014, Indraprastha Medical Corporation Ltd. All rights reserved. 1. Introduction Liver transplant surgery is often associated with considerable bleeding, necessitating transfusion of blood and blood com- ponents.1,2 Bleeding occurs largely because liver is an extremely vascular organ3 and the associated bleeding is compounded by the presence of portal hypertension4 and abnormalities of the haemostatic system.5,6 This poses a challenge to the blood transfusion services, particularly when the supply of blood components is limited.7 Therefore, pre- operative estimation of the blood component requirements in patients undergoing liver transplantation would prove bene- ficial for the blood transfusion services, by improving their preparedness for such a major surgical procedure and helping them in better resource allocation. In order to address this issue, various factors have been hypothesised as the potential predictors of blood component usage in liver transplant surgeries. The proposed factors include the recipient characteristics including recipient’s age, gender, underlying diagnosis and the presence of any previ- ous abdominal surgery; preoperative laboratory parameters like haemoglobin, platelet count, international normalized ratio (INR), renal parameters and the preoperative Model for End Stage Liver Disease (MELD) score.8 However, there have been conflicting reports as to whether such estimation can be made preoperatively.9,10 In addition, only a limited number of such reports are available for living donor liver trans- plantations (LDLT).2 Therefore, the present study was undertaken to document the average blood component consumption and to analyse the effectiveness of preoperative laboratory assessment and MELD score in the estimation of total i.e. intraoperative as well as the postoperative transfusion requirements in LDLT. 2. Material and Methods After the approval of the hospital ethical committee, this study was conducted at the Department of Transfusion Medicine and Department of Surgical Gastroenterology & Liver Transplant, Indraprastha Apollo Hospitals, New Delhi, from January 2009 to May 2012. The records of all the patients who underwent LDLT at our centre, between January 2009 and February 2010, were analysed retrospectively and since, March 2010 all the liver graft recipients were prospectively followed up during their stay in the hospital. At our centre, whenever a liver transplant surgery is planned, a blood component request form is sent to the blood bank for the arrangement of 10 units of cross matched and leukoreduced Packed Red Cells (PRCs), 4 units of cry- oprecipitates, 10 units of fresh frozen plasma (FFP), 2 units of single donor aphaeresis fresh frozen plasma and 2 units of single donor aphaeresis platelets, which are kept ready one day prior to the potential liver transplant surgery. A fresh blood component request form is sent to the blood bank in case a further need arises. The intraoperative blood compo- nent transfusions were based on the clinical condition of the patient and the results of Thromboelastography (Haemoscope Corporation, USA). Unless contraindicated, each recipient received Tranexamic acid in an initial bolus dose of 15 mg/kg during the induction of anaesthesia and its subsequent use was guided by the thromboelastography results. Relevant data, including the patient’s age, gender, history of dialysis in the week prior to surgery and preoperative haematocrit, platelet count, INR, total serum bilirubin, serum creatinine and blood urea, was obtained from the patient’s case file. The formula, MELD ¼ 9.57 Â loge [creatinine mg/ dL] þ 3.78 Â loge [bilirubin mg/dL] þ 11.20 Â loge [INR] þ 0.643 was used to calculate the MELD score of each liver graft recipient, based on the preoperative laboratory values of serum bilirubin, serum creatinine, INR and history of dialysis in the week prior to surgery.11 Data pertaining to the total number of blood components consumed by each liver graft recipient during the intra- operative and postoperative period was obtained from the blood bank issue records. The number of units of plasma (FFP and single donor plasma) was converted into plasma volume in millilitres (ml). This calculation was based on the results of our quality control measurements which show that on an average, 1 unit of FFP is equivalent to 200 ml and the volume of 1 unit of single donor aphaeresis plasma prepared on a cell separator (Haemonetics, USA) is approx- imately 600 ml. Pearson’s correlation coefficients were employed in the univariate statistical analysis to establish the significance of correlation of the preoperative laboratory variables, including haematocrit, platelet count, INR, total bilirubin, serum creat- inine, blood urea and MELD score with the total consumption of PRCs, cryoprecipitates, single donor aphaeresis platelets and FFP. Further, stepwise regression analysis was performed with all these variables to determine the best model that could be employed to predict the utilization of each blood compo- nent. A stepwise regression analysis and multivariate logistic regression was employed to analyse the effect of various pa- rameters on mortality during the hospital stay and post- operative length of stay (PLOS) in the hospital. The various parameters analysed were recipient’s age; preoperative labo- ratory parameters including haematocrit, platelet count, INR, total bilirubin, serum creatinine and blood urea; MELD score and PRC use (intraoperative, postoperative and total). To determine the effect of recipient’s gender on mortality and PLOS in the hospital, Independent t-test and ManneWhitney test were employed. SPSS version 15.0 was used for all sta- tistical analyses and all the correlations were defined as sig- nificant at p-value less than 0.05. a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1 e62 Please cite this article in press as: Makroo RN, et al., Transfusion requirements in living donor liver transplantation e Role of laboratory assessment and Model For End Stage Liver Disease (MELD) score, Apollo Medicine (2014), http://dx.doi.org/10.1016/ j.apme.2014.05.010
  4. 4. 3. Results A total of 534 patients underwent LDLT during the period of study. Out of these, twenty-five cases were excluded, nineteen of the recipients being under 16 years of age, three of the re- cipients had a concomitant renal transplant and three had a second liver transplant. None of the adult recipients included in the study population received a cadaveric donor liver graft and no intraoperative deaths were reported during the study period. Out of the 509 patients remaining in the study popu- lation, 416 (81.7%) were males and 93 (18.3%) were females. The age of the patients included in the study ranged from 16 to 74 years, with a median of 50 years and mean age of 48.38 years (SD ¼ 10.27). The descriptive characteristics of various parameters analysed are shown in Table 1. On an average, a total of 8.44 units (SD ¼ 6.11) of PRCs were consumed in a liver transplant (Fig. 1, Table 2). In the present study, seventeen of the liver graft recipients, required no intraoperative PRC transfusion while in eleven of them, no PRC was transfused even in the postoperative period. Two of the liver graft recipients did not require any transfusion dur- ing the hospital stay. The average consumption of cry- oprecipitates and aphaeresis platelets and per liver transplant was 2.58 units (SD ¼ 2.95) and 0.81 units (SD ¼ 1.16), respectively (Fig. 1, Table 2). The mean volume of FFP consumed in a liver transplant was 2074.85 ml (SD ¼ 1240.20) (Fig. 2, Table 2). As shown in Table 3, univariate analysis demonstrated that except for the preoperative serum creatinine (p value >0.05), all the other variables correlated significantly (p < 0.05) with the consumption of one or more blood components in a liver transplant. Further evaluation with the stepwise discriminant analysis, identified those preoperative factors which have a significant predictive value for the total con- sumption of each blood component in a liver graft recipient. These results were further employed to construct separate prediction models for the utilization of each blood component and their respective R square values were determined. As shown in Table 4, it was observed that the total PRC con- sumption had a significant correlation with preoperative haematocrit, blood urea and the MELD score. The total con- sumption of cryoprecipitates was influenced by four factors including the preoperative platelet count, haematocrit, MELD score and INR. The total utilisation of FFP could be predicted by employing preoperative MELD score, haematocrit and total bilirubin while the preoperative platelet count and MELD score influenced the total platelet transfusions (Table 4). Multivariate logistic regression demonstrated that mor- tality was significantly related to recipient’s age, preoperative MELD score and total PRCs consumed. It was observed that with a one year increase in age, the probability of mortality increases by 4.3 per cent while with a one unit increase in preoperative MELD score and that of total PRCs transfused, there is an increase in the probability of mortality by 4.9 per cent and 9.4 per cent respectively. We also calculated that the total PRC consumption and preoperative blood urea had a significant positive correlation with the PLOS in the hospital. 4. Discussion In the present study, it was calculated that, on an average 8.44 units of PRCs were consumed per LDLT, with a median of 7 units. The average number of cryoprecipitates and single donor aphaeresis platelets transfused was 2.58 units and 0.81 units, respectively while the average utilisation of FFP per liver transplant was 2074.85 ml (Table 2). As shown in Table 4, the total PRC consumption had a significant correlation with preoperative haematocrit, blood urea and the MELD score while the total consumption of cryoprecipitates was influ- enced by the preoperative platelet count, haematocrit, MELD score and the INR. It was also observed that the total uti- lisation of FFP could be predicted by employing preoperative Table 1 e Descriptive characteristics of various parameters. Parameter Mean S.D. Median Minimum Maximum Age (years) 48.38 10.27 50.00 16.00 74.00 Hct 0.27 0.06 0.27 0.13 0.44 Plt (Â109 /L) 74.78 51.47 62.00 7.00 469.00 INR 1.94 0.84 1.80 0.90 9.40 T. bilirubin (mmol/L) 115.25 156.81 54.72 3.42 957.26 B. urea (mg/dL) 38.29 32.10 27.00 8.00 209.00 S. crt (mmol/L) 76.27 66.40 46.98 5.00 433.16 MELD score 19.14 7.39 18.00 6.00 44.00 PLOS (days) 21.04 11.52 18.00 2.00 116.00 Abbreviations: Hct, Haematocrit; Plt, Platelet count; INR, International Normalised Ratio; T. bilirubin, Total bilirubin; B. urea, Blood urea; S. crt, Serum creatinine; MELD, Model for End Stage Liver Disease; PLOS, Postoperative Length of Stay; SD, Standard Deviation. Fig. 1 e Mean number (units) of blood components used in liver transplant. a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1 e6 3 Please cite this article in press as: Makroo RN, et al., Transfusion requirements in living donor liver transplantation e Role of laboratory assessment and Model For End Stage Liver Disease (MELD) score, Apollo Medicine (2014), http://dx.doi.org/10.1016/ j.apme.2014.05.010
  5. 5. MELD score, haematocrit and total bilirubin. Similarly, total platelet transfusions were significantly correlated to preop- erative platelet count, haematocrit and the MELD score (Table 4). Our study demonstrates that the preoperative haematocrit had a negative influence on the consumption of PRCs, cry- oprecipitates, FFPs and platelets i.e. a lower preoperative haematocrit was associated with a higher consumption of these blood components (Table 4). A negative association of preoperative haematocrit with the PRC transfusion in liver transplantation has also been reported previously by Massi- cotte, et al.12 Moreover, the observed association of the pre- operative haematocrit and the consumption of cryoprecipitates, FFPs and platelets can be attributed to a resultant decrease in haematocrit in the wake of active bleeding that is associated with abnormalities of the coagu- lation system and therefore, necessitates transfusion of these blood components. A significant correlation was also demonstrated between the preoperative INR and platelet count with the total consumption of cryoprecipitates and platelets, respectively (Table 4). We also observed that the preoperative blood urea had a positive association with the total utilization of PRCs which can be attributed to uraemia, which is associated with impaired renal function and may lead to disturbed coagula- tion status and subsequent bleeding,13 requiring transfusion with PRCs. Deakin et al, also concluded that elevated blood urea was one of the predictors of bleeding in liver trans- plants.7 The association of renal function impairment and transfusion requirements in liver transplantation has also been described in other studies.14e16 Moreover, renal dysfunction that may be associated with End Stage Liver Disease can aggravate anaemia as a result of reduced levels of erythropoietin, leading to increased requirements of PRC transfusion.17 Our findings show that the preoperative MELD score had a positive correlation with the total consumption of all the blood components including PRCs, cryoprecipitates, FFPs and platelets and the observed associations were highly signifi- cant. It was also reported by Peter E. Frasco, et al that MELD score has a significant association with the blood component therapy in liver transplantation.18 The observed association of MELD score with the blood component utilization may be due to the fact that the MELD score is calculated by using serum bilirubin, serum creatinine and INR11 which represent Table 2 e Blood component use in liver transplant. Blood component Mean S.D. Median Minimum Maximum Intraoperative PRC (units) 6.67 4.39 6.00 0.00 41.00 Cryo (units) 2.39 2.70 2.00 0.00 17.00 FFP (ml) 1735.17 845.25 1600.00 0.00 4400.00 Platelets (units) 0.57 0.73 0.00 0.00 4.00 Postoperative PRC (units) 1.77 3.45 0.00 0.00 31.00 Cryo (units) 0.19 1.13 0.00 0.00 16.00 FFP (ml) 349.02 815.11 0.00 0.00 8000.00 Platelets (units) 0.24 0.78 0.00 0.00 9.00 Total PRC (units) 8.44 6.11 7.00 0.00 41.00 Cryo (units) 2.58 2.95 2.00 0.00 17.00 FFP (ml) 2074.85 1240.20 2000.00 0.00 10,400.00 Platelets (units) 0.81 1.16 0.00 0.00 9.00 Fig. 2 e Mean volume (ml) of FFP used in liver transplant. Table 3 e Univariate analysis of various parameters with blood component transfusion. Total blood components Hct Plt (Â109 /L) INR T. bilirubin (mmol/L) B. urea (Mg/dl) S. crt (mmol/L) MELD PRC (units) Correlation À0.37 À0.08 0.19 0.23 0.32 0.02 0.33 p-value 0.001 0.09 0.001 0.001 0.001 0.62 0.001 Cryo (units) Correlation À0.22 À0.21 0.34 0.27 0.13 À0.03 0.40 p-value 0.001 0.001 0.001 0.001 0.003 0.45 0.001 FFP (ml) Correlation À0.26 À0.09 0.31 0.22 0.19 À0.004 0.38 p-value 0.001 0.05 0.001 0.001 0.001 0.93 0.001 Platelets (units) Correlation À0.24 À0.36 0.17 0.13 0.15 0.014 0.25 p-value 0.001 0.001 0.001 0.004 0.001 0.76 0.001 Abbreviations: Hct, Haematocrit; Plt, Platelet count; INR, International Normalised Ratio; T. bilirubin, Total bilirubin; B. urea, Blood urea; S. crt, Serum creatinine; MELD, Model for End Stage Liver Disease. a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1 e64 Please cite this article in press as: Makroo RN, et al., Transfusion requirements in living donor liver transplantation e Role of laboratory assessment and Model For End Stage Liver Disease (MELD) score, Apollo Medicine (2014), http://dx.doi.org/10.1016/ j.apme.2014.05.010
  6. 6. a recipient’s hepatic, renal and haemostatic status, respectively. We observed that our blood component prediction models could be employed to accurately predict the total utilisation of PRCs, cryoprecipitates, FFP and aphaeresis platelets in 23, 22.6, 17.8 and 20.7 per cent of our patients, respectively (Table 4). This shows that besides the preoperative laboratory parameters and MELD score, other variables might also influence the blood component consumption in liver transplants. These variables could possibly include the intraoperative, technical and general patient factors, which were not considered in the present study. It was also seen that the in hospital mortality was signifi- cantly related to recipient’s age, preoperative MELD score and total PRCs consumed. A one year increase in the recipient’s age, increased the probability of mortality by 4.3 per cent. Similarly, with one unit increase in preoperative MELD score and that of total PRCs transfused, there was an increase in the probability of mortality by 4.9 per cent and 9.4 per cent respectively. PLOS in the hospital was also calculated to be positively influenced by the total PRC consumption and pre- operative blood urea. To the best of our knowledge, the present study is one of the largest single centre studies that have been undertaken to identify the significance of preoperative laboratory assess- ment in estimating the transfusion needs in LDLT. We have tried to present an extensive analysis of the total i.e. intra- operative and postoperative, consumption of various blood components in liver transplantation and have also con- structed separate prediction models to estimate the use of each blood component. However, there still are some limitations in our study. The present study is limited to the preoperative laboratory vari- ables and the MELD score only and does not include the effect of intraoperative, technical and general patient factors on blood component consumption. It is possible that the inclu- sion of all these factors might even have resulted in the con- struction of improved prediction models with higher R square values and better predictive power. However, the main focus of our study was to analyse the effect of preoperative labora- tory parameters and MELD score only, in order to draw defi- nite conclusions with regard to their predictability by analysing their role in such a large number of patients. Moreover, our findings may not be applicable to centres following a different protocol for liver transplantation and to centres performing cadaveric donor liver transplants. To conclude, we have calculated our blood component consumption in 509 LDLTs. Moreover, we have been able to identify those preoperative factors which can be employed to predict the consumption of various blood components in living donor liver graft recipients. These variables were further employed to construct prediction models, separately for each blood component. We also identified those preoper- ative variables which significantly influence the in hospital mortality and PLOS in LDLT recipients. Conflicts of interest All authors have none to declare. r e f e r e n c e s 1. Schroeder RA, Johnson LB, Plotkin JS, Kuo PC, Klein AS. Total blood transfusion and mortality after orthotopic liver transplantation. Anesthesiology. 1999;91:329e330. 2. Steib A, Freys G, Lehmann C, Meyer C, Mahoudeau G. Intraoperative blood losses and transfusion requirements during adult liver transplantation remain difficult to predict. Can J Anaesth. 2001;48:1075e1079. 3. Devi AS. Transfusion practice in orthotopic liver transplantation. Indian J Crit Care Med. 2009;13(3):120e128. 4. 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;3:412e417. 5. Porte RJ, Knot EA, Bontempo FA. Hemostasis in liver transplantation. Gastroenterology. 1989;97:488e501. 6. Lisman T, Leebeek F. Hemostatic alterations in liver disease: a review on pathophysiology, clinical consequences, and treatment. Dig Surg. 2007;24:250e258. 7. Deakin M, Gunson BK, Dunn JA, et al. Factors influencing blood transfusion during adult liver transplantation. Ann Royal Coll Surg Engl. 1993;75:339e344. Table 4 e Blood component prediction models. Predicted blood component Predicting factors R2 (%) Prediction model P-value Total PRC (units) Hct B. urea (mg/dL) MELD score 23.0 12.454e30.7 Â Hct þ 0.036 Â B. urea þ 0.156 Â MELD 0.001 Cryo (units) MELD score Plt (Â109 /L) Hct INR 22.6 1.775 þ 0.113 Â MELDÀ0.012 Â PltÀ4.9 Â Hct þ 0.461 INR 0.001 FFP (ml) MELD score Hct T. bilirubin (mmol/L) 17.8 1748.996 þ 75.310 Â MELDÀ3589.3 Â HctÀ19.870 Â (T. bilirubin/17.1) 0.001 Platelets (units) Plt (Â109 /L) MELD score Hct 20.7 1.317e7.7 Â 10À3 Plt þ 0.037 Â MELDÀ2.3 Â Hct 0.001 Abbreviations: Hct, Haematocrit; Plt, Platelet count; INR, International Normalised Ratio; T. bilirubin, Total bilirubin; B. urea, Blood urea; MELD, Model for End Stage Liver Disease. a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1 e6 5 Please cite this article in press as: Makroo RN, et al., Transfusion requirements in living donor liver transplantation e Role of laboratory assessment and Model For End Stage Liver Disease (MELD) score, Apollo Medicine (2014), http://dx.doi.org/10.1016/ j.apme.2014.05.010
  7. 7. 8. Massicotte L, Sassine M, Lenis S, Roy A. Transfusion predictors in liver transplant. Anesth Analg. 2004;98:1245e1251. 9. Bontempo FA, Lewis JH, Van Thiel DH, et al. The relation of preoperative coagulation findings to diagnosis, blood usage, and survival in adult liver transplantation. Transplantation. 1985;39:532e536. 10. Ritter DM, Rettke SR, Lunn RJ, Bowie EJW, Illstrup D. Preoperative coagulation screen does not predict intraoperative blood product requirements in orthotopic liver transplantation. Transpl Proc. 1989;21:3533e3534. 11. Flode´n A, Castedal M, Friman S, Olausson M, Backman L. Calculation and comparison of the model for end-stage liver disease (MELD) score in patients accepted for liver transplantation in 1999 and 2004. Transpl Proc. 2007;39:385e386. 12. Massicotte L, Beaulieu D, Thibeault L, et al. Coagulation defects do not predict blood product requirements during liver transplantation. Transplantation. 2008;85:956e962. 13. Noris M, Remuzzi G. Uremic bleeding: closing the circle after 30 years of controversies? Blood. 1999;94(8):2569e2574. 14. Modanlou KA, Oliver DA, Grossman BJ. Liver donor’s age and recipient’s serum creatinine predict blood component use during liver transplantation. Transfusion. 2009;49:2645e2651. 15. McCluskey SA, Karkouti K, Wijeysundera DN, et al. Derivation of a risk index for the prediction of massive blood transfusion in liver transplantation. Liver Transpl. 2006;12(11): 1584e1593. 16. Hendriks HG, van der Meer J, Klompmaker IJ, et al. Blood loss in orthotopic liver transplantation: a retrospective analysis of transfusion requirements and the effects of autotransfusion of cell saver blood in 164 consecutive patients. Blood Coagul Fibrinolysis. 2000;11(suppl 1):S87eS93. 17. Snively CS, Gutierrez C. Chronic kidney disease: prevention and treatment of common complications. Am Fam Physician. 2004;70(10):1921e1928. 18. Frasco PE, Poterack KA, Hentz JG, Mulligan DC. A comparison of transfusion requirements between living donation and cadaveric donation liver transplantation: relationship to model of end-stage liver disease score and baseline coagulation status. Anesth Analg. 2005;101:30e37. a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1 e66 Please cite this article in press as: Makroo RN, et al., Transfusion requirements in living donor liver transplantation e Role of laboratory assessment and Model For End Stage Liver Disease (MELD) score, Apollo Medicine (2014), http://dx.doi.org/10.1016/ j.apme.2014.05.010
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