Introduction: Hepatic artery thrombosis (HAT) remains a major comorbidity in pediatric liver transplants often resulting in graft loss and mortality. Controlled hemodilution decreases blood viscosity and has been theorized to aid in decreasing thrombotic events. The use of this modality is not well defined in pediatric liver transplantation. Implementing this technique can be challenging due to patient size and operative complexity. We have successfully employed this technique to limit unnecessary blood transfusions and to assist in decreasing the incidence of (HAT) in infants. Here we present our single center experience in liver transplant recipients between ages of zero to 12 months.

Methods: We performed a retrospective review of infant liver transplant outcomes from 2009-2012 at Lucille-Packard Children's Hospital. We identified the age, weight, cause of liver failure, donor type (whole liver versus reduced size graft), perioperative HCT, and blood transfusion volume in our patients. Primary endpoints include graft survival, patient survival, and the presence of HAT. Every patient underwent protocol hemodilution with a goal perioperative HCT between 22-30%. Expected and observed incidence of HAT in patients with post operative day (POD) 1 HCT <30 was analyzed using a chi-squared test.

Results: Forty-nine infant liver transplants were performed on 46 recipients from 2009-2012. One-year graft and patient survivals were 94% (n=46) and 100%, respectively. Mean age at transplant was 7.9 months (±2.5 months) with an average weight of 7.4kg (± 1.6kg). Biliary atresia was the dominant indication for transplantation (60%, n=30), with metabolic syndromes accounting for 22% (n=10) of recipients. Three patients (6.6%) developed early HAT. Donors included 51% (n=25) reduced size graft including 4 living donors. Patients received on average 40ml/kg (±36ml/kg) of intraoperative PRBC transfusion. This accounts for 31% (±19%) of total intra-operative resuscitation volume. Forty patients (82%) had a HCT of <30% at the completion of the case with an average HCT of 27.9% (±4%). On POD 1, 47 patients were found to be in our target HCT range of <30%. Two patients with HCT greater than 30% developed early HAT (p=0.0001).

Conclusion: Controlled hemodilution in infant liver transplants is possible. High graft and patient survival with low incidence of HAT can be achieved in the setting if controlled hemodilution.

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