Red Blood Cell Transfusion in Pediatric Orthotopic Liver Transplantation: What a Difference a Few Decades Make

This is an observational retrospective study of RBC transfusion data in 271 paediatric patients undergoing 278 liver transplants at a single institution from 2008-2017. There were 259 primary transplants, 15 second transplants, and 4 third transplants. Average age at transplantation was 6.9 years. Total mortality was 4.8% (1.5% during transplant admission and 3.3% subsequently).

Analysis showed 27.3% of cases did not require RBC transfusions. Among those transfused, 89.6% required less than one blood volume (BV). The median BV transfused among all cases was 0.21. Higher volume transfusions occurred in infants (0.46 BV compared to 0.12 BV in >12 mths of age), patients with TPN–related liver failure (3.41 BV) and patients undergoing retransplantion (third transplants median 2.71 BV, second transplants 0.43 BV and primary transplants 0.18 BV).

Living reduced liver transplantations were associated with the highest median blood loss (0.35 BV), followed by cadaveric reduced liver (0.3 BV), cadaveric whole (0.08 BV) and living whole (0.08 BV) liver transplants.


It’s not surprising that smaller infants, split donor livers and retransplant require proportionally higher blood volume transfusions.

This study is compared to one done 34 years ago by Borland in the same institution that reported average transfusions of 5.4 blood volumes and mortality of 34% within 60 days. All these patients had undergone cadaveric whole organ transplantation.

Blood transfusions have been shown to be associated with increased graft failure rates and mortality, so it’s clearly good that improvements in surgical techniques coupled with advances in perioperative care have dramatically changed the intraoperative RBC requirements of pediatric patients undergoing liver transplantation and made our job as anaesthetists easier than it was 34 years ago!

Reviewed by: Dr Graham Knottenbelt