Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan; Department of Hepato-Pancreato-Biliary Surgery, National Liver Institute, Menoufia University, Egypt.
Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan; Department of Gastroenterological and General Surgery, St. Luke's International Hospital, Tokyo, Japan.
Clin Nutr. 2021 Mar;40(3):956-965. doi: 10.1016/j.clnu.2020.06.023. Epub 2020 Jul 1.
BACKGROUND & AIMS: Blood loss during liver transplantation (LT) is one of the major concerns of the transplant team, given the potential negative post-transplant outcomes related to it. Blood loss was reported to be higher in certain body compositions, such as obese patients, undergoing LT. Therefore, we aimed to study the risk factors for high blood loss (HBL) during adult living donor liver transplant (ALDLT) including the body composition markers; visceral-to-subcutaneous adipose tissue area ratio (VSR), skeletal muscle index and intramuscular adipose tissue content. In June 2015, an aggressive perioperative rehabilitation and nutritional therapy (APRNT) program was prescribed in our institute for the patients with abnormal body composition.
We retrospectively analyzed 394 patients who had undergone their first ALDLT between 2006 and 2019. Risk factors for HBL were analyzed in the total cohort. Differences in blood loss and risk factors were analyzed in relation to the APRNT.
Multivariate risk factor analysis in the total cohort showed that a high VSR (odds ratio (OR): 1.98, 95% confidence interval (CI): 1.19-3.29, P = 0.009), was an independent risk factor for HBL during ALDLT, as well as a history of upper abdominal surgery, simultaneous splenectomy and the presence of a large amount of ascites. After the introduction of the APRNT, a significantly lower blood loss was observed during the ALDLT recipient operation (P = 0.003). Moreover, the significant difference in blood loss observed between normal and high VSR groups before the application of the APRNT (P < 0.001), was not observed with the APRNT (P = 0.85). Likewise, before the APRNT, only high VSR was a risk factor for HBL by multivariate analysis (OR: 2.34, CI: 1.33-4.09, P = 0.003). Whereas with the APRNT, high VSR was no longer a significant risk factor for HBL even by univariate analysis (OR: 0.89, CI: 0.26-3.12, P = 0.86).
Increased visceral adiposity was an independent risk factor for high intraoperative blood loss during ALDLT recipient operation. With APRNT, high VSR was not associated with high blood loss. Therefore, APRNT might have mitigated the risk of high blood loss related to high visceral adiposity.
肝移植（LT）过程中的失血是移植团队关注的主要问题之一，因为与之相关的移植后潜在负面结果。据报道，某些体型的患者（如肥胖患者）在接受 LT 时失血更多。因此，我们旨在研究成人活体供肝移植（ALDLT）过程中高失血（HBL）的危险因素，包括体成分标志物；内脏-皮下脂肪组织面积比（VSR）、骨骼肌指数和肌肉内脂肪含量。2015 年 6 月，我们所在的研究所对体型异常的患者采用了积极的围手术期康复和营养治疗（APRNT）方案。
我们回顾性分析了 2006 年至 2019 年间首次接受 ALDLT 的 394 例患者。对总队列中 HBL 的危险因素进行了分析。分析了 APRNT 相关的失血和危险因素的差异。
多变量风险因素分析显示，高 VSR（比值比（OR）：1.98，95%置信区间（CI）：1.19-3.29，P=0.009）是 ALDLT 期间 HBL 的独立危险因素，而上腹部手术史、同时行脾切除术和大量腹水的存在也是 HBL 的独立危险因素。在 APRNT 引入后，ALDLT 受体手术中的出血量明显减少（P=0.003）。此外，在应用 APRNT 之前，VSR 正常和高的两组之间观察到的显著的出血量差异（P<0.001），在应用 APRNT 后并不明显（P=0.85）。同样，在 APRNT 之前，只有高 VSR 是多变量分析中的 HBL 危险因素（OR：2.34，CI：1.33-4.09，P=0.003）。然而，在 APRNT 之后，即使是单变量分析，高 VSR 也不再是 HBL 的显著危险因素（OR：0.89，CI：0.26-3.12，P=0.86）。
内脏脂肪增加是 ALDLT 受体手术中术中失血过多的独立危险因素。通过 APRNT，高 VSR 与高出血量无关。因此，APRNT 可能减轻了与内脏脂肪过多相关的高出血风险。
