Introduction: Pediatric solid organ transplantation is a life-saving treatment for patients with terminal illnesses. Research has shown that multiple factors impact patient and graft survival, including intraoperative (IO) blood products. Most of the available data was collected from adult liver transplant populations. Our objective is to determine if IO blood products influence the incidence of rejection and infection in pediatric liver transplant patients.
Methods: We conducted a retrospective chart review of 250 transplant patients from 2008 to 2019. Data collected includes age, race, gender, weight, blood products (cryoprecipitate, fresh frozen plasma [FFP], packed red blood cells [PRBCs], and platelets [PLT]) administered intraoperatively and within the three days pre/post-transplant, days to rejection and first infection, through the first-year post-transplant. Pathology reports were used to determine the presence and grade (mild to severe) of rejection according to Banff criteria. Indeterminate and suggestive findings of rejection were excluded. Bacterial, viral, and fungal infections were determined based on current CDC definitions. Patients were separated into two groups: rejection vs no rejection. Intraoperative blood product volumes for each group were compared to investigate differences in the incidence of rejection and infection. JMP Pro software was used to determine Chi-square, ANOVA and Kaplan-Meier statistical analysis.
Results: Eighty-seven pediatric liver transplant patients were included. There were no statistically significant changes in the incidence of infection or rejection in patients administered a blood product in general. However, analysis of individual blood products yielded significant results. Patients with rejection by post-operative day (POD) 30, received a higher mean volume (mL/kg) of IO PLT vs those in the non-rejection group, (ANOVA, 10.4 mL/kg vs 2 mL/kg, p = .004). Similar results were seen at POD 120 (p=.02) and 365 (p=.03). Regarding cryoprecipitate, patients with rejection by POD 30 received a higher IO mean volume vs those in the non-rejection group (ANOVA, 5.6 mL/kg vs 0.7 mL/kg, p =.003). Similar findings were seen at POD 120 (p=.01) with a trend at POD 365 (p=.07). In terms of infection, patients administered IO PRBCs and FFP had a lower incidence of viral infections by POD 14 (Fischer’s Exact Test, p=.04).
Conclusions: The data demonstrate that the mean volume of IO cryoprecipitate and PLT may increase the incidence of rejection. In contrast, studies in adults showed an increase in rejection with higher volumes of intraoperative PRBCs. Our findings also suggest that IO PRBCs and FFP may have an anti-viral protective effect within the first two weeks post-transplant. These data would support re-evaluating dosing for IO cryoprecipitate and platelets. Furthermore, investigating which properties in these blood products contribute to the increase in rejection and a decrease in infection is warranted.