Effect of red blood cell transfusion volume on postoperative oxygenation index during lung transplantation_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

WANG Dapeng ¹ , XU Zhongping ¹ , LI Xiaoshan ² , ZHOU Tao ¹ , WANG Song ¹ ,  XU Hongyang ¹

1. Department of Intensive Care Unit, Wuxi People’s Hospital Affiliated to Nanjing Medical University, Wuxi 214023, China;
2. Department of Anesthesiology, Wuxi People’s Hospital Affiliated to Nanjing Medical University, Wuxi 214023, China;

Corresponding author：

XU Hongyang, Email: xhy1912@aliyun.com

Keywords：

Red blood cell transfusion; lung transplantation; recipients; oxygenation index; primary graft dysfunction

DOI：

10.7507/1007-4848.202412014

Video：

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Objective To investigate the impact of intraoperative red blood cell (RBC) transfusion volume on postoperative oxygenation index in lung transplant recipients. Methods A retrospective analysis was conducted on the clinical data of lung transplant recipients at Wuxi People’s Hospital Affiliated to Nanjing Medical University from 2021 to 2023. Patients were divided into a non-severe primary graft dysfunction (PGD) group and a severe PGD group based on whether their oxygenation index was greater than 200 mm Hg at postoperative 0 h, 24 h, and 48 h. General data and intraoperative RBC transfusion volumes were compared between the two groups to assess their effects on postoperative oxygenation indices at 0 h, 24 h, and 48 h. A binary logistic regression model was constructed to explore the effect values [odds ratios (OR) and their 95% confidence intervals (CI) ] of RBC transfusion volume on oxygenation status at different postoperative time points (0 h, 24 h, 48 h), and the area under the receiver operating characteristic curve (AUC) was calculated to evaluate diagnostic efficacy. Results A total of 351 patients were included, comprising 260 males and 91 females, aged 20 to 77 years. At postoperative 0 h, the OR for intraoperative RBC transfusion was 1.486 (95%CI, P=0.061); at postoperative 24 h, the OR was 3.111 (95%CI, P<0.001); and at postoperative 48 h, the OR was 1.583 (95%CI, P=0.038), indicating that the oxygenation status of lung transplant recipients was significantly affected by the volume of intraoperative transfusion over time. Furthermore, a transfusion volume greater than 975 mL significantly impacted oxygenation at postoperative 24 h and 48 h. Conclusion The volume of intraoperative RBC transfusion has a significant effect on oxygenation status at 24 h and 48 h post-surgery. The amount of RBC transfusion during lung transplantation is associated with the occurrence of severe PGD, and controlling RBC transfusion volume during the procedure may help reduce the incidence of severe PGD.

1.	Foroutan F, Malik A, Clark KE, et al. Predictors of 1-year mortality after adult lung transplantation: Systematic review and meta-analyses. J Heart Lung Transplant, 2022, 41(7): 937-951.
2.	Mannem H, Aversa M, Keller T, et al. The lung transplant candidate, indications, timing, and selection criteria. Clin Chest Med, 2023, 44(1): 15-33.
3.	温焕舜, 郝杨, 陈静瑜, 等. 肺移植围手术期大量输血的危险因素及其预后分析. 器官移植, 2021, 12(2): 203-208.Wen HS, Hao Y, Chen JY, et al. Analysis of risk factors and clinical prognosis of massive blood transfusion during perioperative period of lung transplantation. Organ Transplant, 2021, 12(2): 203-208.
4.	Natalini JG, Clausen ES. Critical care management of the lung transplant recipient. Clin Chest Med, 2023, 44(1): 105-119.
5.	Grande B, Oechslin P, Schlaepfer M, et al. Predictors of blood loss in lung transplant surgery-a single center retrospective cohort analysis. J Thorac Dis, 2019, 11(11): 4755-4761.
6.	Melnyk V, Xu W, Ryan JP, et al. Utilization of machine learning to model the effect of blood product transfusion on short-term lung transplant outcomes. Clin Transplant, 2023, 37(6): e14961.
7.	姜蕾, 刘希曦, 王琪, 等. 肺移植患者术中输血的关联因素分析及输血对患者预后的影响. 解放军医学院学报, 2021, 42(10): 1040-1044.Jiang L, Liu XX, Wang Q, et al. Factors associated with intraoperative blood transfusion in lung transplantation and their impacts on prognosis. Acad J Chin PLA Med Sch, 2021, 42(10): 1040-1044.
8.	Fiser SM, Kron IL, McLendon Long S, et al. Early intervention after severe oxygenation index elevation improves survival following lung transplantation. J Heart Lung Transplant, 2001, 20(6): 631-636.
9.	Snell GI, Yusen RD, Weill D, et al. Report of the ISHLT Working Group on Primary Lung Graft Dysfunction, part Ⅰ: Definition and grading-A 2016 Consensus Group statement of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant, 2017, 36(10): 1097-1103.
10.	Atchade E, Elmaleh Y, Zappella N, et al. Massive intraoperative red blood cell transfusion during lung transplantation is strongly associated with 90-day mortality. Anaesth Crit Care Pain Med, 2022, 41(5): 101118.
11.	Wu KA, Kim JK, Rosser M, et al. The impact of bleeding on outcomes following lung transplantation: A retrospective analysis using the universal definition of perioperative bleeding. J Cardiothorac Surg, 2024, 19(1): 466.
12.	Lei J, Xixi L, Qi W, et al. Factors associated with intraoperative blood transfusion in lung transplantation and their impacts on prognosis. Acad J Chin PLA Med Sch 2021, 42(10): 1040-4.
13.	Subramaniam K, Loor G, Chan EG, et al. Intraoperative red blood cell transfusion and primary graft dysfunction after lung transplantation. Transplantation, 2023, 107(7): 1573-1579.
14.	Kaihou T, Toyoda T, Cerier E, et al. The risk of pretransplant blood transfusion for primary graft dysfunction after lung transplant. Ann Thorac Surg Short Rep, 2024, 2(3): 573-577.
15.	Siddiqui AS, Shakil J. Impact of blood products transfusion on patients in the immediate post-lung transplant period: A cohort study. Ann Transplant, 2024 Apr 9: 29: e943652.
16.	Yagi Y, Cerier E, Toyoda T, et al. Pre-transplantation recipient blood transfusions increase the risk of primary graft dysfunction following lung transplantation. J Heart Lung Transplant, 2023, 42(4S): S190.
17.	Subramaniam K, Loor G, Chan EG, et al. Intraoperative red blood cell transfusion and primary graft dysfunction after lung transplantation. Transplantation, 2023, 107(7): 1573-1579.
18.	Atchade E, Elmaleh Y, Zappella N, et al. Massive intraoperative red blood cell transfusion during lung transplantation is strongly associated with 90-day mortality. Anaesth Crit Care Pain Med, 2022, 41(5): 101118.
19.	Seay T, Guinn N, Maisonave Y, et al. The Association of Increased FFP: RBC transfusion ratio to primary graft dysfunction in bleeding lung transplantation patients. J Cardiothorac Vasc Anesth, 2020, 34(11): 3024-3032.
20.	Diamond JM, Lee JC, Kawut SM, et al. Clinical risk factors for primary graft dysfunction after lung transplantation. Am J Respir Crit Care Med, 2013, 187(5): 527-534.
21.	Akimova T, Zhang T, Christensen LM, et al. Obesity-related IL-18 impairs T-regulatory cell function and promotes lung ischemia-reperfusion injury. Am J Respir Crit Care Med, 2021, 204(9): 1060-1074.
22.	Bennett MR, Reilly PJ, Diamond MJ, et al. Body mass index and mortality following primary graft dysfunction: A lung transplant outcomes group study. JHLT Open, 2024, 5C: 5100107.
23.	Xia Y, Patel S, Lee S, et al. Predictors of grade 3 primary graft dysfunction in lung transplant recipients. J Heart Lung Transplant, 2022, 41(4S): S293.
24.	Anderson MR, Udupa JK, Edwin E, et al. Adipose tissue quantification and primary graft dysfunction after lung transplantation: The lung transplant body composition study. J Heart Lung Transplant, 2019, 38(12): 1246-1256.
25.	Palma G, Sorice GP, Genchi VA, et al. Adipose tissue inflammation and pulmonary dysfunction in obesity. Int J Mol Sci, 2022, 23(13): 7349.
26.	Atchade E, De Tymowski C, Lepitre E, et al. Impact of recipient and donor pretransplantation body mass index on early postosperative complications after lung transplantation. BMC Pulm Med, 2024, 24(1): 161.
27.	Qin J, Hu C, Cao X, et al. Development and validation of a nomogram model to predict primary graft dysfunction in patients after lung transplantation based on the clinical factors. Clin Transplant, 2023, 37(10): e15039.
28.	Toyoda T, Manerikar A, Kandula V, et al. Recipient, surgical, and donor factors leading to primary graft dysfunction following lung transplantation. J Heart Lung Transplant, 2022, 41(4S): S293.
29.	Bateman RM, Sharpe MD, Jagger JE, et al. 36th international symposium on intensive care and emergency medicine: Brussels, Belgium. 15-18 march 2016. Crit Care, 2016, 20(Suppl 2): 94.
30.	Themelin N, Biston P, Massart J, et al. Effects of red blood cell transfusion on global oxygenation in anemic critically ill patients. Transfusion, 2021, 61(4): 1071-1079.

1. Foroutan F, Malik A, Clark KE, et al. Predictors of 1-year mortality after adult lung transplantation: Systematic review and meta-analyses. J Heart Lung Transplant, 2022, 41(7): 937-951.
2. Mannem H, Aversa M, Keller T, et al. The lung transplant candidate, indications, timing, and selection criteria. Clin Chest Med, 2023, 44(1): 15-33.
3. 温焕舜, 郝杨, 陈静瑜, 等. 肺移植围手术期大量输血的危险因素及其预后分析. 器官移植, 2021, 12(2): 203-208.Wen HS, Hao Y, Chen JY, et al. Analysis of risk factors and clinical prognosis of massive blood transfusion during perioperative period of lung transplantation. Organ Transplant, 2021, 12(2): 203-208.
4. Natalini JG, Clausen ES. Critical care management of the lung transplant recipient. Clin Chest Med, 2023, 44(1): 105-119.
5. Grande B, Oechslin P, Schlaepfer M, et al. Predictors of blood loss in lung transplant surgery-a single center retrospective cohort analysis. J Thorac Dis, 2019, 11(11): 4755-4761.
6. Melnyk V, Xu W, Ryan JP, et al. Utilization of machine learning to model the effect of blood product transfusion on short-term lung transplant outcomes. Clin Transplant, 2023, 37(6): e14961.
7. 姜蕾, 刘希曦, 王琪, 等. 肺移植患者术中输血的关联因素分析及输血对患者预后的影响. 解放军医学院学报, 2021, 42(10): 1040-1044.Jiang L, Liu XX, Wang Q, et al. Factors associated with intraoperative blood transfusion in lung transplantation and their impacts on prognosis. Acad J Chin PLA Med Sch, 2021, 42(10): 1040-1044.
8. Fiser SM, Kron IL, McLendon Long S, et al. Early intervention after severe oxygenation index elevation improves survival following lung transplantation. J Heart Lung Transplant, 2001, 20(6): 631-636.
9. Snell GI, Yusen RD, Weill D, et al. Report of the ISHLT Working Group on Primary Lung Graft Dysfunction, part Ⅰ: Definition and grading-A 2016 Consensus Group statement of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant, 2017, 36(10): 1097-1103.
10. Atchade E, Elmaleh Y, Zappella N, et al. Massive intraoperative red blood cell transfusion during lung transplantation is strongly associated with 90-day mortality. Anaesth Crit Care Pain Med, 2022, 41(5): 101118.
11. Wu KA, Kim JK, Rosser M, et al. The impact of bleeding on outcomes following lung transplantation: A retrospective analysis using the universal definition of perioperative bleeding. J Cardiothorac Surg, 2024, 19(1): 466.
12. Lei J, Xixi L, Qi W, et al. Factors associated with intraoperative blood transfusion in lung transplantation and their impacts on prognosis. Acad J Chin PLA Med Sch 2021, 42(10): 1040-4.
13. Subramaniam K, Loor G, Chan EG, et al. Intraoperative red blood cell transfusion and primary graft dysfunction after lung transplantation. Transplantation, 2023, 107(7): 1573-1579.
14. Kaihou T, Toyoda T, Cerier E, et al. The risk of pretransplant blood transfusion for primary graft dysfunction after lung transplant. Ann Thorac Surg Short Rep, 2024, 2(3): 573-577.
15. Siddiqui AS, Shakil J. Impact of blood products transfusion on patients in the immediate post-lung transplant period: A cohort study. Ann Transplant, 2024 Apr 9: 29: e943652.
16. Yagi Y, Cerier E, Toyoda T, et al. Pre-transplantation recipient blood transfusions increase the risk of primary graft dysfunction following lung transplantation. J Heart Lung Transplant, 2023, 42(4S): S190.
17. Subramaniam K, Loor G, Chan EG, et al. Intraoperative red blood cell transfusion and primary graft dysfunction after lung transplantation. Transplantation, 2023, 107(7): 1573-1579.
18. Atchade E, Elmaleh Y, Zappella N, et al. Massive intraoperative red blood cell transfusion during lung transplantation is strongly associated with 90-day mortality. Anaesth Crit Care Pain Med, 2022, 41(5): 101118.
19. Seay T, Guinn N, Maisonave Y, et al. The Association of Increased FFP: RBC transfusion ratio to primary graft dysfunction in bleeding lung transplantation patients. J Cardiothorac Vasc Anesth, 2020, 34(11): 3024-3032.
20. Diamond JM, Lee JC, Kawut SM, et al. Clinical risk factors for primary graft dysfunction after lung transplantation. Am J Respir Crit Care Med, 2013, 187(5): 527-534.
21. Akimova T, Zhang T, Christensen LM, et al. Obesity-related IL-18 impairs T-regulatory cell function and promotes lung ischemia-reperfusion injury. Am J Respir Crit Care Med, 2021, 204(9): 1060-1074.
22. Bennett MR, Reilly PJ, Diamond MJ, et al. Body mass index and mortality following primary graft dysfunction: A lung transplant outcomes group study. JHLT Open, 2024, 5C: 5100107.
23. Xia Y, Patel S, Lee S, et al. Predictors of grade 3 primary graft dysfunction in lung transplant recipients. J Heart Lung Transplant, 2022, 41(4S): S293.
24. Anderson MR, Udupa JK, Edwin E, et al. Adipose tissue quantification and primary graft dysfunction after lung transplantation: The lung transplant body composition study. J Heart Lung Transplant, 2019, 38(12): 1246-1256.
25. Palma G, Sorice GP, Genchi VA, et al. Adipose tissue inflammation and pulmonary dysfunction in obesity. Int J Mol Sci, 2022, 23(13): 7349.
26. Atchade E, De Tymowski C, Lepitre E, et al. Impact of recipient and donor pretransplantation body mass index on early postosperative complications after lung transplantation. BMC Pulm Med, 2024, 24(1): 161.
27. Qin J, Hu C, Cao X, et al. Development and validation of a nomogram model to predict primary graft dysfunction in patients after lung transplantation based on the clinical factors. Clin Transplant, 2023, 37(10): e15039.
28. Toyoda T, Manerikar A, Kandula V, et al. Recipient, surgical, and donor factors leading to primary graft dysfunction following lung transplantation. J Heart Lung Transplant, 2022, 41(4S): S293.
29. Bateman RM, Sharpe MD, Jagger JE, et al. 36th international symposium on intensive care and emergency medicine: Brussels, Belgium. 15-18 march 2016. Crit Care, 2016, 20(Suppl 2): 94.
30. Themelin N, Biston P, Massart J, et al. Effects of red blood cell transfusion on global oxygenation in anemic critically ill patients. Transfusion, 2021, 61(4): 1071-1079.

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