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, Jiangsu, P. R. China;
2. Department of Anesthesiology, Wuxi People’s Hospital Affiliated to Nanjing Medical University, Wuxi, 214023, Jiangsu, P. R. 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 the postoperative oxygenation index in lung transplant recipients. Methods This retrospective study analyzed the clinical data of patients who underwent lung transplantation 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 postoperative oxygenation index was>200 mm Hg at 0, 24, and 48 h. General patient data and intraoperative RBC transfusion volumes were compared between the two groups. A binary logistic regression model was constructed to explore the effect size (OR and its 95%CI) of RBC transfusion volume on postoperative oxygenation status at different time points (0, 24, and 48 h). The area under the receiver operating characteristic curve was calculated to evaluate the model's diagnostic performance. Results A total of 351 patients were included (260 males, 91 females), with ages ranging from 20 to 77 years. The OR for the effect of intraoperative RBC transfusion on poor oxygenation was 1.486 (95%CI 0.982 to 2.248, P=0.061) at 0 h postoperatively, 3.111 (95%CI 1.793 to 5.399, P<0.001) at 24 h, and 1.583 (95%CI 1.026 to 2.442, P=0.038) at 48 h. This indicated that as time progressed, the postoperative oxygenation status of lung transplant recipients was affected by the intraoperative transfusion volume. Furthermore, an RBC transfusion volume>975 mLhad a significant impact on patient oxygenation at 24 and 48 h postoperatively. Conclusion The volume of intraoperative RBC transfusion has a significant impact on the oxygenation status at 24 and 48 h postoperatively. Intraoperative RBC transfusion volume is associated with the occurrence of severe PGD after lung transplantation. Controlling the volume of RBC transfusion during lung transplantation may help reduce the incidence of severe PGD.

Citation： WANG Dapeng, XU Zhongping, LI Xiaoshan, ZHOU Tao, WANG Song, XU Hongyang. Effect of red blood cell transfusion volume on postoperative oxygenation index during lung transplantation. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2026, 33(1): 72-78. doi: 10.7507/1007-4848.202412014 Copy

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.	溫煥舜, 郝楊, 陳靜瑜, 等. 肺移植圍手術期大量輸血的危險因素及其預后分析. 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, 劉希曦, 王琪, 等. 肺移植患者術中輸血的關聯因素分析及輸血對患者預后的影響. 解放軍醫學院學報, 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.	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.
18.	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.
19.	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.
20.	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.
21.	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.
22.	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.
23.	Palma G, Sorice GP, Genchi VA, et al. Adipose tissue inflammation and pulmonary dysfunction in obesity. Int J Mol Sci, 2022, 23(13): 7349.
24.	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.
25.	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.
26.	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.
27.	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.
28.	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. 溫煥舜, 郝楊, 陳靜瑜, 等. 肺移植圍手術期大量輸血的危險因素及其預后分析. 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, 劉希曦, 王琪, 等. 肺移植患者術中輸血的關聯因素分析及輸血對患者預后的影響. 解放軍醫學院學報, 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. 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.
18. 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.
19. 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.
20. 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.
21. 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.
22. 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.
23. Palma G, Sorice GP, Genchi VA, et al. Adipose tissue inflammation and pulmonary dysfunction in obesity. Int J Mol Sci, 2022, 23(13): 7349.
24. 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.
25. 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.
26. 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.
27. 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.
28. 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.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Effect of red blood cell transfusion volume on postoperative oxygenation index during lung transplantation

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