Usage Of Plasma In Patients With Liver Cirrhosis In China-a Multi-regional Cross-sectional Study

Background and objectiveTransfusion is an irreplaceable treatment of the clinical critical illness. More and moreattention has been paid on the rationality and safety of blood transfusion as the challenge ofblood shortage and the potential risks of blood transfusion. As a result of themisunderstanding of the reason of blood transfusion, there exits unreasonable transfusion,especially for the plasma infusion. Reasonable transfusion is the key to control the risks ofblood transfusion and save blood resources. Establishing evidence-based blood transfusionguidelines is the basis of reasonable transfusion. Gastrointestinal bleeding andcoagulopathy is the main clinical manifestation of end-stage liver cirrhosis. Patients withliver cirrhosis always receive massive blood products for treatment of bleeding orprophylaxis of bleeding, especially the plasma. While the rationality of prophylactic plasmainfusion in patients with cirrhosis has been in controversy. There are transfusion guidelinesfor single disease abroad. We’d better learn the other countries’ experience ofevidence-based blood transfusion guidlines and draft our own transfusion guideline for livercirrhosis, in order to reduce the risk of blood transfusion. Therefore, it is necessary for us toinvestigate the current status of plasma infusion in patients with liver cirrhosis and find theproblems existing in clinical practice according to the etiology of liver cirrhosis, treatmentfor patients with liver cirrhosis, the blood components available, different race andsomatotype in our country. The investigation may lay the foundation for subsequent clinicalstudy of liver cirrhosis and establish transfusion guideline special for liver cirrhosis in thefuture.MethodsWe conducted a multi-regional cross-sectional survey about the usage of plasma inpatients with liver cirrhosis among11hospitals in China based on a single center five yearsretrospective study. The epidemiology information of patients with liver cirrhosis andpractice of plasma infusion was collcted including the frequency of transfusion, reasons and dose of infusion, effectiveness and adverse reactions, through the electronic patient recordsystem and transfusion record system. Moreover, we preliminarily analyzed theeffectiveness of plasma infusion and the effect on the outcome of patients with livercirrhosis by comparing the changes of coagulation indexes before and after plasma infusion,comparing the hospital mortality in28days and hospitalization days between plasmainfusion group and no plasma infusion group.Results1) A total of1511cases of liver cirrhosis were included in the single centerretrospective survey and408cases underwent plasma transfusion (27%). The infusion rateof plasma declined year by year from2008to2013.2) The main indications of plasma in the first infusion were to correct abnormalcoagulation (51.7%) and supportive therapy (31.9%). The median volume and frequency foreach case were1200ml and5times, which were higher in cases with Child-Pugh grading Cthan those in Grade A and B, respectively (P <0.05).3) The coagulation index has been detected both before and after transfusionaccounted only40percent. The PT value below1.5times of the normal reference rangebefore plasma infusion accounted for85.5%. INR value did not significantly reduced afterinfusion, while patients whose INR value≥1.5was shortened after infusion.4) A total of1595cases were included in the multi-center cross-sectional study, whichwere mainly middle-aged men. The main cause of those patients was viral hepatitis(70.7%）. The patients were mainly in Child-Pugh Grade A and B, including551cases ofGrade A (34.5%）,488cases of grade B (30.6%),146cases of grade C (9.2%).5) There were229cases plasma infused, accounting for14.4%of total. Theprophylaxis plasma-transfusion and treatment infusion accounted for61.1%and38.9%,respectively. The cases whose doses were below the standard of the guidelines (<10ml/kg)occupied94.2%.6) The proportion of plasma infusion in Grade C (43.2%) was higher than that ofGrade B (14.5%) and Grade A (4.5%), respectively (P <0.05).7) About50percent of patients were in absence of blood coagulation records before orafter plasma transfusion, and only about30%of patients had blood coagulation recordsbefore plasma infusion. The INR value in the normal or mildly abnormal range before plasma infusion (INR≤1.5) accounted for36.2%, while the INR value moderatelyprolonged (1.5<INR <2) for33.1%and the INR value significantly prolonged (INR>2)for30.7%.8) Among1595cases, there was only one case of transfusion related adverse reactions(non-hemolytic fever reaction) recorded. The rest cases have no imformation of record.9) The therapeutic effects after infusion were evalued by the changes of INR. Theresults showed that the change of INR value after plasma infusion was very small. Thehigher INR was before infusion, the more obviously decreased after infusion. There’s nostatistical difference between results of INR before and after infusion according toChild-Pugh classification.10) There was no statistical difference in28d in-hospital mortality between patientsreceiving plasma and patients not receiving any plasma products (P＞0.05). But patientsinfused plasma stayed in hospital longer than patients not infused, and further analysisshows that patients receiving plasma with grade A and grade B had higher28d mortalitythan those not receiving plasma. And there’s no statistical difference between the twogroups in patients with grade C (P＞0.05).11) The differences of Child-Pugh scores with liver cirrhosis among11hospitals werestatistically significant. The highest ratio of plasma infusion was31.8%and the lowest5.3%and the difference was statistically significant (P＜0.05).Conclusion1) This study is the first time to investigate the current status of multi-regional bloodtransfusion in patients with liver cirrhosis in our country. We find the status and problemsof plasma infusion in liver cirrhosis and provide clues for subsequent related clinicalresearch of blood transfusion in liver cirrhosis, which will establish the foundation andbasis for standard blood transfusion protocol special for liver cirrhosis.2) Only one case is reported its transfusion related adverse reaction, which is notconsistent with the clinical situation. It suggests the lack of "transfusion reactioninvestigation and handling guidelines" in our country. To develop guidelines and establishnational monitoring system report on blood transfusion is in urgent need.3) The high percentage of prophylactic plasma infusion is worthy of our furtherattention. We could carry out high quality randomized controlled trial (RCT) and deepen the follow-up survey to see the effect of plasma transfusion on the transmitted disease and onits prognostics.4) The traditional coagulation monitoring index cannot completely reflect thecoagulation status of patients, new coagulation monitoring index such asthromboela-stogram (TEG) are in need to reflect the real coagulation status in clinical. Thediagnosis role of TEG in the assessment of coagulation and its guiding role inevidence-based blood transfusion in liver cirrhosis are worthy of further research.5) The ratio of blood coagulation detection after plasma infusion in patients with livercirrhosis is limited, suggesting that the clinical attention of assessing efficacy after plasmainfusion is not enough. Hospitals are needed to implement evaluation system of the efficacyof blood transfusion, which provides a basis for further transfusion and reduce unnecessaryblood transfusion.