Thrombin activatable fibrinolysis inhibitor as a bleeding predictor in liver transplantation: a pilot observational study

Abstract

Objective To correlate the levels of thrombin activatable fibrinolysis inhibitor in the immediate postoperative period and at 24 hours postoperatively with the volume of intraoperative bleeding.Methods Twenty-one patients allocated immediately before (elective or emergency) liver transplantation were analyzed. Blood samples were collected for thrombin activatable fibrinolysis inhibitor analysis at three different time points: immediately before liver transplantation (preoperative thrombin activatable fibrinolysis inhibitor), immediately after the surgical procedure (immediate postoperative thrombin activatable fibrinolysis inhibitor), and 24 hours after surgery (thrombin activatable fibrinolysis inhibitor 24 hours after surgery). The primary outcome of the study was to correlate the preoperative and immediate postoperative levels of thrombin activatable fibrinolysis inhibitor with intraoperative blood loss.Results There was a correlation between the preoperative thrombin activatable fibrinolysis inhibitor levels and bleeding volume (ρ = -0.469; p = 0.05) but no correlation between the immediate postoperative thrombin activatable fibrinolysis inhibitor and bleeding volume (ρ = -0.062; p = 0.79). No variable included in the linear regression analysis (prehemoglobin, prefibrinogen and preoperative thrombin activatable fibrinolysis inhibitor) was a bleeding predictor. There was a similar trend in the variation between the levels of thrombin activatable fibrinolysis inhibitor at the three different time points and fibrinogen levels. Patients who died within 6 months (14.3%) showed decreased preoperative and immediate postoperative levels of thrombin activatable fibrinolysis compared with survivors (preoperative: 1.3 ± 0.15 versus 2.55 ± 0.53, p = 0.06; immediate postoperative: 1.2 ± 0.15 versus 2.5 ± 0.42, p = 0.007).Conclusion There was a moderate correlation between preoperative thrombin activatable fibrinolysis inhibitor and intraoperative bleeding in liver transplantation patients, although the predictive role of this variable independent of other variables remains uncertain. Preoperative and immediate postoperative thrombin activatable fibrinolysis inhibitor levels may have a role in the survival prognosis of this population; however, this possibility requires confirmation in further studies with larger sample sizes.

Preoperative Fibrinogen Level and Bleeding in Liver Transplantation for End-stage Liver Disease: A Cohort Study

“…Previous small studies observed a linear association between fibrinogen level and blood loss or transfusions, but none fully adjusted for potential coagulation, hematological and liver disease severity confounders or explored a threshold effect within a well-powered sample. 45-47 In our study, we observed a nonlinear association between a preoperative fibrinogen level and multiple bleeding-related outcomes, notwithstanding the value of MELD, platelets level, and hemoglobin level (as well as INR and PTT for some models) as well as other potential confounders. Based on the visual analysis of the dose-response curves, we observed that this association was linear below a threshold of 3 g/L, whereas no association was observed above this threshold.…”

Fibrinolysis-Mediated Pathways in Acute Liver Injury

“…One study linking TAFI to ALI found that hepatic TAFI expression and plasma TAFI activity decreased in Wistar rats acutely challenged with CCl 4 , but neither underlying mechanisms explaining this finding nor the specific contributions of TAFI to ALI in this setting were proposed. 64 While the role of TAFI in ALI has not been thoroughly explored, there is a growing amount of data linking TAFI to other settings of liver injury such as liver transplantation outcome, hepatitis B infection, nonalcoholic steatohepatitis (NASH), and cirrhosis in patients [65][66][67][68][69] and chronic liver injury and inflammation in mice. [70][71][72] One study has specifically examined the impact of TAFI deficiency on acetaminophen-induced ALI.…”

Coagulopathy and hemostasis management in patients undergoing liver transplantation: Defining a dynamic spectrum across phases of care

“…[32] However, patients with acutely decompensated (AD) cirrhosis and F I G U R E 1 Dynamic changes in hemostasis across phases of care in patients with liver disease undergoing LT. Changes in primary and secondary hemostasis as well as fibrinolysis are outlined. Initial changes in patients with cirrhosis (yellow) are shown with subsequent dynamic changes associated with the perioperative period (green) and ultimately a return to normalcy in the posttransplant period (orange) [8][9][10][11][12][13][14][15] acute-on-chronic liver failure (ACLF) develop clinically significant changes in the hemostatic system. [33] One in vitro study compared traditional coagulation profiles, thrombin generation, and fibrinolysis across the spectrum from stable cirrhosis to ACLF.…”

“…[ 7 ] Most hepatocyte‐derived coagulation and anticoagulation factors are low in cirrhosis and decrease as liver disease progresses (Figure 1 ). [ 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 ] Elevated vWF and Factor VIII levels and low protein C levels contribute to a hypercoagulable state. [ 16 , 17 ] In addition, low levels of α2‐antiplasmin, Factor XIII, and plasminogen and higher levels of tissue plasminogen activator affect fibrinolysis.…”

“… Dynamic changes in hemostasis across phases of care in patients with liver disease undergoing LT. Changes in primary and secondary hemostasis as well as fibrinolysis are outlined. Initial changes in patients with cirrhosis (yellow) are shown with subsequent dynamic changes associated with the perioperative period (green) and ultimately a return to normalcy in the posttransplant period (orange) [ 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 ] …”