Coagulation management with factor concentrates in liver transplantation: a single‐center experience

Kirchner, Carmen; Dirkmann, Daniel; Treckmann, Jürgen; Paul, Andreas; Hartmann, Matthias; Saner, Fuat H.; Görlinger, Klaus

doi:10.1111/trf.12707

Cited by 125 publications

(121 citation statements)

References 59 publications

Supporting

Mentioning

114

Contrasting

Unclassified

Order By: Relevance

“…Several studies in a variety of clinical settings have demonstrated reduced blood loss, transfusion requirements [95,96] and increased transfusion-free transplantation [97] with use of fibrinogen concentrate (FC). A Cochrane review reported efficacy of FC without increased thromboembolic risk [98] , though a lack of large robust trials was noted.…”

Section: Fibrinogen Concentratesmentioning

confidence: 99%

“…Several European centres have incorporated PCC into POC guided algorithms in view of the potential benefits of low volume delivery of a potent thrombin generator without excess thromboembolic events [79,95] . In trauma patients, concerns remain about the sustained prothrombotic potential for up to 4 d post PCC administration [107] .…”

Section: Prothrombin Complex Concentratesmentioning

confidence: 99%

See 1 more Smart Citation

Reducing transfusion requirements in liver transplantation

Donohue

Mallett

2015

WJT

View full text Add to dashboard Cite

Liver transplantation (LT) was historically associated with massive blood loss and transfusion. Over the past two decades transfusion requirements have reduced dramatically and increasingly transfusionfree transplantation is a reality. Both bleeding and transfusion are associated with adverse outcomes in LT. Minimising bleeding and reducing unnecessary transfusions are therefore key goals in the perioperative period. As the understanding of the causes of bleeding has evolved so too have techniques to minimize or reduce the impact of blood loss. Surgical "piggyback" techniques, anaesthetic low central venous pressure and haemodilution strategies and the use of autologous cell salvage, point of care monitoring and targeted correction of coagulopathy, particularly through use of factor concentrates, have all contributed to declining reliance on allogenic blood products. Pre-emptive management of preoperative anaemia and adoption of more restrictive transfusion thresholds is increasingly common as patient blood management (PBM) gains momentum. Despite progress, increasing use of marginal grafts and transplantation of sicker recipients will continue to present new challenges in bleeding and transfusion management. Variation in practice across different centres and within the literature demonstrates the current lack of clear transfusion guidance. In this article we summarise the causes and predictors of bleeding and present the evidence for a variety of PBM strategies in LT. Core tip: Liver transplantation (LT) was historically associated with massive blood loss. Many factors have contributed to the decline in bleeding and transfusion in the past two decades including refinement of surgical techniques, anaesthetic management and the use of point of care guided goal-directed haemostatic therapies. Increasing awareness of the adverse associations of allogenic transfusion has driven the quest for transfusion-free transplantation. Increasing use of marginal grafts and transplantation of sicker recipients will continue to challenge perioperative care and transfusion practice. Inter-institutional variability suggests a current lack of clear guidance and limited application of the principles of patient blood management to LT.

show abstract

Section: Fibrinogen Concentratesmentioning

confidence: 99%

Section: Prothrombin Complex Concentratesmentioning

confidence: 99%

Reducing transfusion requirements in liver transplantation

Donohue

Mallett

2015

WJT

View full text Add to dashboard Cite

show abstract

“…In this context, a study is of interest in which 4-factor PCC (4-F-PCC) was administered to successfully control acute bleeding in patients following/during surgery [31]. The authors administered a dose of 25 IU/kg body weight (BW) when CT EXTEM was greater than 75 s and of 40 IU/kg BW when CT EXTEM was greater than 100 s. No major side effects or complications were reported.…”

Section: Bleeding Management In Patients With End-stage Liver Diseasementioning

confidence: 99%

“…In our opinion, PCC administration should be guided by TEG to avoid overtreatment and thrombosis. A recent case-control study in 256 liver transplant patients indicated that the use of coagulation factors, including 4-F-PCC, did not increase the rate of thrombotic events compared with patients receiving no coagulation factors [31]. …”

Section: Bleeding Management In Patients With End-stage Liver Diseasementioning

confidence: 99%

Monitoring and Treatment of Coagulation Disorders in End-Stage Liver Disease

Saner

Kirchner

2016

Visc Med

Self Cite

View full text Add to dashboard Cite

Background: Patients with end-stage liver disease (ESLD) are assumed to be at high risk of bleeding when undergoing any kind of invasive intervention (any kind of operation, including transplantation or minimally invasive interventions). Both bleeding and thrombosis are associated with a poor outcome. Methods: A selective literature research was conducted with the following key words: ‘cirrhosis', ‘coagulation', ‘bleeding', ‘INR' (international normalized ratio), ‘aPTT' (activated partial thromboplastin time), and ‘thrombocytopenia'. PubMed was used as the basic database. Results: Pathological values of standard laboratory tests (SLT) and thrombocytopenia have traditionally been regarded as indicators of a high risk for bleeding in all patients, and especially in those with ESLD. However, this approach has been challenged in recent years. The conventional approach in assessing a bleeding risk was based on pathological values of SLT. A 1.5-fold increase of INR or aPTT or platelets < 50/nl is assumed as pathological. The traditional approach of reducing the risk of excessive bleeding during an invasive procedure was to transfuse fresh frozen plasma (FFP) or platelet concentrates in order to improve hemostasis and to avoid bleeding complications. In the recent 20 years, several studies have provided us with a basis for questioning this approach. Their results indicated that SLT were not able to predict hypocoagulation and bleeding complications. Moreover, transfusion of various blood products has been associated with an increased risk for acute lung injury, transfusion-associated circulation overload, bacterial infections, and modulation of the immune system with increased numbers of nosocomial infections. Furthermore, a high volume overload, which is required to correct a hemostasis disorder if FFP are being used in ESLD patients, may increase portal venous pressure. This might significantly increase bleeding in these ESLD patients. Although the first publication about the successful use of a viscoelastic test (VET) in liver transplantation dates back to 1985, physicians are still very reluctant to use VETs (Thrombelastography™ and/or ROTEM™) for the perioperative optimization of hemostasis. However, some very recent studies demonstrated that the use of VETs for assessing the risk of bleeding avoids futile transfusion with a similar safety profile. The implementation of ROTEM-based coagulation management and the use of coagulation factors (prothrombin complex, fibrinogen concentrate) have led to a highly significant reduction of FFP and red blood cell transfusions, without an increased incidence of thrombosis or bleeding. Conclusion: Patients with ESLD often show pathological values of conventional parameters used to analyze coagulation hemostasis. Without overt signs of excessive bleeding, however, they do not require coagulation treatment. The use of FFP, which is associated with fluid overload and increase in portal venous pressure, should be avoided. The preferable coagulation treatment should be based on VET-g...

show abstract

“…In many centers, including our own, PCC is used "off-label" during LT as a rescue therapy during catastrophic bleeding, when coagulopathy is evident. Although the available data on safety in this population does not suggest an increased risk of thrombotic, thromboembolic and ischaemic events associated with PCC use, the data are scarce and need to be confirmed in large trials [51].…”

Section: Prothrombin Complex Concentratementioning

confidence: 99%

Perioperative bleeding in patients undergoing liver transplantation

Starczewska

Giercuszkiewicz²,

Niewiński³

et al. 2016

Anaesthesiol Intensive Ther

View full text Add to dashboard Cite

Liver transplantation (LT) remains one of the most challenging surgical procedures. For many years uncontrolled bleeding and catastrophic haemorrhages were one of the major causes of perioperative mortality and morbidity. During the past fifty years, significant progress in surgical technique and perioperative management has led to a marked change in transfusion practice over time, where up to 79.6% of LTs in experienced transplant centers are performed without any blood product transfusion. Despite this, perioperative bleeding and transfusion requirements remain potent predictors of patient's mortality, as well as postoperative complications and graft survival. The major impact of blood product transfusion on LT recipients outcomes implies that all patients on waiting lists should be carefully screened for the presence of risk factors of perioperative bleeding. Although multiple predictors of transfusion requirements during recipients have been identified, no predictive model validated across centers has been constructed. The most suitable strategies to reduce intraoperative blood loss in this group should be employed on a case-to-case basis. This paper aims to summarize the most up-to-date evidence in the management of haemostasis in LT recipients.Key words: liver transplantation, perioperative management, haemostasis, bleeding Anaesthesiology Intensive Therapy 2016, vol. 48, no 1, 34-40 Liver transplantation (LT) remains one of the most challenging surgical technique. For many years, uncontrolled bleeding and catastrophic haemorrhages were one of the major causes of perioperative mortality and morbidity. During more than the fifty years of experience gained since the first LT was performed by Thomas Starzl in 1963, an improvement in surgical techniques and anaesthetic management has led to a marked change in transfusion practices over time. A recently published retrospective analysis of data from the Mayo Clinic in Rochester has shown that over the last two decades there has been a significant decrease in the amount of perioperatively transfused red blood cells (RBCs), fresh frozen plasma (FFP), platelets, cryoprecipitate and intraoperative autotransfusions [1]. Interestingly, this was noted despite the fact that transfusion triggers remained the same over time [1]. Massicotte et al. [2] reported that currently up to 79.6% of LTs are performed without any blood product transfusion. The major impact of blood product transfusion on LT recipient outcomes implies that all patients on waiting lists should be carefully screened for the presence of risk factors of perioperative bleeding. The most suitable strategies to reduce intraoperative blood loss in this group should be employed on a case-to-case basis. This paper aims to summarize the most up-to-date evidence in management of haemostasis in LT recipients. HAEMOSTATIC ALTERATIONS IN LIVER TRANSPLANT RECIPIENTSThe change in transfusion practices was possible due to a better understanding of alterations in the haemostatic system in LT recipients. The l...

show abstract

Coagulation management with factor concentrates in liver transplantation: a single‐center experience

Cited by 125 publications

References 59 publications

Reducing transfusion requirements in liver transplantation

Reducing transfusion requirements in liver transplantation

Monitoring and Treatment of Coagulation Disorders in End-Stage Liver Disease

Perioperative bleeding in patients undergoing liver transplantation

Contact Info

Product

Resources

About