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

Abstract

Patients with acute and chronic liver disease present with a wide range of disease states and severity that may require liver transplantation (LT). Physiologic alterations occur that are dynamic throughout all phases of perioperative care, creating complex management scenarios that necessitate multidisciplinary clinical care. Specifically, alterations in hemostasis in liver disease can be pronounced and evolve with disease progression over time. Recent studies Anjana A. Pillai and Michael Kriss contributed equally to this study and share co-first authorship.Constantine J. Karvellas and Nicolas Intagliata contributed equally to this study and share co-senior authorship.

Blood products and liver transplantation: A strategy to balance optimal preparation with effective blood stewardship

“…Prediction of intraoperative blood loss remains an elusive and conflicted target. A major factor complicating preoperative prognostication lies in the dynamic coagulopathies associated with progressive end‐stage liver disease 11–13,23 . Across the wide spectrum of disease sequala and severity, heterogenous deficiencies in isolated pro‐ and anti‐thrombotic cascades develop a cumulative, rebalanced hemostatic physiology within the systemic environment 24–29 .…”

“…Across the wide spectrum of disease sequala and severity, heterogenous deficiencies in isolated pro‐ and anti‐thrombotic cascades develop a cumulative, rebalanced hemostatic physiology within the systemic environment 24–29 . Though together these aberrations yield a relatively preserved equilibrium, conventional laboratory tests fail to accurately represent systemic hemostatic physiology 13,16–18 . INR and PTT time captures the deficit of extrinsic and intrinsic coagulation factors; however, the proportional decrease in anticoagulant proteins is not measured 17,26 .…”

“…Similarly, low Plt count does not account for endothelial compensation observed in cirrhotic patients 24,30 . While viscoelastic testing can serve an important role in guiding intraoperative resuscitation, it is best implemented in series and is not routinely used as a standalone assay in the preoperative setting 13 . Furthermore, subjective interpretation is required, and availability is not ubiquitous across institutions, thus limiting its value as a preoperative predictor for increased product utilization during OLT 13 .…”

“…It is well known that end‐stage liver disease yields significant aberrancies in traditional laboratory coagulation tests. However, contemporary understanding of physiologic hemostasis in cirrhotic patients is characterized by a rebalanced pro‐ and anti‐thrombotic system, thus limiting the predictive value of standard preoperative laboratory tests in isolation 11–13 . Further, reperfusion of the allograft liver yields a dramatic physiologic shift that further complicates the systemic coagulation cascade 13–15 .…”

“…However, contemporary understanding of physiologic hemostasis in cirrhotic patients is characterized by a rebalanced pro‐ and anti‐thrombotic system, thus limiting the predictive value of standard preoperative laboratory tests in isolation 11–13 . Further, reperfusion of the allograft liver yields a dramatic physiologic shift that further complicates the systemic coagulation cascade 13–15 . While viscoelastic testing has emerged as an important guide for product resuscitation during transplantation, sole reliance on laboratory coagulation tests in the preoperative period yields a confounded assessment of hemostatic physiology, thus limiting their reliability for predicting intraoperative transfusion requirements 13,16–18 .…”