Delicate Balance of Bleeding and Thrombosis in End-Stage Liver Disease and Liver Transplantation

Saner, Fuat H.; Gieseler, Robert K.; Akız, Hikmet; Canbay, Ali; Görlinger, Klaus

doi:10.1159/000354400

Cited by 92 publications

(86 citation statements)

References 76 publications

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“…No patient required blood transfusion or additional coagulation factors following ML. Moreover, the risk of bleeding during biopsy may be further reduced by point-of-care testing with ROTEM analysis [19]. Thus, ML can be seen as safe, providing on the one hand means to stop bleeding on occurrence and on the other hand a biopsy specimen for diagnostic purposes.…”

Section: Discussionmentioning

confidence: 99%

Mini-Laparoscopy Guided Liver Biopsy Increases Diagnostic Accuracy in Acute Liver Failure

Dechêne¹,

Sowa²,

Schlattjan³

et al. 2014

Digestion

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Background/Aims: For diagnosis, prognosis, and treatment of acute liver failure (ALF), macroscopic evaluation and histological assessment of the liver are important. Due to impaired coagulation in ALF, the risk of bleeding is high after a percutaneous liver biopsy. Our aims were to assess (i) safety and benefit of mini laparoscopy (ML) in patients with ALF and (ii) the potential utility of histological markers in ALF prognosis. Methods: ML was performed in 39 patients with ALF to assess liver surface and to obtain a liver biopsy. Serological markers of liver injury and immunohistochemical detection of cell death and proliferation were compared to a non-ALF group (n = 10). Results: Liver biopsies were successfully performed in all patients with no significant complications. All patients had markedly elevated M30 and M65 levels in the serum. In the liver, M30 and Ki67 immune-reactive cells were more abundant in those with ALF. Importantly, there were significantly more Ki67-positive cells but fewer M30-positive cells in livers of ALF patients who recovered spontaneously. Conclusion: ML with liver biopsy in patients with ALF and severe coagulopathy is safe. Immunohistochemical detection of liver cell death and regeneration may identify individuals who would recover spontaneously or who would need a liver transplant.

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Section: Discussionmentioning

confidence: 99%

Mini-Laparoscopy Guided Liver Biopsy Increases Diagnostic Accuracy in Acute Liver Failure

Dechêne¹,

Sowa²,

Schlattjan³

et al. 2014

Digestion

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“…One of the consequences is a deficiency of vitamin K-dependent coagulation factors II, VII, IX, and X. The proteins C and S, which are also vitamin K-dependent, are decreased as well [2,4]. In contrast, coagulation factors that are not produced in the liver, such as vWF and factor VIII, show increased serum activity compared to controls [5,6].…”

Section: Hemostasis In Cirrhosismentioning

confidence: 99%

“…The time between the addition of TF and calcium and the occurrence of fibrin leafs (start of coagulation) is measured. The main drawback of this coagulation assessment is that only the procoagulant but not the anticoagulant activity is being measured, as in the case of protein C and S activity [4]. Thus, the interaction between procoagulant (factors II, VII, IX, X) and anticoagulant hemostatic components (protein C and S) and platelets cannot be assessed with this standard laboratory analysis.…”

Section: Coagulation Tests In Cirrhosismentioning

confidence: 99%

“…The advantage of both methods is based on clot assessment in whole blood, thus taking into consideration the interaction of the pro- and anticoagulants, as well as the importance of platelets [4]. Both VET methods provide a graphic presentation of the clot formation process, including initiation of coagulation, clot strength, and clot fibrinolysis.…”

Section: Coagulation Tests In Cirrhosismentioning

confidence: 99%

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

Saner

Kirchner

2016

Visc Med

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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...

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“…This concludes that their function might not be as altered as primary thought [9]. And there are compensatory mechanisms to bleeding disorders of the cirrhotic patient, one of them being the elevated level of von Willebrand factor reaching 10-fold the plasma level of control and supporting platelet adhesion better than in healthy volunteers [3,10].…”

Section: Altered Productionmentioning

confidence: 95%

Thrombocytopenia in Liver Transplant

Droc¹

2018

Thrombocytopenia

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Thrombocytopenia is a common complication of both chronic liver disease and liver transplantation (LT). The mechanism of thrombocytopenia is multifactorial implicating not only sequestration in the spleen, or in the graft, reduction in the mean platelet survival but also decreased platelet production due to low synthesis of thrombopoietin (TPO) or direct toxicity to the bone marrow. Platelets play a dualistic role in liver transplant, both beneficial and detrimental. The beneficial role of platelets is due to platelet-derived serotonin that is involved in liver regeneration. During surgery for liver transplant, in addition to the preoperative causes for thrombocytopenia, we have other mechanisms that will contribute to further deterioration of the platelets count and function: hemodilution, immunological reactions, and sequestration in the newly transplanted graft. This might result in a life-threatening level of thrombocytes. The concern is when we should treat thrombocytopenia because despite life-saving benefits, transfusion has also been related to complications and platelet transfusion has been identified as an independent risk factor for postoperative complications. Risks related to platelet concentrate administration are allergic reactions, alloimmunization, bacterial sepsis, and transfusion-related acute lung injury (TRALI). Administration of platelets is not indicated if there is no bleeding or immediate bleeding risk. New emerging therapies like thrombopoietin-receptor agonist will furthermore limit the administration of blood products.

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Delicate Balance of Bleeding and Thrombosis in End-Stage Liver Disease and Liver Transplantation

Cited by 92 publications

References 76 publications

Mini-Laparoscopy Guided Liver Biopsy Increases Diagnostic Accuracy in Acute Liver Failure

Mini-Laparoscopy Guided Liver Biopsy Increases Diagnostic Accuracy in Acute Liver Failure

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

Thrombocytopenia in Liver Transplant

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