Hypercoagulability as a contributor to thrombotic complications in the liver transplant recipient

Arshad, Freeha; Lisman, Ton; Porte, Robert J.

doi:10.1111/liv.12140

Cited by 71 publications

(78 citation statements)

References 65 publications

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“…It has been demonstrated that patients frequently become pro-thrombotic during the perioperative period [49] . This typifies the challenges of haemostatic management during LT since inappropriate correction of a transient coagulopathy could lead to excess thrombotic complications, including hepatic artery thrombosis [50] .…”

Section: Donohue CI Et Al Reducing Transfusion Requirements In Livementioning

confidence: 99%

Reducing transfusion requirements in liver transplantation

Donohue

Mallett

2015

WJT

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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.

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Section: Donohue CI Et Al Reducing Transfusion Requirements In Livementioning

confidence: 99%

Reducing transfusion requirements in liver transplantation

Donohue

Mallett

2015

WJT

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“…18 Also, most pertinently, thromboembolic events are associated with a hypercoagulable state. 19,20 A great many 'risk' factors (including both genetic [21][22][23][24][25][26][27][28] and environmental or 'lifestyle', as well as those accompanying medical interventions [29][30][31][32] ) can contribute to this hypercoagulability, [33][34][35][36][37][38] and understanding these ( Fig. 1) and how they interact probably makes this a problem that is thus best considered using the tools and ideas (e.g.…”

Section: Introductionmentioning

confidence: 99%

The simultaneous occurrence of both hypercoagulability and hypofibrinolysis in blood and serum during systemic inflammation, and the roles of iron and fibrin(ogen)

Kell

Pretorius

2014

Integrative Biology

127

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Although the two phenomena are usually studied separately, we summarise a considerable body of literature to the effect that a great many diseases involve (or are accompanied by) both an increased tendency for blood to clot (hypercoagulability) and the resistance of the clots so formed (hypofibrinolysis) to the typical, 'healthy' or physiological lysis. We concentrate here on the terminal stages of fibrin formation from fibrinogen, as catalysed by thrombin. Hypercoagulability goes hand in hand with inflammation, and is strongly influenced by the fibrinogen concentration (and vice versa); this can be mediated via interleukin-6. Poorly liganded iron is a significant feature of inflammatory diseases, and hypofibrinolysis may change as a result of changes in the structure and morphology of the clot, which may be mimicked in vitro, and may be caused in vivo, by the presence of unliganded iron interacting with fibrin(ogen) during clot formation. Many of these phenomena are probably caused by electrostatic changes in the iron-fibrinogen system, though hydroxyl radical (OH ) formation can also contribute under both acute and (more especially) chronic conditions. Many substances are known to affect the nature of fibrin polymerised from fibrinogen, such that this might be seen as a kind of bellwether for human or plasma health. Overall, our analysis demonstrates the commonalities underpinning a variety of pathologies as seen in both hypercoagulability and hypofibrinolysis, and offers opportunities for both diagnostics and therapies.

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“…Details of the sample preparation and assays are provided in Appendix 1. The protein C/factor VIII ratio was calculated as a surrogate marker of anticoagulant and procoagulant balance [25,26]. Thrombin generation was assessed on plateletpoor plasma using the calibrated automated thrombography method as described by Hemker et al [27].…”

mentioning

confidence: 99%

Alterations in coagulation following major liver resection

Mallett

Sugavanam²,

Krzanicki

et al. 2016

Anaesthesia

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SummaryThe international normalised ratio is frequently raised in patients who have undergone major liver resection, and is assumed to represent a potential bleeding risk. However, these patients have an increased risk of venous thromboembolic events, despite conventional coagulation tests indicating hypocoagulability. This prospective, observational study of patients undergoing major hepatic resection analysed the serial changes in coagulation in the early postoperative period. Thrombin generation parameters and viscoelastic tests of coagulation (thromboelastometry) remained within normal ranges throughout the study period. Levels of the procoagulant factors II, V, VII and X initially fell, but V and X returned to or exceeded normal range by postoperative day five. Levels of factor VIII and Von Willebrand factor were significantly elevated from postoperative day one (p < 0.01). Levels of the anticoagulants, protein C and antithrombin remained significantly depressed on postoperative day five (p = 0.01). Overall, the imbalance between pro-and anticoagulant factors suggested a prothrombotic environment in the early postoperative period.

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Hypercoagulability as a contributor to thrombotic complications in the liver transplant recipient

Cited by 71 publications

References 65 publications

Reducing transfusion requirements in liver transplantation

Reducing transfusion requirements in liver transplantation

The simultaneous occurrence of both hypercoagulability and hypofibrinolysis in blood and serum during systemic inflammation, and the roles of iron and fibrin(ogen)

Alterations in coagulation following major liver resection

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