International survey on anticoagulation and antiplatelet strategies after pediatric liver transplantation

Abstract

In pediatric LT, anticoagulants and antiplatelet agents are regularly used to reduce the risk of vascular thrombosis. As evidence for optimal strategy is lacking, local practices vary greatly. The present survey aimed to compile an international overview of anticoagulation and antiplatelet strategies in pediatric LT. An online survey was sent to 98 pediatric LT centers in North and South America, Europe, Asia, and Australia.Twenty-four centers answered the survey. 20/24 (83%) use some sort of anticoagulation and antiplatelet therapy, yielding 20 different strategies. Perioperative vascular problems, size of the hepatic artery, and patient weight were the most frequent determinants of changes in anticoagulant and antiplatelet strategy. Early HAT rates were reported to be 5% or less in 79% of responding centers. Anticoagulation and antiplatelet strategies were not significantly associated with early HAT rates (P = 0.63), or with the number of pediatric LTs performed per year and center (P = 0.92). Internationally, there is a wide variety in anticoagulation and antiplatelet strategies after pediatric LT. Efforts must be made to design a prospective multicentric trial to identify the optimal antithrombotic strategy. K E Y W O R D Santicoagulation, hepatic artery thrombosis, pediatric liver transplantation

Routine Postoperative Antithrombotic Therapy in Pediatric Liver Transplantation: Impact on Bleeding and Thrombotic Complications

“…It was previously suggested that routine antithrombotic therapy is beneficial in pediatric liver transplant recipients, and it has been demonstrated that the combination of heparin and acetylsalicylic acid is the most commonly used antithrombotic therapy strategy. 15,23,24 Low recipient and donor age, as well as DCD grafts and intraoperative vascular interventions, especially when concerning the hepatic artery, were identified risk factors for posttransplant thrombosis in this study, which is in line with previous studies. 15,20,25 Notably, 38% of the recipients with a posttransplant thrombotic complication had a metabolic liver disease.…”

In Vitro Evaluation of Pro- and Anticoagulant Drugs in Children with End-Stage Liver Disease Undergoing Liver Transplantation

“…Importantly, the risk of postoperative thrombotic complications after adult and pediatric LT is substantial, even in those patients receiving thromboprophylaxis with LMWH, suggesting that improvement of the thromboprophylactic regimen might be indicated. 1,17 The increase in in vitro efficacy of unfractionated heparin, dabigatran, and Cofact reflect the profoundly altered hemostatic environment in patients with severe liver disease, with altered plasma concentrations of pro-and anticoagulant drugs. Whether these differences are clinically relevant requires further study as the drugs that we tested may also have altered pharmacokinetics in patients with ESLD.…”

“…At present, there is a wide range of postoperative thromboprophylactic strategies employed in pediatric transplant centers, with unfractionated heparin, low molecular weight heparin (LMWH), and acetylsalicylic acid as most commonly used agents. 16,17 Yet, an evidence-based decision for the type of drug, dosing, and timing is lacking. Current anticoagulant therapy protocols are mainly based on experiences in pediatric cardiology or adult LT. 17,18 However, in addition to the hemostatic changes associated with liver disease, children have lower levels of hemostatic proteins compared with adults, as hemostasis is an evolving age-depending process with most maturation during childhood.…”

“…16,17 Yet, an evidence-based decision for the type of drug, dosing, and timing is lacking. Current anticoagulant therapy protocols are mainly based on experiences in pediatric cardiology or adult LT. 17,18 However, in addition to the hemostatic changes associated with liver disease, children have lower levels of hemostatic proteins compared with adults, as hemostasis is an evolving age-depending process with most maturation during childhood. 19,20 Due to the complex alterations in hemostasis of patients with ESLD, the efficacy of pro-and anticoagulant drugs are unpredictable.…”

Evidence for a rebalanced hemostatic system in pediatric liver transplantation: A prospective cohort study

“…Because postoperative thrombosis is one of the main challenges in contemporary pediatric liver transplantation, routine antithrombotic therapy is increasingly used. Most centers have included a form of antithrombotic therapy in their clinical practice, mostly using heparin and/or acetylsalicylic acid . Our clinical antithrombotic protocol includes continuous intravenous heparin posttransplantation, targeting an APTT of 50‐65 seconds, replaced by acetylsalicylic acid (19 mg, once daily) after 1 week.…”