Intraoperative Hypertension and Thrombocytopenia Associated With Intracranial Hemorrhage After Liver Transplantation

Abstract

Background. Intracranial hemorrhage (ICH) is a devastating complication. Although hypertension and thrombocytopenia are well-known risk factors for ICH in the general population, their roles in ICH after liver transplantation (LT) have not been well established. Methods. We performed a retrospective study and hypothesized that intraoperative hypertension and thrombocytopenia were associated with posttransplant ICH. New onset of spontaneous hemorrhage in the central nervous system within 30 days after LT were identified by reviewing radiologic reports and medical records. Risk factors were identified by multivariate logistic regression. Receiver operating characteristic analysis and Youden index were used to find the cutoff value with optimal sensitivity and specificity. Results. Of 1836 adult patients undergoing LT at University of California, Los Angeles, 36 (2.0%) developed ICH within 30 days after LT. Multivariate logistic regression demonstrated that intraoperative mean arterial pressure ≥105 mm Hg (≥10 min) (odds ratio, 6.5; 95% confidence interval, 2.7-7.7; P < 0.001) and platelet counts ≤30 × 109/L (odds ratio, 3.3; 95% confidence interval, 14-7.7; P = 0.006) were associated with increased risk of postoperative ICH. Preoperative total bilirubin ≥7 mg/dL was also a risk factor. Thirty-day mortality in ICH patients was 48.3%, significantly higher compared with the non-ICH group (3.0%; P < 0.001). Patients with all 3 risk factors had a 16% chance of developing ICH. Conclusions. In the current study, postoperative ICH was uncommon but associated with high mortality. Prolonged intraoperative hypertension and severe thrombocytopenia were associated with postoperative ICH. More studies are warranted to confirm our findings and develop a strategy to prevent this devastating posttransplant complication.

Low‐dose tissue plasminogen activator is safe and effective in treating major intracardiac thrombosis in liver transplant recipients

“…19 The dose of TPA used in a previous report, 20 mg total, was much higher than in our patients, and was thought to contribute to that patient's degree of neurologic injury. Although the incidence of ICH in our patients who received TPA for ICT was higher (27.3%) compared to the reported incidence in all LT (approximately 2%), 20 all ICH self-resolved, no patients died of ICH or required surgery for ICH, and no patients had residual neurologic deficits.…”

Risk factors prediction of 6-month mortality after noncardiac surgery of older patients in China: a multicentre retrospective cohort study

“…Some studies, such as the study conducted by Gao et al . 35 , have suggested that intraoperative hypertension increases mortality in certain types of surgery, whereas others, such as that of Shimada et al . 36 , have demonstrated that intraoperative hypertension may not be associated with myocardial injury and mortality.…”

Cerebral Diseases in Liver Transplant Recipients: Systematic Review of Clinical Evidence

“…The literature search provided insight into the incidence and risk stratification of ICH in patients after LT. The clinical characteristics of the patients, possible risk factors, and the relationship between arterial blood pressure and postoperative ICH in LT recipients were evaluated in three retrospective cohort studies that enrolled a total of 2506 patients [14][15][16]. These studies report consistent evidence on the incidence of postoperative ICH during the observational period, which ranged between 30 days to 12 months, with figures ranging from 2% to 6.5%.…”

“…Similarly, an increased intraoperative mean arterial pressure (MAP) ≥105 mmHg for 10 min or longer, a greater increase in pre-to posttransplant systolic blood pressure, a lower pretransplant serum fibrinogen level, and a higher pretransplant serum bilirubin level were associated with higher incidences of posttransplant ICH (Table 2) [14,15]. Patients with confirmed ICH had higher Model for End-Stage Liver Disease (MELD) scores and were more likely to have preoperative encephalopathy, be on vasopressors, be respirator-dependent, and have hemodialysis [14,15]. LT recipients seronegative for Epstein-Barr virus before LT had higher PCNSL incidence than seropositive recipients.…”