Methods to decrease blood loss and transfusion requirements for liver transplantation

Gurusamy, Kurinchi Selvan; Pissanou, Theodora; Pikhart, Hynek; Vaughan, J. G.; Burroughs, Andrew K.; Davidson, Brian R

doi:10.1002/14651858.cd009052.pub2

Cited by 63 publications

(41 citation statements)

References 116 publications

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“…However, after review of the final results of the trial and all available data related to the safety of aprotinin, in 2012 the European Medicines Agency recommended that this suspension should be lifted, which was accepted by European Commission in 2013. The available data does not show that in LT recipients the use of aprotinin is associated with an increase in the rate of hepatic artery thrombosis, venous thromboembolism or mortality compared to a placebo [33,47]. Interestingly, a recently published retrospective analysis of patients routinely treated with aprotinin during LT compared to the period post aprotinin withdrawal, did not reveal any increase in the amount of RBCs, FFP, platelet concentrates and cryoprecipitate transfusion since the withdrawal of aprotinin [48].…”

Section: Antifibrinolytic Drugsmentioning

confidence: 97%

“…Unfortunately, the vast majority of the evidence comes from single center studies, with significant heterogeneity amongst the analyzed populations, as well as a variety of transfusion protocols and practices. Therefore, it yields rather low quality evidence, even if the data are pooled for meta-analyses [33]. Amongst specific actions to minimize perioperative blood loss and transfusion requirements during LT, we can distinguish nonpharmacological and pharmacological interventions.…”

Section: Management Of Perioperative Bleedingmentioning

confidence: 99%

Section: Antifibrinolytic Drugsmentioning

confidence: 99%

“…However, as stated by the authors, due to lack of large, double-blinded, multicenter trials and high risk of bias, the quality of the evidence is considered relatively low [33]. It was demonstrated that aprotinin was the only antifibirinolytic agent to significantly reduce the requirements for RBCs, FFP, platelets and cryoprecipitate compared to a placebo [33]. Further trials comparing high with medium and low doses of aprotinin, as well as the mode of administration (bolus vs continuous infusion) have not revealed any differences in the perioperative blood loss and transfusion requirements.…”

Section: Antifibrinolytic Drugsmentioning

confidence: 99%

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Perioperative bleeding in patients undergoing liver transplantation

Starczewska

Giercuszkiewicz²,

Niewiński³

et al. 2016

Anaesthesiol Intensive Ther

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Liver transplantation (LT) remains one of the most challenging surgical procedures. For many years uncontrolled bleeding and catastrophic haemorrhages were one of the major causes of perioperative mortality and morbidity. During the past fifty years, significant progress in surgical technique and perioperative management has led to a marked change in transfusion practice over time, where up to 79.6% of LTs in experienced transplant centers are performed without any blood product transfusion. Despite this, perioperative bleeding and transfusion requirements remain potent predictors of patient's mortality, as well as postoperative complications and graft survival. The major impact of blood product transfusion on LT recipients outcomes implies that all patients on waiting lists should be carefully screened for the presence of risk factors of perioperative bleeding. Although multiple predictors of transfusion requirements during recipients have been identified, no predictive model validated across centers has been constructed. The most suitable strategies to reduce intraoperative blood loss in this group should be employed on a case-to-case basis. This paper aims to summarize the most up-to-date evidence in the management of haemostasis in LT recipients.Key words: liver transplantation, perioperative management, haemostasis, bleeding Anaesthesiology Intensive Therapy 2016, vol. 48, no 1, 34-40 Liver transplantation (LT) remains one of the most challenging surgical technique. For many years, uncontrolled bleeding and catastrophic haemorrhages were one of the major causes of perioperative mortality and morbidity. During more than the fifty years of experience gained since the first LT was performed by Thomas Starzl in 1963, an improvement in surgical techniques and anaesthetic management has led to a marked change in transfusion practices over time. A recently published retrospective analysis of data from the Mayo Clinic in Rochester has shown that over the last two decades there has been a significant decrease in the amount of perioperatively transfused red blood cells (RBCs), fresh frozen plasma (FFP), platelets, cryoprecipitate and intraoperative autotransfusions [1]. Interestingly, this was noted despite the fact that transfusion triggers remained the same over time [1]. Massicotte et al. [2] reported that currently up to 79.6% of LTs are performed without any blood product transfusion. The major impact of blood product transfusion on LT recipient outcomes implies that all patients on waiting lists should be carefully screened for the presence of risk factors of perioperative bleeding. The most suitable strategies to reduce intraoperative blood loss in this group should be employed on a case-to-case basis. This paper aims to summarize the most up-to-date evidence in management of haemostasis in LT recipients. HAEMOSTATIC ALTERATIONS IN LIVER TRANSPLANT RECIPIENTSThe change in transfusion practices was possible due to a better understanding of alterations in the haemostatic system in LT recipients. The l...

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Section: Antifibrinolytic Drugsmentioning

confidence: 97%

Section: Management Of Perioperative Bleedingmentioning

confidence: 99%

Section: Antifibrinolytic Drugsmentioning

confidence: 99%

Section: Antifibrinolytic Drugsmentioning

confidence: 99%

See 2 more Smart Citations

Perioperative bleeding in patients undergoing liver transplantation

Starczewska

Giercuszkiewicz²,

Niewiński³

et al. 2016

Anaesthesiol Intensive Ther

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“…Similar results were found by Ickx et al [103] (n = 51), with the additional finding of inhibition of fibrinolysis by both TXA and aprotinin vs a control. Gurusamy et al [104] addressed different strategies of decreasing blood loss in OLT in their Cochrane review. Although with respect to aprotinin and TXA, they concluded that the clinical trials had been biased, there were no differences in 60-day mortality rates, re-transplantation risk or thromboembolic events in the TXA group vs the control and no difference between aprotinin and TXA in mortality or thromboembolism risk.…”

Section: Hepatic Surgerymentioning

confidence: 99%

Tranexamic acid: a clinical review

Jerath

Wąsowicz

2015

Anaesthesiol Intensive Ther

234

151

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Blood loss and subsequent transfusions are associated with major morbidity and mortality. The use of antifibrinolytics can reduce blood loss in cardiac surgery, trauma, orthopedic surgery, liver surgery and solid organ transplantation, obstetrics and gynecology, neurosurgery and non-surgical diseases. The evidence of their efficacy has been mounting for years. Tranexamic acid (TXA), a synthetic lysine-analogue antifibrinolytic, was first patented in 1957 and its use has been increasing in contrast to aprotinin, a serine protease inhibitor antifibrinolytic. This review aims to help acute care physicians navigate through the clinical evidence available for TXA therapy, develop appropriate dose regimens whilst minimizing harm, as well as understand its broadening scope of applications. Many questions remain unanswered regarding other clinical effects of TXA such as anti-inflammatory response to cardiopulmonary bypass, the risk of thromboembolic events, adverse neurological effects such as seizures, and its morbidity and mortality, all of which necessitate further clinical trials on its usage and safety in various clinical settings.

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Antifibrinolytics (lysine analogues) for the prevention of bleeding in people with haematological disorders

Estcourt

Desborough

Brunskill

et al. 2016

Cochrane Database of Systematic Reviews

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Background People with haematological disorders are frequently at risk of severe or life-threatening bleeding as a result of thrombocytopenia (reduced platelet count). This is despite the routine use of prophylactic platelet transfusions to prevent bleeding once the platelet count falls below a certain threshold. Platelet transfusions are not without risk and adverse events may be life-threatening. A possible adjunct to prophylactic platelet transfusions is the use of antifibrinolytics, specifically the lysine analogues tranexamic acid (TXA) and epsilon aminocaproic acid (EACA). This is an update of a Cochrane review first published in 2013. Objectives To determine the efficacy and safety of antifibrinolytics (lysine analogues) in preventing bleeding in people with haematological disorders. Search methods We searched for randomised controlled trials (RCTs) in the Cochrane Central Register of Controlled Trials (The Cochrane Library 2016, Issue 3), MEDLINE (from 1946), Embase (from 1974), CINAHL (from 1937), the Transfusion Evidence Library (from 1950) and ongoing trial databases to 07 March 2016. Selection criteria We included RCTs involving participants with haematological disorders, who would routinely require prophylactic platelet transfusions to prevent bleeding. We only included trials involving the use of the lysine analogues TXA and EACA. Data collection and analysis Two review authors independently screened all electronically-derived citations and abstracts of papers, identified by the review search strategy, for relevancy. Two review authors independently assessed the full text of all potentially relevant trials for eligibility, completed the data extraction and assessed the studies for risk of bias using The Cochrane Collaboration’s ‘Risk of bias’ tool. We requested missing data from one author but the data were no longer available. The outcomes are reported narratively: we performed no meta-analyses because of the heterogeneity of the available data. Main results We identified three new studies in this update of the review. In total seven studies were eligible for inclusion, three were ongoing RCTs and four were completed studies. The four completed studies were included in the original review and the three ongoing studies were included in this update. We did not identify any RCTs that compared TXA with EACA. Of the four completed studies, one cross-over TXA study (eight participants) was excluded from the outcome analysis because it had very flawed study methodology. Data from the other three studies were all at unclear risk of bias due to lack of reporting of study methodology. Three studies (two TXA (12 to 56 participants), one EACA (18 participants) reported in four articles (published 1983 to 1995) were included in the narrative review. All three studies compared the drug with placebo. All three studies included adults with acute leukaemia receiving chemotherapy. One study (12 participants) only included participants with acute promyelocytic leukaemia. None of the studies included child...

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Methods to decrease blood loss and transfusion requirements for liver transplantation

Cited by 63 publications

References 116 publications

Perioperative bleeding in patients undergoing liver transplantation

Perioperative bleeding in patients undergoing liver transplantation

Tranexamic acid: a clinical review

Antifibrinolytics (lysine analogues) for the prevention of bleeding in people with haematological disorders

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