Perioperative Thromboelastometry for Adult Living Donor Liver Transplant Recipients with a Tendency to Hypercoagulability: A Prospective Observational Cohort Study

Abstract

Background: Hypercoagulability can lead to serious thromboembolic events. The aim of this study was to assess the perioperative coagulation status in liver transplant recipients with a tendency to hypercoagulability. Methods: In a prospective observational study (South African Cochrane Registry 201405000814129), 151 potential liver transplant recipients were screened for thrombophilic factors from October 2014 to June 2017, and 57 potential recipients fulfilled the inclusion criterion of presenting two or more of the following thrombophilic factors: low protein C, low protein S, low anti-thrombin, increased homocystein, increased antiphospholipid IgG/IgM antibodies, increased lupus anticoagulant, and positive Factor V Leiden mutation. Seven patients were excluded from the study because they fulfilled the exclusion criteria of cancelling the liver transplantation, oral anticoagulation, or intraoperative treatment with rFVIIa. Accordingly, 50 patients were included in the final analysis. Thromboelastometry (ROTEM) (EXTEM, INTEM and FIBTEM) and conventional coagulation tests (CCT) were performed preoperatively, during the anhepatic phase, post reperfusion, and on postoperative days (POD) 1, 3 and 7. ROTEM was used to guide blood product transfusion. Heparin was infused (60-180 U/kg/day) postoperatively for 3 days and then was replaced by low-molecular-weight heparin (20 mg/12 h). Results: FIBTEM MCF significantly increased postoperatively above reference range on POD 7 despite normal fibrinogen plasma concentrations (p < 0.05). Both EXTEM and INTEM demonstrated significant changes with the phases of transplantation (p < 0.05), but with no intra- or postoperative hypercoagulability observed. INTEM CT (reference range, 100-240 s) normalized on POD 3 and 7 (196.1 ± 69.0 and 182.7 ± 63.8 s, respectively), despite prolonged aPTT (59.7 ± 18.7 and 46.4 ± 15.7 s, respectively; reference range, 20-40 s). Hepatic artery thrombosis (HAT) and portal vein thrombosis (PVT) were reported in 12.0% and 2.0%, respectively, mainly after critical care discharge and with high FIBTEM MCF values in 57% on POD 3 and 86% on POD 7. Receiver operating characteristics curve analyses of FIBTEM MCF were significant predictors for thromboembolic events with optimum cut-off, area under the curve and standard error on POD 3 (>23 mm, 0.779 and 0.097; p = 0.004) and POD 7 (>28 mm, 0.706 and 0.089; p = 0.020). Red blood cells (mean ± SD, 8.68 ± 5.81 units) were transfused in 76%, fresh frozen plasma (8.26 ± 4.14 units) in 62%, and cryoprecipitate (12.0 ± 3.68 units) in 28% of recipients. None of the recipients received intraoperative platelet transfusion or any postoperative transfusion. Main transplant indication was hepatitis C infection in 82%. 76% of recipients included in this highly selected patient population showed increased lupus anticoagulant, 2% increased antiphospholipid IgG/IgM antibodies, 20% increased homocysteine, 74% decreased anti-thrombin, 78% decreased protein C, 34% decreased protein S, and 24% a positive Factor V Leiden mutation....

Hemostasis in Coronavirus Disease 2019—Lesson from Viscoelastic Methods: A Systematic Review

“…Both these parameters reflect the strength of the blood clot and depend on platelet count and function and the integrity of the fibrin network (fibrin levels and polymerization, factor XIII). 41,45 High MA and MCF values have been strongly associated with an increased risk of thromboembolic complications in hospitalized patients [46][47][48][49] ; however, these data are derived from non-COVID-19 studies. A clinical consequence of hypercoagulability in severely ill COVID-19 patients may be the frequent occurrence of venous and arterial thrombotic events.…”

The role of evidence-based algorithms for rotational thromboelastometry-guided bleeding management

“…tibodies) and patients with hepatocellular or cholangiocellular carcinoma [138][139][140][141]. Again, this emphasizes the need for a correct dose-adjustment and that overtreatment-also with fibrinogen-should strictly be avoided.…”

The role of rotational thromboelastometry during the COVID-19 pandemic: a narrative review

“…Several studies prior to the COVID-19 pandemic demonstrated that an EXTEM or INTEM MCF of > 68 mm (A10 > 61.5 mm) is a strong indicator of hypercoagulability and predictor of thrombosis [ 17 , 18 ]. A FIBTEM MCF value of > 25 mm is associated with a five-fold increased risk of developing thrombosis in cirrhotic patients with hepatocellular carcinoma [ 19 , 20 ]. Hypercoagulability in COVID-19 patients was assessed by rotational thromboelastometry, which is used as a diagnostic tool [ 21 , 22 ].…”