Thromboelastographic reference ranges for a cirrhotic patient population undergoing liver transplantation

Abstract

AIMTo describe the thromboelastography (TEG) “reference” values within a population of liver transplant (LT) candidates that underline the differences from healthy patients.METHODSBetween 2000 and 2013, 261 liver transplant patients with a model for end-stage liver disease (MELD) score between 15 and 40 were studied. In particular the adult patients (aged 18-70 years) underwent to a first LT with a MELD score between 15 and 40 were included, while all patients with acute liver failure, congenital bleeding disorders, and anticoagulant and/or antiplatelet drug use were excluded. In this population of cirrhotic patients, preoperative haematological and coagulation laboratory tests were collected, and the pretransplant thromboelastographic parameters were studied and compared with the parameters measured in a previously studied population of 40 healthy subjects. The basal TEG parameters analysed in the cirrhotic population of liver candidates were as follows: Reaction time (r), coagulation time (k), Angle-Rate of polymerization of clot (α Angle), Maximum strenght of clot (MA), Amplitudes of the TEG tracing at 30 min and 60 min after MA is measured (A30 and A60), and Fibrinolysis at 30 and 60 min after MA (Ly30 and Ly60). The possible correlation between the distribution of the reference range and the gender, age, MELD score (higher or lower than 20) and indications for transplantation (liver pathology) were also investigated. In particular, a MELD cut-off value of 20 was chosen to verify the possible correlation between the thromboelastographic reference range and MELD score.RESULTSMost of the TEG reference values from patients with end-stage liver disease were significantly different from those measured in the healthy population and were outside the suggested normal ranges in up to 79.3% of subjects. Wide differences were found among all TEG variables, including r (41.5% of the values), k (48.6%), α (43.7%), MA (79.3%), A30 (74.4%) and A60 (80.9%), indicating a prevailing trend to hypocoagulability. The differences between the mean TEG values obtained from healthy subjects and the cirrhotic population were statistically significant for r (P = 0.039), k (P < 0.001), MA (P < 0.001), A30 (P < 0.001), A60 (P < 0.001) and Ly60 (P = 0.038), indicating slower and less stable clot formation in the cirrhotic patients. In the cirrhotic population, 9.5% of patients had an r value shorter than normal, indicating a tendency for faster clot formation. Within the cirrhotic patient population, gender, age and the presence of hepatocellular carcinoma or alcoholic cirrhosis were not significantly associated with greater clot firmness or enhanced whole blood clot formation, whereas greater clot strength was associated with a MELD score < 20, hepatitis C virus and cholestatic-related cirrhosis (P < 0.001; P = 0.013; P < 0.001).CONCLUSIONThe range and distribution of TEG values in cirrhotic patients differ from those of healthy subjects, suggesting that a specific thromboelastographic reference range is required for liver transplant can...

Balanced blood product transfusion during liver transplantation

“…Our results may seem contrary to prior studies that have demonstrated a stepwise increase in 90-day mortality with each additional transfused unit of platelets in patients receiving on average 7 units 34,37 We hypothesize that high MELD patients undergoing significant blood loss experience hypocoaguloability and decreased clot strength predominantly, and thus, the prevalence of hypercoagulability in our population may be lower than that reported in the literature. Thus, until the appropriate reference ranges and clinical end-points of viscoelastic testing are further studied and standardized in OLT, BBPT remains an important tool to treat hemorrhage in the OLT recipient.…”

“…Studies have demonstrated 6%‐9% of cirrhotic patients undergoing OLT have decreased R time and up to 15% of patients have increased clot strength. However, these studies were performed in low MELD populations (mean MELDs of 24 and 15, respectively) compared to the mean MELD of 35 in our population . We hypothesize that high MELD patients undergoing significant blood loss experience hypocoaguloability and decreased clot strength predominantly, and thus, the prevalence of hypercoagulability in our population may be lower than that reported in the literature.…”

“…Thromboelastography results were variable across MELD and underlying disease. Higher MELD was associated with decreased clot strength . Other studies estimate that 27% of patients will have a “flat line” thromboelastography after reperfusion .…”

“…While conventional coagulation testing was used to determine the need for transfusion in our study, viscoelastic testing has gained popularity as a method of directing and decreasing transfusion during OLT . However, there is a lack of consensus on what thromboelastography values need to be corrected to what end‐points given the unique coagulation profile of cirrhotic patients . Moreover, thromboelastography has yet to be associated with a definitive mortality benefit in OLT.…”

Thromboelastography‐Guided Blood Component Use in Patients With Cirrhosis With Nonvariceal Bleeding: A Randomized Controlled Trial

“…TEG is a point‐of‐care, global hemostasis assessment device that measures the viscoelastic changes that occur during the hemostatic process, providing real‐time reports. TEG is often normal in patients with compensated cirrhosis and can display hypocoagulable features in patients with advanced cirrhosis …”