Coagulation During and After Orthotopic Transplantation of the Human Liver

Groth, Carl G.; Pechet, Liberto; Starzl, Thomas E.

doi:10.1001/archsurg.1969.01340070049006

Cited by 80 publications

(49 citation statements)

References 7 publications

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“…Third, other investigators stressed disseminated intravascular coagulation (DIC) as a major cause of the change (2,5), but there is little evidence of DIC in this study. Groth et al suggested that loss of hepatic clearance function played a role in fibrinolytic activation or that antigen-antibody reaction might lead to DIC (2). However, the lack of high levels of circulating fibrin monomers and FDP found in this study does not support a major role for DIC as a cause of excessive bleeding.…”

Section: Discussioncontrasting

confidence: 83%

Intraoperative Changes in Blood Coagulation and Thrombelastographic Monitoring in Liver Transplantation

Kang

Martin

Marquez

et al. 1985

Anesthesia & Analgesia

630

432

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The blood coagulation system of 66 consecutive patients undergoing consecutive liver transplantations was monitored by thrombelastograph and analytic coagulation profile. A poor preoperative coagulation state, decrease in levels of coagulation factors, progressive fibrinolysis, and whole blood clot lysis were observed during the preanhepatic and anhepatic stages of surgery. A further general decrease in coagulation factors and platelets, activation of fibrinolysis, and abrupt decrease in levels of factors V and VIII occurred before and with reperfusion of the homograft. Recovery of blood coagulability began 30-60 min after reperfusion of the graft liver, and coagulability had returned toward baseline values 2 hr after reperfusion. A positive correlation was shown between the variables of thrombelastography and those of the coagulation profile. Thrombelastography was shown to be a reliable and rapid monitoring system. Its use was associated with a 33% reduction of blood and fluid infusion volume, whereas blood coagulability was maintained without an increase in the number of blood product donors. Keywords BLOOD-coagulation; LIVER-transplantationLiver transplantation, which began as highly experimental surgery 20 yr ago, is now recognized as a major means of therapy for patients with end-stage liver disease (1). However, massive blood loss during liver transplantation is still a major concern. The liver produces most of the blood coagulation factors, so it is not surprising that we see very low levels of these factors and prolonged prothrombin time (PT) and activated partial thromboplastin time (aPTT) in many patients receiving liver transplants (2). Frequently we have seen thrombocytopenia, which may result from gastrointestinal bleeding, splenomegaly, or malnutrition (3). At the same time, numerous collateral channels and portal hypertension, together with increased capillary fragility, make maintenance of surgical hemostasis very difficult.Previous studies on the blood coagulation system in humans and in animals undergoing liver transplantation have demonstrated dilutional coagulopathy associated with massive blood transfusion, decreased fibrinogen levels, and thrombocytopenia (4,5). Fibrinolysis, beginning during the anhepatic stage of surgery and becoming "explosive" on reperfusion of the homograft, has been reported (6). A consumption coagulopathy accompanied by an increased level of fibrin degradation products appeared to play a major role (7). However, these observations were limited to a few patients in the early era of liver transplantation, and comprehensive information is still lacking.Another difficulty in the intraoperative management of liver transplantation has been actively monitoring the coagulation system and determining the appropriate treatment during dynamic blood volume changes. The use of the thrombelastograph (TEG) was suggested by von Kaulla et al. (4) and Howland et al. (8). However, the efficacy of thrombelastographic monitoring of blood coagulation during liver transplantatio...

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Section: Discussioncontrasting

confidence: 83%

Intraoperative Changes in Blood Coagulation and Thrombelastographic Monitoring in Liver Transplantation

Kang

Martin

Marquez

et al. 1985

Anesthesia & Analgesia

630

432

View full text Add to dashboard Cite

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“…20 Furthermore, our results suggest that the decline in coagulation factor levels (V, VII, IX, and X) in discordant xenografting are similar to those seen in the early reperfusion period of hepatic allotransplantation. [21][22][23] The most striking findings regarding hemorrhage in discordant hepatic xenotransplantation pertain to platelets. Platelets are activated and then sequestered within an xenografted kidney or heart, forming microthrombi that are a hallmark of hyperacute rejection.…”

Section: Discussionmentioning

confidence: 99%

Aberrations in hemostasis and coagulation in untreated discordant hepatic xenotransplantation: Studies in the dog-to-pig model

Tector

Fridell

Elias

et al. 2002

Liver Transplantation

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Discordant liver xenotransplantation is a poorly explored entity. Data from the few large animal studies of hepatic xenotransplantation suggest that severe hemorrhage is encountered. The purpose of the studies described here is to characterize the nature of the hemorrhage that accompanies liver xenotransplantation. Canine livers were transplanted into porcine recipients, and lethal hemorrhage was encountered. Analysis of recipient blood showed that factors V, IX, and X were present in adequate levels until after the hemorrhage appeared, suggesting that coagulation factor loss was the result and not the cause of hemorrhage. Platelet counts decreased dramatically in recipients within minutes of graft reperfusion. There also was no evidence of clotting activity in the blood of recipients of liver xenografts within minutes of graft reperfusion. This loss of clotting activity was specific to liver xenografts, was not seen in renal xenografts with or without venovenous bypass, and also was absent in pig-to-pig liver allografts. In brief, the hemorrhage that accompanies liver xenotransplantation occurs because of a decrease in the number and function of circulating platelets in the recipient.

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“…Previous investigations of coagulation during canine and/or human liver transplantation and in human liver disease have been alternatively interpreted to show strong evidence for activation of fibrinolysis (7,8), for disseminated intravascular coagulation (DIC) (9-12) or for both (13). DIC (14) causes consumption of multiple coagulation factors, antithrombin III and platelets and the appearance of high levels of fibrin monomers, fibrin split products and microthrombi (7).…”

Section: Discussionmentioning

confidence: 99%

Liver transplantation: Intraoperative changes in coagulation factors in 100 first transplants

et al. 1989

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Six intraoperative blood samples were obtained at intervals from each of 100 individuals undergoing their first liver transplants. The patients fell into the following diagnostic categories: postnecrotic cirrhosis 28, primary biliary cirrhosis 20, sclerosing cholangitis 19, miscellaneous diseases 14, carcinoma/neoplasia 12 and fulminant hepatitis 7. Coagulation factor values in the initial (baseline) blood samples varied by patient diagnosis. In general, all factor levels were reduced except factor VIII:C, which was increased to almost twice normal. The slight intraoperative changes in factors II, VII, IX, X, XI and XII suggested that a steady-state relationship existed between depletion (consumption/bleeding) and repletion (transfusion, transit from extra-to intravascular space), even in the anhepatic state. In contrast, there were rapid and very significant falls in factor VIII and fibrinogen and a less pronounced decrease in factor V, all reaching their nadirs in early to mid-Stage III. The cause of these coagulation changes appears to be activation of the fibrinolytic system. Liver transplantation has been used to treat end-stage liver disease caused by a wide variety of congenital or acquired disorders. Improved methods for procurement and preservation of the donor livers, innovative surgical techniques and improved immunosuppressive agents have made liver transplantation feasible for many patients with severely damaged liver parenchyma, vasculature or bile ducts. However, one of the major difficulties has been the need for multiple blood transfusions, which reflects the large loss of blood during the operation. This study deals with intraoperative changes in coagulation parameters and the quantities of red blood cells (RBC) transfused. MATERIALS AND METHODS PatientsDuring an approximate 2-year period, intraoperative coagulation studies were carried out on 100 adult individuals undergoing their first liver transplants. All of these transplants were done with an axillofemoral venous bypass using tubing with a heparinized surface (ARGYLE ® tubing) which shunted the major blood flow away from the operative area. No patient received systemic heparin. All patients were transfused with a premixed "cocktail" of equal volumes (250 ml) of RBC, fresh-frozen plasma and Plasmalyte A ® , which contained 526 mg per 100 ml sodium chloride, 502 mg per 100 ml sodium gluconate, 368 mg per 100 ml sodium acetate trihydrate, 37 mg per 100 ml potassium chloride, 30 mg per 100 ml Copyright © 1989 The patients were categorized by pathological diagnosis as previously described (2). An additional diagnostic group, fulminant hepatitis, was included. The 100 patients fell into the six diagnostic groups shown in Table 1. The largest group comprised 28 patients with postnecrotic cirrhosis (PNC) and included patients with chronic active hepatitis, lupoid hepatitis or cryptogenic cirrhosis. The second largest group contained 20 female patients with primary biliary cirrhosis (PBC). An additional 19 patients had primary sclerosing...

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Coagulation During and After Orthotopic Transplantation of the Human Liver

Cited by 80 publications

References 7 publications

Intraoperative Changes in Blood Coagulation and Thrombelastographic Monitoring in Liver Transplantation

Intraoperative Changes in Blood Coagulation and Thrombelastographic Monitoring in Liver Transplantation

Aberrations in hemostasis and coagulation in untreated discordant hepatic xenotransplantation: Studies in the dog-to-pig model

Liver transplantation: Intraoperative changes in coagulation factors in 100 first transplants

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