Fibrinolysis Shutdown Is Associated With Thrombotic and Hemorrhagic Complications and Poorer Outcomes After Liver Transplantation

Abstract

Detrimental consequences of hypofibrinolysis, also known as fibrinolysis shutdown (FS), have recently arisen, and its significance in liver transplantation (LT) remains unknown. To fill this gap, this retrospective study included 166 adults who received transplants between 2016 and 2018 for whom baseline thromboelastography was available. On the basis of percent of clot lysis 30 minutes after maximal amplitude, patients were stratified into 3 fibrinolysis phenotypes: FS, physiologic fibrinolysis, and hyperfibrinolysis. FS occurred in 71.7% of recipients, followed by physiologic fibrinolysis in 19.9% and hyperfibrinolysis in 8.4%. Intraoperative and postoperative venous thrombosis events occurred exclusively in recipients with the FS phenotype. Intraoperative thrombosis occurred with an overall incidence of 4.8% and was associated with 25.0% in-hospital mortality. Incidence of postoperative venous thrombosis within the first month was deep venous thrombosis/pulmonary embolism (PE; 4.8%) and portal vein thrombosis/ hepatic vein thrombosis (1.8%). Massive transfusion of ≥20 units packed red blood cells was required in 11.8% of recipients with FS compared with none in the other 2 phenotype groups (P = 0.01). Multivariate analysis identified 2 pretransplant risk factors for FS: platelet count and nonalcoholic steatohepatitis/cryptogenic cirrhosis. Recursive partitioning identified a critical platelet cutoff value of 50 × 10 9 /L to be associated with FS phenotype. The hyperfibrinolysis phenotype was associated with the lowest 1-year survival (85.7%), followed by FS (95.0%) and physiologic fibrinolysis (97.0%). Infection/multisystem organ failure was the predominant cause of death; in the FS group, 1 patient died of exsanguination, and 1 patient died of massive intraoperative PE. In conclusion, there is a strong association between FS and thrombohemorrhagic complications and poorer outcomes after LT. Liver Transplantation 25 380-387 2019 AASLD.

Visceral arterial embolization prior to multivisceral transplantation in recipient with cirrhosis, extensive portomesenteric thrombosis, and hostile abdomen: Performance and outcome analysis

“…Figure displays our intra‐operative hemostatic algorithm. We routinely administer intravenous heparin thromboprophylaxis (30 units/kg) to all recipients of liver or visceral transplantation just prior to clamping of aorta and cava (MVT or heterotopic visceral allograft without liver), or aorta and portal system (orthotopic visceral allograft without liver) . We recently reported clinically meaningful reduction in incidence of intra‐operative cardiovascular thrombosis with this regimen; with no change in intra‐operative demand for blood products .…”

Susceptibility‐directed anticoagulation after pancreas transplantation: A single‐center retrospective study

“…In the absence of severe anemia or thrombocytopenia, prolonged Col/Epi assay alone suggests a mild intrinsic or aspirin‐induced platelet dysfunction, while prolongation of both assays suggests a significant intrinsic or potent antiaggregant‐induced (other than aspirin) platelet dysfunction . Based on LY30 (% clot lysis 30 minutes after maximal amplitude) on pre‐incisional TEG (Haemonetics ® ), patients were retrospectively stratified into three fibrinolysis phenotypes: fibrinolytic shutdown (LY30 0%‐0.80%), physiologic fibrinolysis (LY30 0.81%‐2.9%), and hyperfibrinolysis (LY30 > 3) …”

Risk Factors for Intracardiac Thrombus During Liver Transplantation

“…(4) Additionally, an association between fibrinolytic shutdown and perioperative thrombohemorrhagic complications was revealed. (4) Although 30 units/kg of heparin was previously (5) validated, we currently give prophylactic heparin to maintain a TEG R time ratio ≥5 during the anhepatic phase. Recognizing its prothrombotic proclivity, we are inclined to administer heparin during severe hypotensive hypoperfusion states.…”

“…With TEE being used in all cases, we recently reported a cardiovascular thrombosis incidence of 4.8% and a 25% rate of in-hospital mortality. (4) With intraoperative heparin prophylaxis, a 3-fold decrease in ICT was reported without an increase in packed red blood cell demand or postoperative hemorrhagic complications. (4) Additionally, an association between fibrinolytic shutdown and perioperative thrombohemorrhagic complications was revealed.…”

“…(4) With intraoperative heparin prophylaxis, a 3-fold decrease in ICT was reported without an increase in packed red blood cell demand or postoperative hemorrhagic complications. (4) Additionally, an association between fibrinolytic shutdown and perioperative thrombohemorrhagic complications was revealed. (4) Although 30 units/kg of heparin was previously (5) validated, we currently give prophylactic heparin to maintain a TEG R time ratio ≥5 during the anhepatic phase.…”