Is antivitamin K reversal required in patients with cirrhosis undergoing liver transplantation?

Abstract

Background Antivitamin K agent (AVK) reversal in patients with cirrhosis awaiting liver transplantation (LT) is not defined in guidelines. We investigated the effect of reversion with prothrombin complex concentrate (PCC) on intraoperative transfusion, bleeding, and safety in LT patients on AVK. Study design and methods In 511 patients undergoing LT, we identified 25 patients treated with AVK (AVK group) and 13 patients with incidental portal vein thrombosis (PVT) without AVK (incidental PVT group). Fifty patients who underwent LT without PVT or AVK matched by age, model for end stage of liver disease (MELD), body mass index (BMI), and cirrhosis etiology were selected as the control group. Results There were no significant differences between the three groups in intraoperative blood loss, transfusion, and postoperative bleeding. In the AVK group, there were no differences between patients who received PCC and those who did not in intraoperative blood loss, red blood cells, fibrinogen, and platelet transfusion, or postoperative bleeding. PCC use had no effect on RBC transfusion in patients who had international normalized ratio or clotting time above versus below median values of the two parameters at baseline (2.3 and 103 s, respectively). No thrombotic events were detected in patients who received PCC. Discussion These data suggest that systematic administration of PCC to revert AVK prior to LT should be reconsidered.

Efficacy and Safety of Prothrombin Complex Concentrates in Liver Transplantation: Evidence from Observational Studies

“…In the end, five publications were reviewed, four of which were included in the meta-analysis (see Figure 1). One study was excluded from the quantitative analysis because PCC was only administered in a sub-population of LT recipients to reverse anti-vitamin k agents prior to LT [34].…”

“…The mean age was 52.5 (standard deviation, SD: 9.87) years and the mean MELD score was 25.89 (SD: 9.83). Four-factor PCC (Beriplex ® /Kcentra ® , CSL Behring GmbH, Marburg, Germany) was administered in three studies [4,5,34], while two studies [6,7] did not report the type of PCC used. In all studies, viscoelastic tests guided perioperative coagulation management.…”

Coagulopathy and hemostasis management in patients undergoing liver transplantation

“…[ 59 ] Reversal of LMWH and VKAs have historically been required prior to major surgery; however, a recent study of patients undergoing LT found no difference in bleeding in patients on VKAs who received prothrombin complex concentrate (PCC) compared with those who did not, implying reversal may not be necessary. [ 60 ]…”

Deceased donor liver transplantation in patients on direct oral anticoagulants at the time of transplant surgery

“…[7,8] This is in line with a larger report that found no difference in intraoperative blood loss or transfusions in patients that were on vitamin K antagonists and given either prothrombin complex concentrate (PCC) or no reversal at the time of liver transplantation. [9] Conversely, Intagliata et al describe switching a patient from apixaban to dabigatran prior to liver transplantation to facilitate reversal prior to surgery with idarucizumab without any blood transfusions given during the operation or new thrombosis. [10] To address this issue, we reviewed management and outcomes of four patients who underwent DDLT who presented for transplant on either apixaban or rivaroxaban.…”