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

Abstract

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...

Orthotopic liver transplantation with preservation of portocaval flow compared with venovenous bypass

“…20 Similarly, hyperfibrinolysis caused by an imbalance between activators (tPA) and inhibitors (PAI), which tends to develop during the anhepatic phase, occurred in both groups, as shown by the dramatic shortening of euglobulin lysis time. The increase in aPTT at revascularization has been analyzed previously 21,22 and attributed to hyperfibrinolysis, disseminated intravascular coagulation, dilution, and metabolic disorders.…”

Requirements for transfusion and postoperative outcomes in orthotopic liver transplantation: A meta-analysis on aprotinin

“…However, despite great improvements in graft preservation, surgical skills, anesthetic techniques and perioperative management [2,3] , OLT is still associated with severe bleeding and considerable transfusion requirements, which in turn greatly contribute to the peri-operative morbidity and mortality [4] . Severe bleeding in OLT occurs for several reasons, among which hemostatic abnormalities remain a major cause [5,6] . Aprotinin, a serine protease inhibitor, is more and more commonly being used in surgeries, such as cardiac surgeries and liver transplantations, to reduce bleeding and the need for transfusions.…”

Coagulation profiles and intraoperative substitution requirements during elective piggyback liver transplantation with prophylactic antifibrinolytic therapy

“…In contrary fashion, if coagulation components are deliberately substituted, aPTT prolongation is seldom found at the end of surgery, as it was demonstrated in standard OLT [l, 14,18,191.…”

“…The underlying liver disease with impaired liver function coincides with a deficient hepatic synthesis of coagulation factors and their inhibitors [ 12, 231. As a result, abnormal preoperative levels of procoagulants and coagulation factors (I, 11, V, VII, IX-XIII) [2,11,14,18,19,221, inhibitors (AT-I11 and alpha-2-antiplasmin) [l, 26, 271 and regulatory proteins (C1 inhibitor and prekallikrein) [7, 271 are frequently observed. In addition, portal hypertension, peripheral vasodilatation, and thrombocytopenia are frequently found in states of liver cirrhosis [12,231.…”