Review: The Perioperative Use of Thromboelastography for Liver Transplant Patients

Hawkins, Russell B.; Raymond, Steven L.; Hartjes, Tonja M.; Efron, Phillip A.; Larson, Shawn D.; Andreoni, Kenneth A.; Thomas, Elizabeth

doi:10.1016/j.transproceed.2018.07.032

Cited by 42 publications

(29 citation statements)

References 59 publications

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“…Therefore, INR has been suggested to be unsuitable to evaluate blood coagulation in patients with liver disease (5,7). However, unlike INR, thromboelastography (TEG) is a viscoelastic test that may be used to evaluate the hemostatic function of whole blood, from clot formation to thrombolysis, which is useful for investigating global hemostasis in patients with liver failure (8). TEG, which was first described by H. Hartert in 1948, has been widely used to monitor blood coagulation during liver transplantation (LT) (8,9).…”

Section: Introductionmentioning

confidence: 99%

“…However, unlike INR, thromboelastography (TEG) is a viscoelastic test that may be used to evaluate the hemostatic function of whole blood, from clot formation to thrombolysis, which is useful for investigating global hemostasis in patients with liver failure ( 8 ). TEG, which was first described by H. Hartert in 1948, has been widely used to monitor blood coagulation during liver transplantation (LT) ( 8 , 9 ). Previous studies have indicated that TEG was beneficial in reducing blood transfusion during invasive procedures in patients with liver disease ( 8-10 ), and predicting re-bleeding in patients with cirrhosis and variceal bleeding ( 5 ).…”

Section: Introductionmentioning

confidence: 99%

“…TEG, which was first described by H. Hartert in 1948, has been widely used to monitor blood coagulation during liver transplantation (LT) ( 8 , 9 ). Previous studies have indicated that TEG was beneficial in reducing blood transfusion during invasive procedures in patients with liver disease ( 8-10 ), and predicting re-bleeding in patients with cirrhosis and variceal bleeding ( 5 ).…”

Section: Introductionmentioning

confidence: 99%

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Thromboelastography maximum amplitude predicts short‑term mortality in patients with hepatitis B virus‑related acute‑on‑chronic liver failure

Zhu

Ke³

et al. 2020

Exp Ther Med

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Patients with hepatitis B virus (HBV)-related acute-on-chronic liver failure (ACLF) exhibit complex hemostatic defects. Thromboelastography (TEG) can be used to reveal global hemostasis in patients with liver disease; however, little is known about the association between TEG and the outcome of patients with HBV-related ACLF. The present study aimed to investigate the value of TEG for predicting 90 day mortality in patients with HBV-related ACLF. A total of 51 patients with HBV-related ACLF, 26 patients with chronic hepatitis B (CHB) and 26 healthy controls (HC) were enrolled in the present study. TEG, standard coagulation tests, routine blood tests, biochemical markers and demographic variables were recorded and assessed for prognostic value. The results indicated that a prolonged reaction and kinetics (K) time, a shortened α angle and a decreased maximum amplitude (MA) and coagulation index (CI) were observed in patients with HBV-related ACLF, compared with CHB and HC subjects. Patients with HBV-related ACLF in the mortality group exhibited a decrease in α angle, MA, lysis at 30 min, CI, fibrinogen and platelet count, and an increase in K time, international normalized ratio (INR) and the model for end-stage liver disease (MELD) score in comparison with the survival group. MA and INR were two independent predictors of 90 day mortality in patients with HBV-related ACLF, with hazard ratios of 0.918 (95% CI, 0.867-0.971; P=0.003) and 3.141 (95% CI, 1.843-5.354; P<0.001) respectively. When predicting 90 day mortality, MA + INR exhibited the highest area under the receiver operating characteristic curve, followed by INR, MELD score and MA. Patients with ACLF and MA ≤51.5 mm exhibited a poorer outcome than those with MA >51.5 mm, as revealed via the Kaplan-Meier analysis. In summary, the findings of the present study suggested that TEG MA was associated with 90 day mortality in patients with HBV-related ACLF, and a combination of MA and INR was superior to MA, INR and MELD score in terms of prognostic value.

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Thromboelastography maximum amplitude predicts short‑term mortality in patients with hepatitis B virus‑related acute‑on‑chronic liver failure

Zhu

Ke³

et al. 2020

Exp Ther Med

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“…Both end‐stage liver disease and ALF lead to simultaneously hyper‐ and hypo‐coagulable states, resulting in an increased risk for both thromboembolic and bleeding complications . Perioperatively, these severe coagulopathies can trigger frequent transfusions in order to prevent bleeding and pre‐transplant death . Protocols determining transfusion timing and blood product utilization have yet to be established.…”

Section: Introductionmentioning

confidence: 99%

Eliminating international normalized ratio threshold for transfusion in pediatric patients with acute liver failure

Lee

Mendoza

Brubaker

et al. 2020

Clinical Transplantation

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Introduction Transfusion protocols are not well‐studied for pediatric patients with acute liver failure (ALF). This study evaluates the utility of an international normalized ratio (INR)‐based transfusion threshold for these patients. Methods Forty‐four ALF pediatric patients from 2009 to 2018 were reviewed and divided into two groups: (a) a threshold group including patients between 2009 and 2015 who were transfused for an INR above 3.0, per institutional policy (n = 30), and (b) a post‐threshold group including patients after 2015 through 2018 who were transfused based on clinical judgment (n = 14). Preoperative INRs, preoperative transfusions, intraoperative transfusions, early reoperation, renal function, graft function and deaths were compared. Results Liver failure severity was similar between threshold and post‐threshold groups. Threshold patients had a lower average INR prior to transplantation, 2.8 (range 1.8‐3.8) vs 4.4 (range 2.1‐9.0), respectively (P = .01). Twenty‐six threshold patients (87%) received preoperative FFP compared with seven post‐threshold patients (50%, P = .0088). Two threshold patients (7%) received preoperative cryoprecipitate compared with five post‐threshold patients (36%, P = .014). The incidence of pre‐transplant bleeding, operative transfusions, and 1‐year patient and graft survival did not differ significantly. Conclusion Clinical judgment vs an INR‐based threshold for transfusions did not increase perioperative complications in children with ALF.

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“…36 Overall, there is an overwhelming amount of evidence to suggest that the hemostasis in ALF is complex and rebalanced ( Table 2, 11,[39][40][41][42] TEG and ROTEM have long been utilized in liver transplantation as its use reduces blood and fluid infusion volume during surgery. [43][44][45] In ALF, the parameters reflecting primary and secondary hemostasis are typically normal on TEG. Stravitz et al 11 conducted a prospective ancillary project to The Acute Liver Failure Study Group and performed TEG on 50 patients with ALI/ALF on admission.…”

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confidence: 99%

Clinical Considerations of Coagulopathy in Acute Liver Failure

Kim¹,

Niu²,

Woreta³

et al. 2020

Journal of Clinical and Translational Hepatology

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Acute liver failure (ALF) is the rapid onset of severe liver dysfunction, defined by the presence of hepatic encephalopathy and impaired synthetic function (international normalized ratio of $1.5) in the absence of underlying liver disease. The elevated international normalized ratio value in ALF is often misinterpreted as an increased hemorrhagic tendency, which can lead to inappropriate, prophylactic transfusions of blood products. However, global assessments of coagulopathy via viscoelastic tests or thrombin generation assay suggest a reestablished hemostatic, or even hypercoagulable, status in patients with ALF. Although the current versions of global assays are not perfect, they can provide more nuanced insights into the hemostatic system in ALF than the conventional measures of coagulopathy.

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Review: The Perioperative Use of Thromboelastography for Liver Transplant Patients

Cited by 42 publications

References 59 publications

Thromboelastography maximum amplitude predicts short‑term mortality in patients with hepatitis B virus‑related acute‑on‑chronic liver failure

Thromboelastography maximum amplitude predicts short‑term mortality in patients with hepatitis B virus‑related acute‑on‑chronic liver failure

Eliminating international normalized ratio threshold for transfusion in pediatric patients with acute liver failure

Clinical Considerations of Coagulopathy in Acute Liver Failure

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