The role of thromboelastometry in the assessment and treatment of coagulopathy in liver transplant patients

ABSTRACT Perioperative monitoring of coagulation is vital to assess bleeding risks, diagnose deficiencies associated with hemorrhage, and guide hemostatic therapy in major surgical procedures, such as liver transplantation. Routine static tests demand long turnaround time and do not assess platelet function; they are determined on plasma at a standard temperature of 37°C; hence these tests are ill-suited for intraoperative use. In contrast, methods which evaluate the viscoelastic properties of whole blood, such as thromboelastogram and rotational thromboelastometry, provide rapid qualitative coagulation assessment and appropriate guidance for transfusion therapy. These are promising tools for the assessment and treatment of hyper- and hypocoagulable states associated with bleeding in liver transplantation. When combined with traditional tests and objective assessment of the surgical field, this information provides ideal guidance for transfusion strategies, with potential improvement of patient outcomes.

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Viscoelastic coagulation test for liver transplantation

Anesthesia and Pain Medicine ◽

10.17085/apm.2020.15.2.143 ◽

2020 ◽

Vol 15 (2) ◽

pp. 143-151

Author(s):

Sun Young Park

Keyword(s):

Liver Transplantation ◽

Management Strategy ◽

Point Of Care ◽

Turnaround Time ◽

Coagulation Test ◽

Blood Management ◽

Coagulation Tests ◽

Perioperative Monitoring ◽

Plasmatic Coagulation ◽

Hemostatic Therapy

Coagulation and transfusion management in patients undergoing liver transplantation is challenging. Proper perioperative monitoring of hemostasis is essential to predict the risk of bleeding during surgery, to detect potential causes of hemorrhage in time, and to guide hemostatic therapy. The value of conventional coagulation test is questionable in the acute perioperative setting due to their long turnaround time and the inability to adequately reflect the complex changes in hemostasis in patients with liver disease. Viscoelastic coagulation tests provide simultaneous measurement of multiple aspects of whole-blood coagulation including plasmatic coagulation and fibrinolytic factors and inhibitors that reflect most aspects of hemostasis. Coagulation initiation, mechanical clot stability, and fibrinolysis can be estimated immediately using point-of-care techniques. Therefore, viscoelastic coagulation tests including ROTEM & TEG would be useful to guide patient blood management strategy during liver transplantation.

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Usage of 25% albumin solution in the intraoperative and early postoperative periods of liver transplantation from a cadaveric donor.

Тромбоз, гемостаз и реология ◽

10.25555/thr.2021.4.1000 ◽

2021 ◽

Author(s):

С.В. Журавель ◽

Н.К. Кузнецова ◽

В.Э. Александрова ◽

П.В. Гаврилов ◽

А.М. Талызин ◽

...

Keyword(s):

Liver Transplantation ◽

Postoperative Period ◽

Human Albumin ◽

Early Postoperative Period ◽

Hemodynamic Parameters ◽

Albumin Solution ◽

Transfusion Therapy ◽

Group 2 ◽

Human Albumin Solution ◽

Group 1

Введение. Терапевтическое использование раствора человеческого альбумина у пациентов в периоперационном периоде трансплантации печени (ТП) представляет интерес в контексте осложнений и исходов операции. Цель исследования: оценить влияние интраоперационной трансфузии 25% раствора человеческого альбумина на течение раннего послеоперационного периода при ортотопической ТП от посмертного донора. Материалы и методы. В исследование включены 47 пациентов, которым была выполнена трупная ТП. Были сформированы 2 группы: пациенты группы 1 (n = 21) получали трансфузию 25% раствора человеческого альбумина в конце операции ТП и через 24 ч после операции; пациенты группы 2 (n = 26) получали трансфузию 25% раствора человеческого альбумина в первые сутки послеоперационного периода. Осуществляли контроль лабораторных параметров крови пациента перед началом оперативного вмешательства, через 24 ч и через 48 ч после операции. Интраоперационно оценивали значения систолического (САД) и диастолического (ДАД) артериального давления, частоту сердечных сокращений (ЧСС), дозу вазопрессоров, объем инфузионно-трансфузионной терапии, кровопотерю и диурез. В послеоперационном периоде фиксировали возможные осложнения, проведенные сеансы заместительной почечной терапии (ЗПТ), а также количество дней в стационаре. Результаты. Оценка значений САД, ДАД и ЧСС в начале и конце операции показала достоверно лучшие показатели гемодинамики и снижение дозировок вазопрессорной поддержки в конце вмешательства в группе 1 по сравнению с группой 2 (p < 0,05). В послеоперационном периоде инфекционные осложнения зарегистрированы у одного пациента группы 1 и у трех пациентов группы 2. Проведение ЗПТ потребовалось двум пациентам из группы 2. Все пациенты обеих групп были выписаны из стационара, при этом число дней госпитализации в группе 2 было статистически значимо больше по сравнению с пациентами группы 1: 26,9 ± 3,9 против 17,2 ± 4,3 (p < 0,05). Заключение. Интраоперационная инфузия 25% раствора альбумина позволяет стабилизировать показатели гемодинамики в конце операции ТП, снизить потребность в кардиотонической поддержке и сократить время госпитализации у пациентов после ТП. Background. The therapeutic use of human albumin solution in patients in the perioperative period of liver transplantation (LT) is of interest in the context of complications and outcomes of surgery. Objectives: to assess the effect of intraoperative transfusion of 25% human albumin solution on the early postoperative period in orthotopic LT from a postmortem donor. Patients/Methods. The study included 47 patients who underwent cadaveric LT. Two groups were formed: patients in group 1 (n = 21) received transfusion of 25% human albumin solution at the end of LT and 24 hours after surgery; patients in group 2 (n = 26) received transfusion of 25% human albumin solution on the first day of the postoperative period. The laboratory parameters of the patient’s blood were monitored before surgery, 24 hours later, and 48 hours after surgery. Intraoperatively, the values of systolic (SBP) and diastolic (DBP) blood pressure, heart rate (HR), dose of vasopressors, volume of infusion- transfusion therapy, blood loss and diuresis were assessed. In the postoperative period, possible complications, renal replacement therapy (RRT) sessions performed, and the number of days in the hospital were recorded. Results. Assessment of SBP, DBP and HR values showed significantly better hemodynamic parameters and reduced dosages of vasopressor support at the end of surgery in group 1 compared to group 2 (p < 0.05). In the postoperative period, infectious complications were registered in one patient of group 1 and in three patients of group 2. Two patients from group 2 required RRT. All patients were discharged from the hospital, while the number of hospitalization days in group 2 was statistically significantly greater than in patients in group 1: 26.9 ± 3.9 versus 17.2 ± 4.3 (p < 0.05). Conclusions. Intraoperative infusion of 25% albumin solution allows stabilizing hemodynamic parameters at the end of LT surgery, reducing the need for cardiotonic support and shortening the hospitalization time in patients after LT.

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Effect of "the Awakening Protocol" in the outcome of liver transplantation

Acta Cirurgica Brasileira ◽

10.1590/s0102-86502013001300014 ◽

2013 ◽

Vol 28 (suppl 1) ◽

pp. 72-76

Author(s):

Agnaldo Soares Lima ◽

Leandro Ricardo de Navarro Amado ◽

Malvina Maria de Freitas Duarte ◽

Marcelo Dias Sanches ◽

Alexandre Prado de Resende ◽

...

Keyword(s):

Liver Transplantation ◽

Base Excess ◽

Risk Index ◽

Graft Loss ◽

Early Morning ◽

Meld Score ◽

The Awakening ◽

Transplant Patients ◽

Surgical Tactics ◽

Patient And Graft Survival

PURPOSE: To analyze mortality (7 days) or graft loss in liver transplantation (Tx) performed within the Awakening Protocol (AP) compared to sequential Tx. METHODS: Analysis of 243 liver tx (230 patients), divided into sequential tx or PD (early morning) to compare graft loss or death (7 days). Significant differences at p <0.05 RESULTS: The PD was adopted in 32.5% of tx. The cold ischemia time (p <0.01) and the interval until transplantation (p <0.01) were significantly different. Age of the donor and recipient, Donor Risk Index, MELD score, and donor base excess, sodium, creatinine and glucose were not different between groups. Previous abdominal surgery was a risk factor for early mortality, but was equally distributed between the groups. There was no difference in mortality or graft loss within 7 days (p = 0.521) CONCLUSION: The adoption of PD, to start tx the morning when harvesting occurs after 10p.m. did not result in worse patient and graft survival. Transplant patients with fulminant hepatic failure and high-risk grafts do not apply to this surgical tactics.

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The potential of radionuclide diagnostic imaging in diffuse liver disease and portal hypertension

Transplantologiya The Russian Journal of Transplantation ◽

10.23873/2074-0506-2019-11-3-188-200 ◽

2019 ◽

Vol 11 (3) ◽

pp. 188-200

Author(s):

E. V. Migunova ◽

M. Sh. Khubutiya ◽

N. E. Kudryashova ◽

O. G. Sinyakova ◽

G. A. Berdnikov ◽

...

Keyword(s):

Bone Marrow ◽

Liver Transplantation ◽

Portal Hypertension ◽

Liver Function ◽

Objective Assessment ◽

Left Lobe ◽

Control Group ◽

Diffuse Liver Disease ◽

Quantitative Parameters ◽

Pugh Class

Objective. The study objective was to assess the scintigraphy potential in the evaluation of portal hypertension and the severity of liver damage in diffuse diseases and after liver transplantation.Material and methods. The study enrolled 325 patients suffering from hepatitis and liver cirrhosis of various etiology and severity, including those after liver transplantation, namely, the patients with hepatitis (n=96), patients with liver cirrhosis of Child–Pugh class A (n=24), class B (n=87), and class C (n=118); 11 more healthy volunteers without clinical and laboratory signs of diffuse liver disease were enrolled as controls. The assessment of liver reticuloendothelial system was performed by scintigraphy with (99m)Tc-phytate colloid in a static planar mode and "whole body" mode by SPECT (Infinia II, GE).Results. In contrast to the control group, significant radionuclide signs of hepatosplenomegaly were revealed with the predominant functional activity of the left lobe; the liver function was found impaired that correlated with the cirrhosis severity evaluated according to the Child–Pugh Сlassification. The analysis of scintigraphy quantitative parameters showed that the most informative of them were the intensity of radiopharmaceutical accumulation in the spleen (S%) and in bone marrow (Вm%), and the radiopharmaceutical uptake by the reticuloendothelial cells of the liver and spleen in percentage from the administered activity (Lwb%, Swb%). Depending on the cirrhosis severity assessed by the Child–Pugh Score, the changes in quantitative parameters were accompanied by a progressive enlargement of the spleen, liver left lobe, the increase of (99m)Tc-phytate uptake by the bone marrow with a decreased radiopharmaceutical uptake by the liver. The study results showed that among the Child–Pugh class C patients, the impairment of liver reticuloendothelial function was more pronounced in the patients with cirrhosis of viral and mixed etiology, when compared to those with alcoholic cirrhosis.Conclusion. The paper has identified the most informative parameters characterizing portal hypertension and the reticuloendothelial function for all Child–Pugh defined classes of cirrhosis. These parameters include the increase of (99m) Tc-phytate accumulation in the spleen (S%) and bone marrow (Bm%); the liver and spleen uptake of the radiopharmaceutical in percentage from the administered activity (Lwb%, Swb%). The calculation of the remaining parameters is necessary for a detailed description of the organ function and for the assessment of the portal hypertension severity in repeated studies.Summary. Criteria for the objective assessment of reticuloendothelial function and portal hypertension in diffuse liver diseases, including after liver transplantation, have been developed. Contrary to the control group, in patients with diffuse liver diseases, the radionuclide signs of hepatosplenomegaly (or a decreased liver size) with a predominant functional activity of the left lobe were identified, as were the changes in the quantitative parameters of the radiopharmaceutical uptake by the liver (Lwb%), including the radiopharmaceutical accumulation in the liver left lobe (Ll%), spleen (Swb%), bone marrow (Bm%), and the liver-to-spleen area ratio (Lar/Sar). The informative and reliable (p<0.05) parameters of the function Lwb%, S%, Swb% and Bm% correlating with the cirrhosis classes assessed by Child–Pugh were identified. The radionuclide method, being highly reproducible one, can be recommended for an objective assessment of liver function and the detection of portal hypertension in hepatitis and cirrhosis, as well as for post-transplant monitoring of the liver function to prevent complications in the early and late postoperative periods.

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Pharmaceutical support in liver transplantation at a reference center in Rio Grande do Sul

Brazilian Journal of Transplantation ◽

10.53855/bjt.v20i2.80 ◽

2017 ◽

Vol 20 (2) ◽

pp. 6-8

Author(s):

Mariana de Andrade Pranke ◽

Maria Lúcia Zanotelli ◽

Alfeu Fleck Jr. ◽

Ajácio Brandão ◽

Cláudio Marroni ◽

...

Keyword(s):

Liver Transplantation ◽

Dose Adjustment ◽

Rio Grande ◽

New Drugs ◽

Rio Grande Do Sul ◽

Treatment Results ◽

Reference Center ◽

Transplant Patients ◽

Transplantation Center

The introduction of the everolimus as immunosuppressant in the liver transplantation has been shown to be safe and effective in the prophylaxis and preservation of the renal function. Prospective follow-up and chart analysis of liver transplant patients treated with everolimus was performed. Purpose: To highlight the importance of the pharmacist in transplantation centers. Method: Along the study, 93 patients were included, being 72 under active treatment. The successful treatment depends on the multidisciplinary follow-up, and it is extremely important the involvement of the patient, making him to become positive and an active part of the treatment. Results: The most frequent problems were: patients cutting the everolimus tablet, late SL after dose adjustment, lack of adhesion to the collection, and serum level collection out of time. Discussion: Upon the introduction of new drugs, it is required to observe possible adverse events further to ensure that the patient correctly follows the treatment. Conclusion: The presence of the pharmacist in the transplantation center allows the patient to get a reference to clarify doubts on the proper use of immunosuppressant.

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Monoclonal Fluorescence Polarization Immunoassay Evaluated for Monitoring Cyclosporine in Whole Blood After Kidney, Heart, and Liver Transplantation

Clinical Chemistry ◽

10.1093/clinchem/38.1.123 ◽

1992 ◽

Vol 38 (1) ◽

pp. 123-126 ◽

Cited By ~ 28

Author(s):

M Winkler ◽

G Schumann ◽

D Petersen ◽

M Oellerich ◽

K Wonigeit

Keyword(s):

Monoclonal Antibody ◽

Liver Transplantation ◽

Whole Blood ◽

Fluorescence Polarization ◽

Fluorescence Polarization Immunoassay ◽

Transplant Patients ◽

Specific Radioimmunoassay ◽

Metabolite Concentrations ◽

A Prospective Study

Abstract In a prospective study we evaluated a novel fluorescence polarization immunoassay (FPIA) for determining cyclosporine (CsA) in whole blood. FPIA uses a monoclonal antibody and is performed on the TDx (Abbott). The within-series (CV less than 2%) and between-days (CV less than 3.3%) precision of the assay was excellent. The results obtained by the monoclonal FPIA in samples from transplant patients (n = 100) averaged 31.9% and 20.2% higher than those by HPLC and a specific radioimmunoassay (INCStar), respectively. Results by all three methods correlated well. Follow-up studies during the early course after liver transplantation, however, suggested that high metabolite concentrations affect FPIA results. This is explained by previously described cross-reactions of the monoclonal antibody with some CsA metabolites. The FPIA results in samples of such patients should be interpreted cautiously.

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Transcatheter Arterial Chemoembolization of Hepatocellular Carcinoma as a Bridge to Liver Transplantation: A Retrospective Study

International Journal of Hepatology ◽

10.4061/2011/974514 ◽

2011 ◽

Vol 2011 ◽

pp. 1-7 ◽

Cited By ~ 13

Author(s):

Antoine Bouchard-Fortier ◽

Réal Lapointe ◽

Pierre Perreault ◽

Louis Bouchard ◽

Gilles Pomier-Layrargues

Keyword(s):

Hepatocellular Carcinoma ◽

Liver Transplantation ◽

Transcatheter Arterial Chemoembolization ◽

Milan Criteria ◽

Tumor Extension ◽

Impaired Liver Function ◽

Transplant Patients ◽

Impaired Liver ◽

Cirrhotic Patients ◽

Arterial Chemoembolization

Background. Transcatheter arterial lipiodol chemoembolization (TACE) can be used in cirrhotic patients with hepatocellular carcinoma to avoid tumor progression before transplantation.Objective. To evaluate the efficacy and safety of TACE used as a bridge to liver transplantation.Methods. TACE was performed in 30 cirrhotic patients with hepatocellular carcinoma. Milan criteria were used to select patients for transplant. Patients had a good or moderately impaired liver function, no arterioportal fistulae, and a good portal perfusion.Results. 48 TACE were performed in 30 patients. Before transplantation, 4 patients were dropped off the list due to tumor extension or liver failure. Complete necrosis of the tumor was observed in 11 patients and partial necrosis in 15 patients. After transplantation, 6 patients died and tumor recurrence was observed in 5 patients with a tumor beyond Milan criteria or no response to TACE.Conclusion. TACE is useful as a bridge to liver transplantation in a selected group of cirrhotic patients with hepatocellular carcinoma. A combined therapeutic approach before surgery might improve the prognosis in these patients.

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Two Cases and a Review of Graft-Versus-Host Disease and the Role of Hepatitis C Treatment in Liver Transplant Patients

Progress in Transplantation ◽

10.1177/1526924818781558 ◽

2018 ◽

Vol 28 (3) ◽

pp. 267-270 ◽

Cited By ~ 1

Author(s):

Sonali D. Advani ◽

Anoma Nellore ◽

Giorgos Hadjivassiliou ◽

Devin E. Eckhoff ◽

Donna Salzman ◽

...

Keyword(s):

Liver Transplantation ◽

Hepatitis C ◽

Graft Versus Host Disease ◽

High Dose ◽

Solid Organ ◽

Hcv Treatment ◽

Host Disease ◽

Graft Versus Host ◽

Transplant Patients

Graft-versus-host disease (GvHD) is a rare but fatal complication after solid organ transplantation arising in 1% to 2% of cases. We report 2 cases of GvHD after orthotopic liver transplantation. Both patients had a history of hepatitis C virus (HCV) infection prior to transplantation. Both cases presented between 1 and 4 months after transplantation with rash, pancytopenia, and/or diarrhea. Our second case also developed oral and ocular manifestations after liver transplantation, which are more commonly described after stem cell transplantation. Diagnosis in both cases was made by clinical presentation in conjunction with histopathology and flow cytometry. Both patients were treated by increasing immunosuppression with tacrolimus and high-dose steroids. Response to treatment differed based on the degree of pancytopenia. Our case report is distinguished by several factors such as the context of GvHD presentation and the role of HCV treatment. Diagnosis of GvHD is difficult and often delayed due to nonspecific presentation that overlaps with other conditions. Furthermore, the relation between HCV treatment and potential initiation of GvHD in solid organ transplant patients is unclear.

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Incidence, Etiology, and Outcomes of Altered Mental Status in the Perioperative Setting of Liver Transplantation

The Neurohospitalist ◽

10.1177/1941874417738689 ◽

2017 ◽

Vol 8 (3) ◽

pp. 124-128 ◽

Cited By ~ 1

Author(s):

Christopher Lening ◽

Vatche G. Agopian ◽

Ronald W. Busuttil ◽

David S. Liebeskind

Keyword(s):

Liver Transplantation ◽

Mental Status ◽

Chart Review ◽

Retrospective Chart Review ◽

Altered Mental Status ◽

Sudden Onset ◽

Transplant Patients ◽

Significant Difference ◽

Presentation Group

Background: We examined neurologic consultations for altered mental status in perioperative liver transplant patients to determine the overall incidence, to assess the presumed etiology and the data reviewed to determine that etiology, and to assess outcomes. Methods: Retrospective chart review conducted for all 728 adult patients receiving orthotopic liver transplantation (OLT) between January 01, 2010, to June 30, 2014, with identification of 218 receiving neurology consults between 30 days pre-OLT and 90 days post-OLT, with review of all records necessary to determine initial findings and follow-up examination. Results: Seventy-three consults for 69 patients were identified, with 27 felt to be altered since a procedure, 20 with sudden-onset altered mentation, and 26 with gradual or waxing–waning course. A single underlying etiology was identified in only 19 cases, with multiple factors involved in all others, with metabolic, toxic, infectious, and structural etiologies most often implicated. There was no statistically significant difference in outcome for those with altered mental status consults versus the total OLT population, though the sudden-onset presentation group did show significantly increased mortality rates. Conclusions: This systematic study illustrates the variety of potential causes of altered mentation within the perioperative setting of liver transplantation. Workup including neuroimaging (preferably magnetic resonance imaging), infectious cultures, and expanded metabolic laboratory tests should be undertaken.

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Nurse Management of Posttransplant Hypertension in Liver Transplant Patients

Journal of Transplant Coordination ◽

10.1177/090591999600600308 ◽

1996 ◽

Vol 6 (3) ◽

pp. 139-144

Author(s):

Lora Schwartz ◽

Jo Augustine ◽

Joann Raymer ◽

Vincent Canzanello ◽

Sandra Taler ◽

...

Keyword(s):

Blood Pressure ◽

Liver Transplantation ◽

Orthotopic Liver Transplantation ◽

Antihypertensive Treatment ◽

Cardiovascular Complications ◽

Transplant Patients ◽

Hypertension Clinic ◽

Nurse Clinician ◽

Over Time

Hypertension develops soon after organ transplantation using cyclosporine- or FK506-based immunosuppression. Sustained rises in blood pressure require intervention to reduce the risk of intracranial bleeding and other cardiovascular complications. Antihypertensive treatment is complicated by reduced renal function and potential interference with absorption and/or metabolism of cyclosporine or FK506. To manage early and long-term hypertension related to immunosuppression with cyclosporine or FK506 and prednisone following orthotopic liver transplantation, a comprehensive nurse-managed hypertension clinic was developed. Blood pressure, heart rate, and antihypertensive and immunosuppressive regimens were evaluated according to a standard protocol at 1, 4, 12, 24, and 36 months after orthotopic liver transplantation. Data indicate that posttransplantation hypertension develops within the first months after orthotopic liver transplantation and persists indefinitely. If comprehensively managed by the hypertension nurse-clinician, the percentage of controlled hypertension patients can increase over time.

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