Transfusion and coagulation management in liver transplantation

Abstract

There is wide variation in the management of coagulation and blood transfusion practice in liver transplantation. The use of blood products intraoperatively is declining and transfusion free transplantations take place ever more frequently. Allogenic blood products have been shown to increase morbidity and mortality. Primary haemostasis, coagulation and fibrinolysis are altered by liver disease. This, combined with intraoperative disturbances of coagulation, increases the risk of bleeding. Meanwhile, the rebalancing of coagulation homeostasis can put patients at risk of hypercoagulability and thrombosis. The application of the principles of patient blood management to transplantation can reduce the risk of transfusion. This includes: preoperative recognition and treatment of anaemia, reduction of perioperative blood loss and the use of restrictive haemoglobin based transfusion triggers. The use of point of care coagulation monitoring using whole blood viscoelastic testing provides a picture of the complete coagulation process by which to guide and direct coagulation management. Pharmacological methods to reduce blood loss include the use of anti-fibrinolytic drugs to reduce fibrinolysis, and rarely, the use of recombinant factor VIIa. Factor concentrates are increasingly used; fibrinogen concentrates to improve clot strength and stability, and prothrombin complex concentrates to improve thrombin generation. Non-pharmacological methods to reduce blood loss include surgical utilisation of the piggyback technique and maintenance of a low central venous pressure. The use of intraoperative cell salvage and normovolaemic haemodilution reduces allogenic blood transfusion. Further research into methods of decreasing blood loss and alternatives to blood transfusion remains necessary to continue to improve outcomes after transplantation.

Keywords: Liver disease; Transplantation; Coagulation; Transfusion; Patient blood management; Thromboelastography; Cell salvage

Core tip: Liver transplantation was historically associated with major blood loss. Over the years, improvements in both surgical and anaesthetic management have made transfusion free transplantation an increasingly attainable reality. Research into the complex nature of the coagulopathy of liver disease, has led to the concept that the haemostatic profile is “re-balanced” in these patients, and that stable patients do not have an inherent bleeding diathesis, but rather a reduced reserve, and can be readily tipped towards a bleeding or thrombotic tendency. This review article discusses the various approaches that can be taken to adopt the principles of patient blood management in these patients.