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Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jan 28, 2016; 22(4): 1541-1550
Published online Jan 28, 2016. doi: 10.3748/wjg.v22.i4.1541
Hemostasis in liver transplantation: Pathophysiology, monitoring, and treatment
Matthias Hartmann, Cynthia Szalai, Fuat H Saner
Matthias Hartmann, Cynthia Szalai, Klinik für Anaesthesiologie und Intensivmedizin, Universitätsklinikum Essen, Universität Duisburg-Essen, D-45122 Essen, Germany
Fuat H Saner, Klinik für Allgemeinchirurgie, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen, Universität Duisburg-Essen, D-45122 Essen, Germany
Author contributions: Hartmann M wrote the manuscript; Szalai C and Saner FH discussed and corrected the manuscript.
Conflict-of-interest statement: Hartmann M and Saner FH have received honoria and funding for scientific lectures and retrospective data analyses from Behring GmbH, Marburg; Szalai C declares no conflict of interest.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Matthias Hartmann, Professor, Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Hufelandstr. 55, D-45122 Essen, Germany.
Telephone: +49-201-7231402 Fax: +49-201-7235949
Received: April 27, 2015
Peer-review started: April 29, 2015
First decision: August 26, 2015
Revised: September 29, 2015
Accepted: November 13, 2015
Article in press: November 13, 2015
Published online: January 28, 2016

Recent findings in the pathophysiology and monitoring of hemostasis in patients with end stage liver disease have major impact on coagulation management during liver transplantation. There is increasing evidence, that the changes in both coagulation factors and platelet count regularly observed in patients with liver cirrhosis cannot be interpreted as a reliable indicator of diffuse bleeding risk. Instead, a differentiated view on hemostasis has led to the concept of a rebalanced coagulation system: While it is important to recognize that procoagulant factors are reduced in liver cirrhosis, it is also evident that synthesis of anticoagulant factors and fibrinolytic proteins produced in the liver is also diminished. Similarly, the decreased platelet count may be counterbalanced by increased platelet aggregability caused by highly active von Willebrand multimeres. The coagulation system is therefor stated to be rebalanced. While under normal “unstressed” conditions diffuse bleeding is rarely observed, however both diffuse bleeding or thrombus formation may occur when compensation mechanisms are exhausted. While most patients presenting for liver transplantation have severe cirrhosis, liver function and thus production of pro- and anticoagulant factors can be preserved especially in cholestatic liver disease. During liver transplantation, profound changes in the hemostasis system can occur. Surgical bleeding can lead to diffuse bleeding as coagulation factors and platelets are already reduced. Ischemia and tissue trauma can lead to alterations of hemostasis comparable to trauma induced coagulopathy. A further common disturbance often starting with the reperfusion of the transplanted organ is hyperfibrinolysis which can eventually precipitate complete consumption of fibrinogen and an endogenous heparinization by glycocalyx shedding. Moreover, thrombotic events in liver transplantations are not uncommon and contribute to increased mortality. Besides conventional laboratory methods, bed-side monitoring of hemostasis (e.g., thrombelastography, thrombelastometry) is often used during liver transplantation to rapidly diagnose decreases in fibrinogen and platelet count as well as hyperfibrinolysis and to guide treatment with blood products, factor concentrates, and antifibrinolytics. There is also evidence which suggests when algorithms based on bed-side hemostasis monitoring are used a reduction of blood loss, blood product use, and eventual mortality are possible. Notably, the bed-side monitoring of anticoagulant pathways and the thrombotic risk is not possible at time and thus a cautious and restrictive use of blood products is recommended.

Keywords: Liver transplantation, Hemostasis, Bed-side monitoring, Thrombelastography, Thrombelastometry, Coagulation factors

Core tip: Hemostasis in patients presenting for liver transplantation is often characterized by a reduction in both pro- and anticoagulant factors. During surgery, the rebalanced hemostasis system can be stressed by bleeding, hemodynamic shock, tissue damage or substitution of blood products with resultant diffuse bleeding or thrombus formation. Thrombelastography/thrombelastometry can guide substitution of blood products and reduces bleeding, transfusion of blood products, and eventual mortality. It is, however, important to state that bed-side methods are not capable of detecting alterations in anticoagulant pathways. Thus cautious coagulation management is recommended to avoid potential devastating thrombotic complications.