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Punzo G, Di Franco V, Perilli V, Sacco T, Sollazzi L, Aceto P. Efficacy and Safety of Prothrombin Complex Concentrates in Liver Transplantation: Evidence from Observational Studies. J Clin Med 2023; 12:jcm12113749. [PMID: 37297943 DOI: 10.3390/jcm12113749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 05/21/2023] [Accepted: 05/25/2023] [Indexed: 06/12/2023] Open
Abstract
The risk/benefit ratio of using prothrombin complex concentrates (PCCs) to correct coagulation defects in patients with end-stage liver disease is still unclear. The primary aim of this review was to assess the clinical effectiveness of PCCs in reducing transfusion requirements in patients undergoing liver transplantation (LT). This systematic review of non-randomized clinical trials was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The protocol was previously registered (PROSPERO:CRD42022357627). The primary outcome was the mean number of transfused units for each blood product, including red blood cells (RBCs), fresh frozen plasma, platelets, and cryoprecipitate. Secondary outcomes included the incidence of arterial thrombosis, acute kidney injury, and haemodialysis, and hospital and intensive care unit length of stay. There were 638 patients from 4 studies considered for meta-analysis. PCC use did not affect blood product transfusions. Sensitivity analysis, including only four-factor PCC, showed a significant reduction of RBC effect size (MD: 2.06; 95%CI: 1.27-2.84) with no true heterogeneity. No significant differences in secondary outcomes were detected. Preliminary evidence indicated a lack of PCC efficacy in reducing blood product transfusions during LT, but further investigation is needed. In particular, future studies should be tailored to establish if LT patients will likely benefit from four-factor PCC therapy.
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Affiliation(s)
- Giovanni Punzo
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Valeria Di Franco
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Valter Perilli
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Teresa Sacco
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Liliana Sollazzi
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Paola Aceto
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
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Tomić Mahečić T, Baronica R, Mrzljak A, Boban A, Hanžek I, Karmelić D, Babić A, Mihaljević S, Meier J. Individualized Management of Coagulopathy in Patients with End-Stage Liver Disease. Diagnostics (Basel) 2022; 12:diagnostics12123172. [PMID: 36553179 PMCID: PMC9777026 DOI: 10.3390/diagnostics12123172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 12/02/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022] Open
Abstract
Over the last decades, individualized approaches and a better understanding of coagulopathy complexity in end-stage liver disease (ESLD) patients has evolved. The risk of both thrombosis and bleeding during minimally invasive interventions or surgery is associated with a worse outcome in this patient population. Despite deranged quantitative and qualitative coagulation laboratory parameters, prophylactic coagulation management is unnecessary for patients who do not bleed. Transfusion of red blood cells (RBCs) and blood products carries independent risks for morbidity and mortality, including modulation of the immune system with increased risk for nosocomial infections. Optimal coagulation management in these complex patients should be based on the analysis of standard coagulation tests (SCTs) and viscoelastic tests (VETs). VETs represent an individualized approach to patients and can provide information about coagulation dynamics in a concise period of time. This narrative review will deliver the pathophysiology of deranged hemostasis in ESLD, explore the difficulties of evaluating the coagulopathies in liver disease patients, and examine the use of VET assays and management of coagulopathy using coagulation factors. Methods: A selective literature search with PubMed as the central database was performed with the following.
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Affiliation(s)
- Tina Tomić Mahečić
- Clinic of Anesthesiology, Reanimatology and Intensive Care Medicine, and Pain Treatment, University Hospital Center Zagreb, 10000 Zagreb, Croatia
- Correspondence: ; Tel.: +385-98-457-189
| | - Robert Baronica
- Clinic of Anesthesiology, Reanimatology and Intensive Care Medicine, and Pain Treatment, University Hospital Center Zagreb, 10000 Zagreb, Croatia
- School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
| | - Anna Mrzljak
- School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
- Liver Transplant Center, Department of Gastroenterology and Hepatology, University Hospital Center Zagreb, 10000 Zagreb, Croatia
| | - Ana Boban
- School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
- Department of Hematology, University Hospital Center Zagreb, 10000 Zagreb, Croatia
| | - Ivona Hanžek
- Clinic of Anesthesiology, Reanimatology and Intensive Care Medicine, and Pain Treatment, University Hospital Center Zagreb, 10000 Zagreb, Croatia
| | - Dora Karmelić
- Clinic of Anesthesiology, Reanimatology and Intensive Care Medicine, and Pain Treatment, University Hospital Center Zagreb, 10000 Zagreb, Croatia
| | - Anđela Babić
- Clinic of Anesthesiology, Reanimatology and Intensive Care Medicine, and Pain Treatment, University Hospital Center Zagreb, 10000 Zagreb, Croatia
| | - Slobodan Mihaljević
- Clinic of Anesthesiology, Reanimatology and Intensive Care Medicine, and Pain Treatment, University Hospital Center Zagreb, 10000 Zagreb, Croatia
- School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
| | - Jens Meier
- Clinic of Anesthesiology and Intensive Care Medicine, Kepler University Clinic, Johannes Kepler University, 4040 Linz, Austria
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Salerno DM, Lee-Riddle GS, Brar S, Samstein B, Brown RS, Lennon C. Deceased donor liver transplantation in patients on direct oral anticoagulants at the time of transplant surgery: A case series. Liver Transpl 2022; 28:1681-1684. [PMID: 35657735 DOI: 10.1002/lt.26521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/27/2022] [Accepted: 05/17/2022] [Indexed: 01/13/2023]
Affiliation(s)
- David M Salerno
- Department of Pharmacy, NewYork-Presbyterian Hospital, New York, New York, USA
| | - Grace S Lee-Riddle
- Department of Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Seema Brar
- Department of Anesthesiology, Weill Cornell Medical Center, New York, New York, USA
| | - Benjamin Samstein
- Department of Surgery, Weill Cornell Medical Center, New York, New York, USA
| | - Robert S Brown
- Department of Medicine, Weill Cornell Medical Center, New York, New York, USA
| | - Christine Lennon
- Department of Anesthesiology, Weill Cornell Medical Center, New York, New York, USA
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Pillai AA, Kriss M, Al‐Adra DP, Chadha RM, Cushing MM, Farsad K, Fortune BE, Hess AS, Lewandowski R, Nadim MK, Nydam T, Sharma P, Karvellas CJ, Intagliata N. Coagulopathy and hemostasis management in patients undergoing liver transplantation: Defining a dynamic spectrum across phases of care. Liver Transpl 2022; 28:1651-1663. [PMID: 35253365 PMCID: PMC9790275 DOI: 10.1002/lt.26451] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 02/23/2022] [Accepted: 02/24/2022] [Indexed: 01/10/2023]
Abstract
Patients with acute and chronic liver disease present with a wide range of disease states and severity that may require liver transplantation (LT). Physiologic alterations occur that are dynamic throughout all phases of perioperative care, creating complex management scenarios that necessitate multidisciplinary clinical care. Specifically, alterations in hemostasis in liver disease can be pronounced and evolve with disease progression over time. Recent studies and society guidance address this emerging paradigm and offer recommendations to assist with hemostatic management in patients with liver disease. However, patients undergoing LT are unique and diverse, often with unstable disease that requires specialized approaches. Our aim is to provide a focused review of hemostatic management of the LT patient, distinguish unique aspects of the three main phases of care (before LT, perioperative, and after LT), and identify knowledge gaps and critical areas of future research.
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Affiliation(s)
- Anjana A. Pillai
- Department of MedicineUniversity of Chicago MedicineChicagoIllinoisUSA
| | - Michael Kriss
- Department of Internal MedicineUniversity of ColoradoAuroraColoradoUSA
| | - David P. Al‐Adra
- Department of SurgerySchool of Medicine and Public HealthUniversity of WisconsinMadisonWisconsinUSA
| | - Ryan M. Chadha
- Department of Anesthesiology and Perioperative MedicineMayo ClinicJacksonvilleFloridaUSA
| | - Melissa M. Cushing
- Department of Pathology and Laboratory MedicineWeill Cornell MedicineNew YorkNew YorkUSA
| | - Khashayar Farsad
- Department of Interventional RadiologyOregon Health & Science UniversityPortlandOregonUSA
| | | | - Aaron S. Hess
- Department of AnesthesiologyUniversity of WisconsinMadisonWisconsinUSA,Department of Pathology & Laboratory MedicineUniversity of WisconsinMadisonWisconsinUSA
| | | | - Mitra K. Nadim
- Department of MedicineUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Trevor Nydam
- Department of SurgeryUniversity of ColoradoAuroraColoradoUSA
| | - Pratima Sharma
- Department of MedicineUniversity of MichiganAnn ArborMichiganUSA
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