Pre-Liver Transplant ROTEM™ Clot Lysis Index Is Associated with 30-Day Mortality, But Is Not a Measure for Fibrinolysis.

Matthias Hartmann,Fuat H Saner,Bogdan Craciun,Andreas Paul,Thorsten Brenner

doi:10.3390/jcm9103298

Matthias Hartmann, Fuat H Saner + Show 3 more

Open Access

https://doi.org/10.3390/jcm9103298

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Abstract

Complex alterations of the coagulation system in end stage liver disease lead to an increased risk of bleeding and mortality. In the present study, we investigated; 1. the association of pre-liver transplant rotational thrombelastometry (ROTEM™) variables with bleeding as well as 30-day-mortality and 2. the underlying pathophysiology. After approval from the local ethics committee, rotational thrombelastometry variables, conventional laboratory coagulation values, MELD score (model of end-stage liver disease), red blood cell loss, blood product use, coagulation factors, underlying disease, and demographic data were retrospectively analysed. Pre-transplant thrombelastometry clot lysis index (CLI) and MELD were the only variables associated with mortality, bleeding and blood product use, respectively. Mortality was 4.2%, when CLI was <85%, and increased to 25.7% when the CLI was >95%. Multivariate analysis including CLI and MELD score identified the CLI as an independent and the best predictor of 30-day-mortality. Interestingly, the inhibition of fibrinolysis did neither affect CLI nor the association of the variable with mortality. Thus, fibrinolysis can be excluded as the reason for low CLI values. In conclusion, low CLI values measured before the beginning of liver transplantation are associated with reduced bleeding and mortality, but do not indicate fibrinolysis.

Highlights

Surgical techniques and experience in the liver transplantation (LTX) setting have largely increased in the last decade, the mortality is still high
We investigated whether pre-transplant variables obtained by rotational thrombelastometry and conventional laboratory coagulation tests are predictors of outcome in patients undergoing LTX
The pre-liver transplant clot lysis index (CLI) is associated with mortality; the variable was a better predictor than the MELD score

Summary

Introduction

Surgical techniques and experience in the liver transplantation (LTX) setting have largely increased in the last decade, the mortality is still high. Reasons for an adverse outcome are nowadays often related to the severity of the underlying liver disease, quality of the transplant, immunosuppression and concomitant diseases of the patient [1]. End stage liver disease (ESLD) leads to decreased hepatic plasma protein production and often induces a proinflammatory disease state [2]. Reduced plasma concentrations and activities of various proteins of the coagulant, anticoagulant and fibrinolytic pathways can often be observed [3]. As the components of the three pathways are reduced, haemostasis in ESLD has been claimed a rebalanced system [4]. During major surgery (liver transplantation), the loss and activation of components of the three pathways can induce an imbalance of coagulant, anticoagulant and fibrinolytic pathways, resulting in bleeding or thrombosis [3]

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