What are the preoperative risk factors for blood loss during liver transplantation?

Updated: Apr 19, 2019
  • Author: Vanessa A Olcese, MD, PhD; Chief Editor: Ron Shapiro, MD  more...
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Preoperative factors associated with blood loss during liver transplantation include liver failure, cirrhosis, cholestasis, and splenomegaly. Many complex derangements of hemostasis are associated with ESLD.

Patients with acute or chronic liver failure do not synthesize normal amounts of clotting factors II (prothrombin), VII, IX, and X. Decreased production of these factors may lead to a coagulopathy, which is typically identified by a prolonged prothrombin time (PT). Patients with severe deficiencies also may exhibit a prolonged activated partial thromboplastin time (aPTT). Cholestasis leads to decreased synthesis of vitamin K–dependent clotting factors (II, VII, IX, and X), further contributing to abnormal clotting. In advanced liver failure, this abnormality may not be correctable, even with oral or parenteral vitamin K administration.

Thrombocytopenia is another common problem in cirrhotic patients. The liver is the primary site of thrombopoietin synthesis, and thrombopoietin deficiency due to cirrhosis leads to low platelet production. In addition to the decreased formation of platelets, splenomegaly caused by portal hypertension leads to platelet sequestration and destruction. Thrombocytopenia is sometimes reversed in patients who undergo OLT, although occasional patients have severe, persistent thrombocytopenia after OLT and require splenectomy.

Besides low levels of coagulation factors and platelets, some patients with end-stage liver disease (ESLD) demonstrate increased fibrinolytic activity. This results in a low-grade disseminated intravascular coagulation–like picture.

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