Coagulation management with factor concentrates in liver transplantation: a single-center experience.

Dr. Kirchner and colleagues retrospectively studied 266 patients planned for hepatic transplantation managed according to the ROTEM-guided coagulation factor algorithm from Essen, Germany. The main outcome was safety (thromboembolic or ischaemic events). No statistically significant difference was observed between the two groups (however, the incidence of adverse events was 7.1% of patients receiving coagulation factor concentrates and 4.5% in patients receiving none [p = 0.31]).

ROTEM-guided intraoperative coagulation management was used in all patients, with administration of tranexamic acid, fibrinogen concentrate, prothombin complex concentrate and fresh frozen plasma based on point-of-care results. In this non-randomised study, 156 patients received coagulation factor concentrates (CFC group), and 110 none (non-CFC group), related to ROTEM monitoring and bleeding characteristics.

The CFC group experienced more bleeding and received more allogeneic transfusions (RBC, FFP and PLT) and higher volumes of retransfused salvaged blood during surgery, compared with patients not receiving coagulation factors. This is maybe somewhat surprising to most readers! The reason for this is the significant difference in severity of hepatic disease leading to increased coagulopathy, diffuse bleeding, and need for coagulation factor concentrates as well as blood products. This is an interesting study, showing us the important limitations of this type of non-randomised retrospective design having two non-comparable groups, and just stressing the extremely urgent need for randomised controlled trials testing coagulation factor therapy in bleeding patients.

– Jakob Stensballe