Patients with cirrhosis undergoing liver transplantation have unique challenges with regard to the prevention and management of thrombosis and hemorrhage. Patients with cirrhosis have an unstable balance of the coagulation system due to defects in both prothrombotic and antithrombotic components. These changes make laboratory monitoring challenging, prophylaxis against bleeding and thrombosis controversial, and therapy for the same uncertain. When cirrhotic patients undergo liver transplantation, they frequently have significant transfusion requirements. Emerging evidence may help aid in predicting which recipients will have the greatest blood product requirements, but the ideal blood product regimen to support them through the surgical procedure remains elusive. After these patients receive a liver they are at risk for both venous and arterial thrombotic complications. Unique to liver transplantation is the possibility of acquiring an inherited defect in coagulation, most commonly leading to a predisposition to thrombosis. Further high-quality prospective studies focusing on the management of cirrhotic patients are needed to better guide clinicians.
This review provides an overview of the pathophysiology of hemostasis in liver disease, highlights challenges in laboratory monitoring, and offers recommendations for management of bleeding and thrombosis in the liver transplant recipient.
1 Department of Critical Care, University of Alberta, Edmonton, AB, Canada.
2 Division of Hematology, Department of Medicine, University of Alberta, Edmonton, AB, Canada.
3 Division of Gastroenterology/Hepatology, Department of Medicine, University of Alberta, Edmonton, AB, Canada.
Received 16 November 2017. Revision received 2 May 2018.
Accepted 3 May 2018.
The authors declare no funding or conflicts of interest.
A.P. and C.J.K. contributed to writing the article.
Correspondence: Constantine J Karvellas MD SM FRCPC, Department of Critical Care Medicine, Division of Gastroenterology (Liver Unit), University of Alberta, 1-40 Zeidler Ledcor Building, Edmonton, Alberta, Canada T6G-2X8. (firstname.lastname@example.org).