Low plasma fibrinogen levels and blood product transfusion in liver transplantation

Aim: Risk of bleeding in liver transplantation is determined by surgical technique, preoperative hemoglobin and antifibrinolitic therapy. We hypothesized that keeping these confounders factors identical, preoperative plasma fibrinogen level of ≤2 g/L influenced on blood product requirements. Methods: Adult patients underwent orthotropic liver transplantation (LT) during the period between January 1998 and December 2009. Cases were selected according to a propensity matching analysis meeting the following criteria: surgical vena cava preservation, tranexamic acid administration and hemoglobin range between 90 to 120 g/L. Intraoperative management was protocolized. The main variable was the percentage of patients that did not require red blood cells (RBC's). Results: Six hundred sixty-four patients with LT, 208 excluded, 266 who cannot be matched, the analysis was performed on 190 patients. Two cohorts: Low fibrinogen (≤2 g/L) (61 cases) and standard fibrinogen (>2 g/L) (129 cases) were analyzed. Preoperative platelet count (73.5±52 vs. 104±65; 103/mm3) was different in contrast to the hemoglobin (104.2±8.6 vs. 105.6±8.3; g/L). Use of RBC's resulted significantly higher in the low fibrinogen group (median, 3 vs. 2). The number of patients with no blood product requirements was fewer in the low fibrinogen group (8 cases, 13% vs. 45 cases, 35%). The critical level of plasma fibrinogen (1 g/L) was reached after graft reperfusion in 7 cases (5.5%) in the standard fibrinogen group vs. 24 cases (39%) in the low fibrinogen group. Conclusion: Our data suggest that preoperative plasma fibrinogen level of ≤2 g/L increases requirements for blood products during the surgical procedure of liver transplantation