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Tomić Mahečić T, Baronica R, Mrzljak A, Boban A, Hanžek I, Karmelić D, Babić A, Mihaljević S, Meier J. Individualized Management of Coagulopathy in Patients with End-Stage Liver Disease. Diagnostics (Basel) 2022; 12:diagnostics12123172. [PMID: 36553179 PMCID: PMC9777026 DOI: 10.3390/diagnostics12123172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 12/02/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022] Open
Abstract
Over the last decades, individualized approaches and a better understanding of coagulopathy complexity in end-stage liver disease (ESLD) patients has evolved. The risk of both thrombosis and bleeding during minimally invasive interventions or surgery is associated with a worse outcome in this patient population. Despite deranged quantitative and qualitative coagulation laboratory parameters, prophylactic coagulation management is unnecessary for patients who do not bleed. Transfusion of red blood cells (RBCs) and blood products carries independent risks for morbidity and mortality, including modulation of the immune system with increased risk for nosocomial infections. Optimal coagulation management in these complex patients should be based on the analysis of standard coagulation tests (SCTs) and viscoelastic tests (VETs). VETs represent an individualized approach to patients and can provide information about coagulation dynamics in a concise period of time. This narrative review will deliver the pathophysiology of deranged hemostasis in ESLD, explore the difficulties of evaluating the coagulopathies in liver disease patients, and examine the use of VET assays and management of coagulopathy using coagulation factors. Methods: A selective literature search with PubMed as the central database was performed with the following.
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Affiliation(s)
- Tina Tomić Mahečić
- Clinic of Anesthesiology, Reanimatology and Intensive Care Medicine, and Pain Treatment, University Hospital Center Zagreb, 10000 Zagreb, Croatia
- Correspondence: ; Tel.: +385-98-457-189
| | - Robert Baronica
- Clinic of Anesthesiology, Reanimatology and Intensive Care Medicine, and Pain Treatment, University Hospital Center Zagreb, 10000 Zagreb, Croatia
- School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
| | - Anna Mrzljak
- School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
- Liver Transplant Center, Department of Gastroenterology and Hepatology, University Hospital Center Zagreb, 10000 Zagreb, Croatia
| | - Ana Boban
- School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
- Department of Hematology, University Hospital Center Zagreb, 10000 Zagreb, Croatia
| | - Ivona Hanžek
- Clinic of Anesthesiology, Reanimatology and Intensive Care Medicine, and Pain Treatment, University Hospital Center Zagreb, 10000 Zagreb, Croatia
| | - Dora Karmelić
- Clinic of Anesthesiology, Reanimatology and Intensive Care Medicine, and Pain Treatment, University Hospital Center Zagreb, 10000 Zagreb, Croatia
| | - Anđela Babić
- Clinic of Anesthesiology, Reanimatology and Intensive Care Medicine, and Pain Treatment, University Hospital Center Zagreb, 10000 Zagreb, Croatia
| | - Slobodan Mihaljević
- Clinic of Anesthesiology, Reanimatology and Intensive Care Medicine, and Pain Treatment, University Hospital Center Zagreb, 10000 Zagreb, Croatia
- School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
| | - Jens Meier
- Clinic of Anesthesiology and Intensive Care Medicine, Kepler University Clinic, Johannes Kepler University, 4040 Linz, Austria
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2
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Eyraud D, Suner L, Dupont A, Bachelot-Loza C, Smadja DM, Helley D, Bertil S, Gostian O, Szymezak J, Loncar Y, Puybasset L, Lebray P, Vezinet C, Vaillant JC, Granger B, Gaussem P. Evolution of platelet functions in cirrhotic patients undergoing liver transplantation: A prospective exploration over a month. PLoS One 2018; 13:e0200364. [PMID: 30071043 PMCID: PMC6072007 DOI: 10.1371/journal.pone.0200364] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 06/25/2018] [Indexed: 12/23/2022] Open
Abstract
This prospective observational study was designed to analyze platelet functions across time in 50 patients scheduled for liver transplantation (LT) secondary to decompensated cirrhosis or hepatocellular carcinoma. Platelet functions were assessed before LT (pre-LT), one week (D7) and 1 month (D28) after LT. Platelet count significantly increased from pre-LT time to day 28 as well as circulating CD34+hematopoietic stem cells. To avoid any influence of platelet count on assays, platelet function was evaluated on platelet-rich-plasma adjusted to pre-LT platelet count. Although platelet secretion potential did not differ between time-points, as evaluated by the expression of CD62P upon strong activation, platelet aggregation in response to various agonists significantly increased along time, however with no concomitant increase of circulating markers of platelet activation: platelet microvesicles, platelet-leukocyte complexes, soluble CD40L and soluble CD62P. In the multivariate analysis, hepatic function was associated with platelet count and function. A lower platelet aggregation recovery was correlated with Child C score. History of thrombosis or bleeding was associated with respective higher or lower values of platelet aggregation. This longitudinal analysis of platelet functions in LT patients showed an improvement of platelet functions along time together with platelet count increase, with no evidence of platelet hyperactivation at any time-point.
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Affiliation(s)
- Daniel Eyraud
- AP-HP, Pitié-Salpêtrière University Hospital, Department of Anesthesiology and Reanimation, Paris, France
- AP-HP, Pitié-Salpêtrière University Hospital, Department of Digestive, HPB Surgery, and Liver Transplantation, Paris, France
- Université Pierre et Marie Curie, Paris, France
| | - Ludovic Suner
- AP-HP, European University Hospital Georges Pompidou, Hematology Department, Paris, France
| | - Axelle Dupont
- Université Pierre et Marie Curie, Paris, France
- AP-HP, Pitié-Salpêtrière University Hospital, Department of statistics, Clinical Research Unit, Paris, France
| | - Christilla Bachelot-Loza
- Inserm UMR-S1140, Faculté de Pharmacie, Paris, France
- Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - David M. Smadja
- AP-HP, European University Hospital Georges Pompidou, Hematology Department, Paris, France
- Inserm UMR-S1140, Faculté de Pharmacie, Paris, France
- Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Dominique Helley
- AP-HP, European University Hospital Georges Pompidou, Hematology Department, Paris, France
- Université Paris Descartes, Sorbonne Paris Cité, Paris, France
- Inserm UMR-S970, Paris, France
| | - Sébastien Bertil
- AP-HP, European University Hospital Georges Pompidou, Hematology Department, Paris, France
| | - Ovidiu Gostian
- AP-HP, Pitié-Salpêtrière University Hospital, Department of Anesthesiology and Reanimation, Paris, France
- Université Pierre et Marie Curie, Paris, France
| | - Jean Szymezak
- AP-HP, European University Hospital Georges Pompidou, Hematology Department, Paris, France
| | - Yann Loncar
- AP-HP, Pitié-Salpêtrière University Hospital, Department of Anesthesiology and Reanimation, Paris, France
- Université Pierre et Marie Curie, Paris, France
| | - Louis Puybasset
- AP-HP, Pitié-Salpêtrière University Hospital, Department of Anesthesiology and Reanimation, Paris, France
- Université Pierre et Marie Curie, Paris, France
| | - Pascal Lebray
- AP-HP, Pitié-Salpêtrière University Hospital, Hepatology Department, Paris, France
| | - Corinne Vezinet
- AP-HP, Pitié-Salpêtrière University Hospital, Department of Anesthesiology and Reanimation, Paris, France
| | - Jean-Christophe Vaillant
- AP-HP, Pitié-Salpêtrière University Hospital, Department of Digestive, HPB Surgery, and Liver Transplantation, Paris, France
- Université Pierre et Marie Curie, Paris, France
| | - Benjamin Granger
- Université Pierre et Marie Curie, Paris, France
- AP-HP, Pitié-Salpêtrière University Hospital, Department of statistics, Clinical Research Unit, Paris, France
| | - Pascale Gaussem
- AP-HP, European University Hospital Georges Pompidou, Hematology Department, Paris, France
- Inserm UMR-S1140, Faculté de Pharmacie, Paris, France
- Université Paris Descartes, Sorbonne Paris Cité, Paris, France
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3
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Palyu E, Harsfalvi J, Tornai T, Papp M, Udvardy M, Szekeres-Csiki K, Pataki L, Vanhoorelbeke K, Feys HB, Deckmyn H, Tornai I. Major Changes of von Willebrand Factor Multimer Distribution in Cirrhotic Patients with Stable Disease or Acute Decompensation. Thromb Haemost 2018; 118:1397-1408. [PMID: 29972862 PMCID: PMC6202934 DOI: 10.1055/s-0038-1661393] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Background
There is an unstable balance between pro- and anti-haemostatic processes in patients with cirrhosis. We hypothesized, that in patients with acute decompensation (AD) the major alterations of von Willebrand factor (VWF) could contribute to the pro-thrombotic situation as compared to patients with stable (ST) cirrhosis.
Patients and Methods
We analysed different parameters of VWF, including detailed multimer distribution by densitometry and platelet adhesion, together with
ad
isintegrin-like
a
nd
m
etalloproteinase with
t
hrombo
s
pondin type-1 motifs
13
(ADAMTS13) activity and antigen and C-reactive protein (CRP) levels in patients with ST cirrhosis (
n
= 99), with AD (
n
= 54) and controls (
n
= 92).
Results
VWF antigen, ristocetin co-factor as well as collagen-binding activities were elevated in both cirrhotic groups in a stepwise manner. There was a decrease in high and an increase in low molecular weight multimer ratios in the majority of ST cirrhosis. However, in 24 out of 54 AD patients, ultra-large VWF multimers (ultra-large molecular weight multimers [ULMWM]) were found. ADAMTS13 activity in ST and AD patients without ULMWM was similar to controls (median [interquartile range; IQR]%: 98 [67–132] and 91 [60–110] vs. 106 [88–117], respectively). The presence of ULMWM in AD patients was associated with low ADAMTS13 activity [33 (24–49)%] and high CRP level [23 (7.1–83.6) mg/L]. Adhesion of normal platelets showed a stepwise increase in the presence of cirrhotic plasmas, reaching the highest level in AD patients with ULMWM.
Conclusion
Characteristic changes of VWF parameters are seen in ST cirrhosis. In AD patients, highly increased VWF and reduced ADAMTS13 activity could be found, along with the presence of ULMWM, which are possible markers and contributors of the disease progression.
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Affiliation(s)
- Eszter Palyu
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Jolan Harsfalvi
- Department of Biophysics and Radiation Biology, Semmelweis University, Budapest, Hungary
| | - Tamas Tornai
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Maria Papp
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Miklos Udvardy
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Katalin Szekeres-Csiki
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Lajos Pataki
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Karen Vanhoorelbeke
- Laboratory for Thrombosis Research, IRF Life Science, KU Leuven Kulak, Kortrijk, Belgium
| | - Hendrik B Feys
- Transfusion Research Center, Belgian Red Cross-Flanders, Ghent, Belgium.,Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Hans Deckmyn
- Laboratory for Thrombosis Research, IRF Life Science, KU Leuven Kulak, Kortrijk, Belgium
| | - Istvan Tornai
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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Saner FH, Kirchner C. Monitoring and Treatment of Coagulation Disorders in End-Stage Liver Disease. Visc Med 2016; 32:241-248. [PMID: 27722160 DOI: 10.1159/000446304] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Patients with end-stage liver disease (ESLD) are assumed to be at high risk of bleeding when undergoing any kind of invasive intervention (any kind of operation, including transplantation or minimally invasive interventions). Both bleeding and thrombosis are associated with a poor outcome. METHODS A selective literature research was conducted with the following key words: 'cirrhosis', 'coagulation', 'bleeding', 'INR' (international normalized ratio), 'aPTT' (activated partial thromboplastin time), and 'thrombocytopenia'. PubMed was used as the basic database. RESULTS Pathological values of standard laboratory tests (SLT) and thrombocytopenia have traditionally been regarded as indicators of a high risk for bleeding in all patients, and especially in those with ESLD. However, this approach has been challenged in recent years. The conventional approach in assessing a bleeding risk was based on pathological values of SLT. A 1.5-fold increase of INR or aPTT or platelets < 50/nl is assumed as pathological. The traditional approach of reducing the risk of excessive bleeding during an invasive procedure was to transfuse fresh frozen plasma (FFP) or platelet concentrates in order to improve hemostasis and to avoid bleeding complications. In the recent 20 years, several studies have provided us with a basis for questioning this approach. Their results indicated that SLT were not able to predict hypocoagulation and bleeding complications. Moreover, transfusion of various blood products has been associated with an increased risk for acute lung injury, transfusion-associated circulation overload, bacterial infections, and modulation of the immune system with increased numbers of nosocomial infections. Furthermore, a high volume overload, which is required to correct a hemostasis disorder if FFP are being used in ESLD patients, may increase portal venous pressure. This might significantly increase bleeding in these ESLD patients. Although the first publication about the successful use of a viscoelastic test (VET) in liver transplantation dates back to 1985, physicians are still very reluctant to use VETs (Thrombelastography™ and/or ROTEM™) for the perioperative optimization of hemostasis. However, some very recent studies demonstrated that the use of VETs for assessing the risk of bleeding avoids futile transfusion with a similar safety profile. The implementation of ROTEM-based coagulation management and the use of coagulation factors (prothrombin complex, fibrinogen concentrate) have led to a highly significant reduction of FFP and red blood cell transfusions, without an increased incidence of thrombosis or bleeding. CONCLUSION Patients with ESLD often show pathological values of conventional parameters used to analyze coagulation hemostasis. Without overt signs of excessive bleeding, however, they do not require coagulation treatment. The use of FFP, which is associated with fluid overload and increase in portal venous pressure, should be avoided. The preferable coagulation treatment should be based on VET-guided administration of coagulation factor concentrates.
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Affiliation(s)
- Fuat H Saner
- Department of General, Visceral and Transplant Surgery, University Hospital, University Duisburg-Essen, Essen, Germany
| | - Carmen Kirchner
- Department of General, Visceral and Transplant Surgery, University Hospital, University Duisburg-Essen, Essen, Germany
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5
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Arshad F, Lisman T, Porte RJ. Hypercoagulability as a contributor to thrombotic complications in the liver transplant recipient. Liver Int 2013; 33:820-7. [PMID: 23490221 DOI: 10.1111/liv.12140] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Accepted: 02/04/2013] [Indexed: 12/13/2022]
Abstract
Traditionally, perioperative bleeding complications were a major concern during orthotopic liver transplantation, but a tremendous decline in transfusion requirements has been reported over the last decade. In recent years, there has been an increasing awareness towards perioperative thrombotic complications, including liver vessel thrombosis, and systemic venous and arterial thromboembolic events. Whereas a number of these thrombotic complications were previously categorized as surgical complications, increasing clinical and laboratory evidence suggest a role for the haemostatic system in thrombotic complications occurring during and after transplantation. High levels of the platelet adhesive protein von Willebrand factor with low levels of its regulator ADAMTS13, an increased potential to generate thrombin, and temporary hypofibrinolysis are all indicative of increased haemostatic potential after transplantation. Clinical evidence for a role of the haemostatic system in post-operative thromboses includes a higher thrombotic risk in patients with various acquired thrombotic risk factors. Although data on efficacy of anticoagulant therapy after liver transplantation are scarce, one study has shown a significant decrease in the risk for late hepatic artery thrombosis by antithrombotic therapy with aspirin. These findings suggest that antihaemostatic therapy in prevention or treatment of thromboembolic complications after liver transplantation may be relevant. Studies on efficacy and safety of these interventions are required as many of the thrombotic complications have a pronounced negative impact on graft and patient survival.
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Affiliation(s)
- Freeha Arshad
- Section Hepatobiliairy Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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7
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Vos JJ, Scheeren TWL, Lukes DJ, de Boer MT, Hendriks HGD, Wietasch JKG. Intraoperative ICG plasma disappearance rate helps to predict absence of early postoperative complications after orthotopic liver transplantation. J Clin Monit Comput 2013; 27:591-8. [DOI: 10.1007/s10877-013-9474-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Accepted: 05/06/2013] [Indexed: 01/27/2023]
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8
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Lisman T, Porte RJ. Platelet function in patients with cirrhosis. J Hepatol 2012; 56:993-4; author reply 994-5. [PMID: 22424439 DOI: 10.1016/j.jhep.2011.08.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2011] [Accepted: 08/23/2011] [Indexed: 12/12/2022]
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9
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Lisman T, Leuvenink HGD, Porte RJ, Ploeg RJ. Activation of hemostasis in brain dead organ donors: an observational study. J Thromb Haemost 2011; 9:1959-65. [PMID: 21762465 DOI: 10.1111/j.1538-7836.2011.04442.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Brain death is associated with a systemic inflammatory response resulting in diminished organ function in individuals transplanted with organs from brain dead donors. As inflammation is accompanied by activation of coagulation, we hypothesized that activation of hemostasis occurs in brain dead organ donors. OBJECTIVES To assess the hemostatic status in brain dead organ donors. PATIENTS AND METHODS In this study, we systematically assessed the hemostatic system in samples taken from 30 brain dead donors. As controls, blood samples from 30 living kidney donors were included. RESULTS AND CONCLUSIONS Compared with the living donors, brain dead donors showed significant platelet activation (assessed by glycocalicin plasma levels), and a profound dysbalance in the von Willebrand factor/ADAMTS13 axis, which is key in platelet attachment to damaged vasculature. Furthermore, compared with the living donors, brain dead donors showed a significantly increased activation of secondary hemostasis with formation of fibrin (assessed by plasma levels of prothrombin fragment 1 + 2, fibrinopeptide A and D-dimer). Finally, brain dead donors showed profound hypofibrinolysis as assessed by a global clot lysis assay, which was attributed to substantially elevated plasma levels of plasminogen activator inhibitor type 1. Collectively, our results show activation of hemostasis and dysregulated fibrinolysis in brain dead organ donors. This prothrombotic state may contribute to formation of microthrombi in transplantable organs, which potentially contributes to deterioration of organ function.
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Affiliation(s)
- T Lisman
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
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10
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Prothrombotic Gene Polymorphisms: Possible Contributors to Hepatic Artery Thrombosis After Orthotopic Liver Transplantation. Transplantation 2011; 92:587-93. [DOI: 10.1097/tp.0b013e318228063b] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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11
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Ekser B, Gridelli B, Veroux M, Cooper DK. Clinical pig liver xenotransplantation: how far do we have to go? Xenotransplantation 2011; 18:158-67. [DOI: 10.1111/j.1399-3089.2011.00642.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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12
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Esch JSA, Jurk K, Knoefel WT, Roeder G, Voss H, Tustas RY, Schmelzle M, Krieg A, Eisenberger CF, Topp S, Rogiers X, Fischer L, Aken HV, Kehrel BE. Platelet activation and increased tissue factor expression on monocytes in reperfusion injury following orthotopic liver transplantation. Platelets 2010; 21:348-59. [DOI: 10.3109/09537101003739897] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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