Controlled trial of antithrombin III supplementation in fulminant hepatic failure

Antithrombin III for critically ill patients: a systematic review with meta-analysis and trial sequential analysis

Purpose

Antithrombin III (AT III) is an anticoagulant with anti-inflammatory properties. We assessed the benefits and harms of AT III in critically ill patients.

Methods

We searched from inception to 27 August 2015 in CENTRAL, MEDLINE, EMBASE, CAB, BIOSIS and CINAHL. We included randomized controlled trials (RCTs) irrespective of publication status, date of publication, blinding status, outcomes published or language.

Results

We included 30 RCTs with a total of 3933 participants. The majority of included trials were at high risk of bias. Combining all trials, regardless of bias, showed no statistically significant effect of AT III on mortality (RR 0.95, 95 % CI 0.88–1.03, I² = 0 %, fixed-effect model, 29 trials, 3882 participants). Among those with severe sepsis and disseminated intravascular coagulation (DIC), AT III showed no impact on mortality (RR 0.95, 95 % Cl 0.88–1.03, I² = 0 %, fixed-effect model, 12 trials, 2858 participants). We carried out multiple subgroup and sensitivity analyses to assess the benefits and harms of AT III and to examine the impact of risk of bias. AT III significantly increased bleeding events (RR 1.58, 95 % CI 1.35–1.84, I² = 0 %, fixed-effect model, 11 trials, 3019 participants). However, for all other outcome measures and analyses, the results did not reach statistical significance.

Conclusions

There is insufficient evidence to support AT III substitution in any category of critically ill participants including those with sepsis and DIC. AT III did not show an impact on mortality, but increased the risk of bleeding.

Electronic supplementary material

The online version of this article (doi:10.1007/s00134-016-4225-7) contains supplementary material, which is available to authorized users.

Antithrombin III for critically ill patients

BACKGROUND

Critical illness is associated with uncontrolled inflammation and vascular damage which can result in multiple organ failure and death. Antithrombin III (AT III) is an anticoagulant with anti-inflammatory properties but the efficacy and any harmful effects of AT III supplementation in critically ill patients are unknown. This review was published in 2008 and updated in 2015.

OBJECTIVES

To examine:1. The effect of AT III on mortality in critically ill participants.2. The benefits and harms of AT III.We investigated complications specific and not specific to the trial intervention, bleeding events, the effect on sepsis and disseminated intravascular coagulation (DIC) and the length of stay in the intensive care unit (ICU) and in hospital in general.

SEARCH METHODS

We searched the following databases from inception to 27 August 2015: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid SP), EMBASE (Ovid SP,), CAB, BIOSIS and CINAHL. We contacted the main authors of trials to ask for any missed, unreported or ongoing trials.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) irrespective of publication status, date of publication, blinding status, outcomes published, or language. We contacted the investigators and the trial authors in order to retrieve missing data. In this updated review we include trials only published as abstracts.

DATA COLLECTION AND ANALYSIS

Our primary outcome measure was mortality. Two authors each independently abstracted data and resolved any disagreements by discussion. We presented pooled estimates of the intervention effects on dichotomous outcomes as risk ratios (RR) with 95% confidence intervals (CI). We performed subgroup analyses to assess risk of bias, the effect of AT III in different populations (sepsis, trauma, obstetrics, and paediatrics), and the effect of AT III in patients with or without the use of concomitant heparin. We assessed the adequacy of the available number of participants and performed trial sequential analysis (TSA) to establish the implications for further research.

MAIN RESULTS

We included 30 RCTs with a total of 3933 participants (3882 in the primary outcome analyses).Combining all trials, regardless of bias, showed no statistically significant effect of AT III on mortality with a RR of 0.95 (95% CI 0.88 to 1.03), I² statistic = 0%, fixed-effect model, 29 trials, 3882 participants, moderate quality of evidence). For trials with low risk of bias the RR was 0.96 (95% Cl 0.88 to 1.04, I² statistic = 0%, fixed-effect model, 9 trials, 2915 participants) and for high risk of bias RR 0.94 (95% Cl 0.77 to 1.14, I² statistic = 0%, fixed-effect model, 20 trials, 967 participants).For participants with severe sepsis and DIC the RR for mortality was non-significant, 0.95 (95% Cl 0.88 to 1.03, I² statistic = 0%, fixed-effect model, 12 trials, 2858 participants, moderate quality of evidence).We conducted 14 subgroup and sensitivity analyses with respect to the different domains of risk of bias, but detected no statistically significant benefit in any subgroup analyses.Our secondary objective was to assess the benefits and harms of AT III. For complications specific to the trial intervention the RR was 1.26 (95% Cl 0.83 to 1.92, I² statistic = 0%, random-effect model, 3 trials, 2454 participants, very low quality of evidence). For complications not specific to the trial intervention, the RR was 0.71 (95% Cl 0.08 to 6.11, I² statistic = 28%, random-effects model, 2 trials, 65 participants, very low quality of evidence). For complications other than bleeding, the RR was 0.72 ( 95% Cl 0.42 to 1.25, I² statistic = 0%, fixed-effect model, 3 trials, 187 participants, very low quality of evidence). Eleven trials investigated bleeding events and we found a statistically significant increase, RR 1.58 (95% CI 1.35 to 1.84, I² statistic = 0%, fixed-effect model, 11 trials, 3019 participants, moderate quality of evidence) in the AT III group. The amount of red blood cells administered had a mean difference (MD) of 138.49 (95% Cl -391.35 to 668.34, I² statistic = 84%, random-effect model, 4 trials, 137 participants, very low quality of evidence). The effect of AT III in patients with multiple organ failure (MOF) was a MD of -1.24 (95% Cl -2.18 to -0.29, I² statistic = 48%, random-effects model, 3 trials, 156 participants, very low quality of evidence) and for patients with an Acute Physiology and Chronic Health Evaluation score (APACHE) at II and III the MD was -2.18 (95% Cl -4.36 to -0.00, I² statistic = 0%, fixed-effect model, 3 trials, 102 participants, very low quality of evidence). The incidence of respiratory failure had a RR of 0.93 (95% Cl 0.76 to 1.14, I² statistic = 32%, random-effects model, 6 trials, 2591 participants, moderate quality of evidence). AT III had no statistically significant impact on the duration of mechanical ventilation (MD 2.20 days, 95% Cl -1.21 to 5.60, I² statistic = 0%, fixed-effect model, 3 trials, 190 participants, very low quality of evidence); on the length of stay in the ICU (MD 0.24, 95% Cl -1.34 to 1.83, I² statistic = 0%, fixed-effect model, 7 trials, 376 participants, very low quality of evidence) or on the length of stay in hospital in general (MD 1.10, 95% Cl -7.16 to 9.36), I² statistic = 74%, 4 trials, 202 participants, very low quality of evidence).

AUTHORS' CONCLUSIONS

There is insufficient evidence to support AT III substitution in any category of critically ill participants including the subset of patients with sepsis and DIC. We did not find a statistically significant effect of AT III on mortality, but AT III increased the risk of bleeding events. Subgroup analyses performed according to duration of intervention, length of follow-up, different patient groups, and use of adjuvant heparin did not show differences in the estimates of intervention effects. The majority of included trials were at high risk of bias (GRADE; very low quality of evidence for most of the analyses). Hence a large RCT of AT III is needed, without adjuvant heparin among critically ill patients such as those with severe sepsis and DIC, with prespecified inclusion criteria and good bias protection.

Antithrombin III injection via the portal vein suppresses liver damage

AIM: To investigate the effects of antithrombin III (AT III) injection via the portal vein in acute liver failure.

METHODS: Thirty rats were intraperitoneally challenged with lipopolysaccharide (LPS) and D-galactosamine (GalN) and divided into three groups: a control group; a group injected with AT III via the tail vein; and a group injected with AT III via the portal vein. AT III (50 U/kg body weight) was administrated 1 h after challenge with LPS and GalN. Serum levels of inflammatory cytokines and fibrin degradation products, hepatic fibrin deposition, and hepatic mRNA expression of hypoxia-related genes were analyzed.

RESULTS: Serum levels of alanine aminotransferase, tumor necrosis factor-α and interleukin-6 decreased significantly following portal vein AT III injection compared with tail vein injection, and control rats. Portal vein AT III injection reduced liver cell destruction and decreased hepatic fibrin deposition. This treatment also significantly reduced hepatic mRNA expression of lactate dehydrogenase and heme oxygenase-1.

CONCLUSION: A clinically acceptable dose of AT III injection into the portal vein suppressed liver damage, probably through its enhanced anticoagulant and anti-inflammatory activities.

Impact of antithrombin III concentrates on portal vein thrombosis after splenectomy in patients with liver cirrhosis and hypersplenism

OBJECTIVE

The aim of this study was to determine the role of antithrombin III (AT-III) in portal vein thrombosis (PVT) after splenectomy in cirrhotic patients.

SUMMARY BACKGROUND DATA

There is no standard treatment for PVT after splenectomy in liver cirrhosis.

METHODS

A total of 50 consecutive cirrhotic patients who underwent laparoscopic splenectomy for hypersplenism were enrolled into this study. From January 2005 to December 2005, 25 cirrhotic patients received no prophylactic anticoagulation therapy after the operation (AT-III [-] group). From January 2006 to July 2006, 25 cirrhotic patients received prophylactic administration of AT-III concentrates (1500 U/d) on postoperative day (POD) 1, 2, and 3 (AT-III [+] group).

RESULTS

In AT-III (-) group, 9 (36.0%) patients developed PVT up to POD 7, and risk factors for PVT were identified as: low platelet counts, low AT-III activity, and increased spleen weight. Although there were no significant differences in the clinical characteristics, including the above risk factors, between the 2 groups, only 1 (4.0%) patient developed PVT on POD 30 in AT-III (+) group, and the incidence of PVT was significantly lower than in AT-III (-) group (P = 0.01). In AT-III (-) group, AT-III activity was significantly decreased from POD 1 to POD 7, as compared with the preoperative level, whereas AT-III concentrates prevented the postoperative decrease in AT-III activity.

CONCLUSIONS

These results demonstrate that low AT-III activity and further decreases in this activity are associated with PVT after splenectomy in cirrhotic patients, and that treatment with AT-III concentrates is likely to prevent the development of PVT in these patients.

Early prediction of short-term development of hepatic encephalopathy in patients with acute liver disease unrelated to paracetamol. A prospective study in Japan

BACKGROUND/AIMS

The aim of our study was to provide a predictive model for early recognition of the risk of short-term development of hepatic encephalopathy (HE) in patients with symptomatic acute liver disease (ALD).

METHODS

From a retrospective analysis of 220 patients with ALD, prothrombin time (PT) equal to, or lower than, 80% of normal, was set as the registration criteria in the subsequent patient cohorts of the study. Then, a HE-prediction model was derived by a logistic regression analysis of data in 259 new patients, and prospectively validated in 124 other patients, both groups of patients were affected by ALD unrelated to paracetamol (non-P ALD).

RESULTS

The following HE-prediction model was established: lambda = [0.692 x ln(1 + total bilirubin(mg/dL))] - 0.065 x PT(%) + [1.388 x Age(years)] + [0.868 x Etiology] - 1.156, where Age is 1 in patients older than 50 years and Etiology is 1 when the cause of non-P ALD is flare-up of type B hepatitis, auto-immune hepatitis or unknown, and 0 otherwise. In the validation group, according to the model-based risk of subsequent development of HE, sensitivity and specificity of the model were 100% and 69.0%, respectively, in patients with an evaluated risk lower than 20%, and 62.5% and 93.1%, respectively, in those with an evaluated risk equal to, or greater than, 50%.

CONCLUSION

In Japanese patients with symptomatic non-P ALD, our model, which includes four of the five items used in the King's College Hospital criteria, represents an acceptable, effective model to allow early detection of the risk of short-term development of HE. Using this model in other populations requires further validation specific to each of them.

[Heparin resistance and antithrombin deficiency]

The phenomenon of heparin resistance (HR) is characterized by high doses of unfractionated heparin (UFH) being required to bring activated partial thromboplastin time (aPTT) and activated coagulation time (ACT) within therapeutically desired ranges, or by the impossibility of reaching these ranges. At UFH dosages > 35,000 IU/d, HR should be considered a factor. The most frequent cause of HR is deficiency of antithrombin (AT), the presence of which is essential for UFH to exert its anticoagulatory effect. AT in concentrate form may be applied to overcome AT-dependent HR. The main clinically relevant situations in which AT-dependent HR occurs, with possible indication of AT substitution, are congenital AT deficiency, asparaginase therapy, disseminated intravascular coagulation (DIC) and administration of high doses of heparin during extracorporeal circulation, where it is significant, due to the need to maintain a very high ACT (> 400 s), that use of heart-lung machines is associated with an HR incidence of approximately 20%. The following procedure is recommended when there is no DIC and when extracorporeal circulation is not used: if HR is suspected and AT activity is < or = 60%, UFH should first be reduced to 500 IU/h (to prevent bleeding complications), before AT is substituted. AT activity should then exceed 80%. Under normalized and stable AT activity, the UFH dose should be adjusted such that aPTT is within a range of 60-100 s. If anticoagulation over a longer term is indicated, then overlapping anticoagulation with a vitamin K antagonist should be started as quickly as possible.

Antithrombin III for critically ill patients

BACKGROUND

Critical illness is associated with uncontrolled inflammation and vascular damage which can result in multiple organ failure and death. Antithrombin III (AT III) is an anticoagulant with anti-inflammatory properties but the efficacy and any harmful effects of AT III supplementation in critically ill patients are unknown.

OBJECTIVES

To assess the benefits and harms of AT III in critically ill patients.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); MEDLINE; EMBASE; Science Citation Index Expanded; International Web of Science; CINAHL; LILACS; and the Chinese Biomedical Literature Database (up to November 2006). We contacted authors and manufacturers in the field.

SELECTION CRITERIA

We included all randomized clinical trials, irrespective of blinding or language, that compared AT III with no intervention or placebo in critically ill patients.

DATA COLLECTION AND ANALYSIS

Our primary outcome measure was mortality. We each independently abstracted data and resolved any disagreements by discussion. We presented pooled estimates of the intervention effects on dichotomous outcomes as relative risks (RR) with 95% confidence intervals (CI). We performed subgroup analyses to assess risk of bias, the effect of AT III in different populations (sepsis, trauma, obstetric, and paediatric patients), and the effect of AT III in patients with or without the use of concomitant heparin. We assessed the adequacy of the available number of participants and performed a trial sequential analysis to establish the implications for further research.

MAIN RESULTS

We included 20 randomized trials with a total of 3458 participants; 13 of these trials had high risk of bias. When we combined all trials, AT III did not statistically significantly reduce overall mortality compared with the control group (RR 0.96, 95% CI 0.89 to 1.03; no heterogeneity between trials). A total of 32 subgroup and sensitivity analyses were carried out. Analyses based on risk of bias, different populations, and the role of adjuvant heparin gave insignificant differences. AT III reduced the multiorgan failure score among survivors in an analysis involving very few patients. AT III increased bleeding events (RR 1.52, 95% CI 1.30 to 1.78).

AUTHORS' CONCLUSIONS

AT III cannot be recommended for critically ill patients based on the available evidence. A randomized controlled trial of AT III, without adjuvant heparin, with prespecified inclusion criteria and good bias protection is needed.

Acute and chronic liver insufficiency

The term “liver insufficiency” denotes a break down in the functions of the liver. The syndrome of functional liver failure covers a wide spectrum of clinical, biochemical and neurophysiological changes. In principle, liver insufficiency can occur without previous liver damage as well as with already existing liver disease. It is characterized by a deterioration in the synthesizing, regulatory and detoxifying function of the liver. This final stage of liver disease terminates in hepatic coma.

A systematic review of antithrombin concentrate use in patients with disseminated intravascular coagulation of severe sepsis

The objective was to estimate the effect of antithrombin therapy on mortality in disseminated intravascular coagulation (DIC) of severe sepsis and septic shock. Randomized clinical trials (RCT) on patients with DIC and severe sepsis or septic shock assigned to intravenous antithrombin or placebo were searched. Eligible studies reported death as the outcome measure. Of 35 RCT, 32 trials were excluded because patients were not randomized to antithrombin versus placebo, or no separate data on patients with DIC were given. In three RCT, 364 patients with severe sepsis or septic shock and DIC were randomized. The disease severity, definition of DIC, dose and duration of treatment varied among the trials. In two of the three RCT, data were from subgroup analyses (patients not stratified by DIC). The combined odds ratio for short-term all-cause mortality in those who received antithrombin was 0.649 (95% confidence interval, 0.422-0.998). Data on bleeding complications in patients treated with antithrombin were reported only in one of the RCT and were not considered suitable for systematic safety estimation. In sepsis patients with DIC, administration of antithrombin concentrate may increase overall survival. Current available evidence, however, is not suited to sufficiently inform clinical practice.

Single-shot antithrombin in human pancreas-kidney transplantation: reduction of reperfusion pancreatitis and prevention of graft thrombosis*

Reperfusion pancreatitis and graft thrombosis often induce early graft loss in simultaneous pancreas-kidney (SPK) transplantation. Antithrombin (AT) is a coagulatory inhibitor with pleiotropic activities that reduces experimental ischemia/reperfusion injury. This study retrospectively analyses prophylactic high-dose AT application in patients with first SPK. In an university transplantation center, 53 consecutive patients with SPK were studied without randomization. In one group, 3000 IU of AT was given intravenously before pancreatic reperfusion (AT, n = 24). Patients receiving standard therapy including postoperative AT supplementation (controls, n = 29) served as controls. Daily blood sampling was performed as a part of the clinical routine during four postoperative days. There were no differences in demographic and laboratory parameters [donor/recipient age, ischemia time, perfusion solution, body weight, mismatches] between both groups. Baseline creatinine values were lower in the control group versus AT group (P < 0.05). Coagulatory parameters and bleeding incidence were not influenced by AT, while incidence of graft thrombosis was reduced (control: 7/29; AT: 4/24; relative reduction of risk: -33%; P < 0.05). Single-shot AT application during SPK modulated serum lipase activity on postoperative days 2 and 3, and minimized risk for graft thromboses without increasing perioperative bleeding. This new concept should deserve testing in a prospective clinical trial.

Effects of acute liver injury on blood coagulation

The mechanisms leading to the hemostatic changes of acute liver injury are poorly understood. To study these further we have assessed coagulation and immune changes in patients with acute paracetamol overdose and compared the results to patients with chronic cirrhosis and normal healthy controls. The results demonstrate that in paracetamol overdose coagulation factors (F)II, V, VII and X were reduced to a similar degree and were significantly lower than FIX and FXI (mean levels 0.28, 0.16, 0.13, 0.19, 0.51 and 0.72 IU mL(-1), respectively). In cirrhosis, by contrast, FII, FV, FVII, FIX and FX were equally reduced whilst FXI was lower than the other factors (mean levels 0.64, 0.69, 0.62, 0.60, 0.66 and 0.40 IU mL-1, respectively). FVIII was raised in paracetamol overdose patients but normal in those with cirrhosis (mean levels 1.95 and 1.01 IU mL(-1), respectively). Interleukin-6 and tumor necrosis factor-alpha levels were raised in both patient groups, but higher levels were found in paracetamol overdose, compared to cirrhosis. Thrombin-antithrombin and soluble tissue factor levels were higher in those with acute liver injury but normal in cirrhosis. Antithrombin levels were reduced in both acute liver injury and cirrhosis. From these data we put forward a novel mechanism for the coagulation changes in acute paracetamol induced liver injury. We propose that immune activation leads to tissue factor-initiated consumption of FII, FV, FVII and FX, but that levels of FIX and FXI are better preserved because antithrombin inhibits the thrombin induced positive feedback loop that activates these latter factors.

Recombinant activated factor VII for coagulopathy in fulminant hepatic failure compared with conventional therapy

Severe coagulopathy in fulminant hepatic failure (FHF) is difficult to correct by conventional means. Recombinant activated factor VII (rFVIIa) is an antihemophilic factor that has shown promise in treating coagulopathy in liver disease. Our aim is to review our experience with rFVIIa in treating the coagulopathy of FHF and compare these results with those of conventional therapy. Fifteen patients with FHF who met King's College criteria for orthotopic liver transplantation were studied. All were ascertained from our liver disease registry. Eight consecutive patients were administered fresh frozen plasma (FFP) alone, whereas seven consecutive patients were administered FFP and rFVIIa (40 microg/kg intravenous bolus). The two groups, with similar demographic characteristics, were compared in terms of measured parameters of coagulopathy (prothrombin time and international normalized ratio), amount of plasma infused, development of anasarca, ability to undergo intracranial pressure (ICP) transducer placement, bleeding complications, ability to undergo transplantation, and survival. All patients administered rFVIIa (after a single dose) versus none administered FFP alone had temporary (2- to 6-hour) correction of coagulopathy (P <.0002). All patients administered rFVIIa versus 38% administered FFP alone were able to have an ICP transducer placed (P =.03). The rFVIIa group had less anasarca (P =.04). An equal number of patients underwent transplantation from each group, but overall survival was slightly better in the rFVIIa group (P =.04). Five of seven patients in the rFVIIa group were administered one or more subsequent doses of rFVIIa after placement of the ICP monitor (two patients, for additional procedures; three patients, prophylactically in the first 24 hours after ICP transducer placement) at the discretion of the attending physicians. We conclude that rFVIIa is effective in transiently correcting laboratory parameters of coagulopathy in patients with FHF. It facilitates the performance of invasive procedures and is associated with less frequent anasarca compared with conventional therapy. Our preliminary experience supports the need for further studies to define the optimal dosing, safety, and efficacy of rFVIIa in patients with FHF.

The influence of antithrombin III (AT III) substitution to supranormal activities on systemic procoagulant turnover in patients with end-stage chronic liver disease

OBJECTIVE

Since antithrombin III (AT III) substitution to normal activities could not be shown to have major beneficial effects in patients with end-stage chronic liver disease in a variety of clinical settings, we tested the hypothesis that substitution to supranormal activities decreases systemic procoagulant turnover better in this patient group.

DESIGN

Controlled prospective clinical study.

SETTING

Operating rooms at a University Hospital.

PATIENTS

Twenty-four patients with histologically verified liver cirrhosis consecutively scheduled for liver transplantation.

INTERVENTIONS

Nineteen patients were given an antithrombin III concentrate to achieve either 100% (n = 10) or 175% (n = 9) AT III activity. Control patients (n = 5) received saline 0.9% instead.

MEASUREMENTS AND RESULTS

Molecular markers of coagulation activation, platelet count and aggregability, and global coagulation variables were measured prior to AT III infusion and 60 min thereafter. In both AT III-treated groups thrombin-antithrombin III-complex increased significantly (p < 0.005), whereas prothrombin fragment F1 + 2, soluble fibrin and D-dimer concentrations, as well as other variables, did not show major changes.

CONCLUSIONS

Despite thrombin inhibition by AT III in patients with end-stage chronic liver disease, systemic procoagulant turnover was not significantly decreased 60 min after AT III application even to supranormal activities. Replenishment of the inhibitory antithrombin III pool, decreased in chronic liver disease, should not be expected to slow down the baseline consumptive component of the haemostatic disorder in this patient group.

Treatment of hepatic failure--1996: current concepts and progress toward liver dialysis

Liver failure, especially in its acute form, is a medical emergency that quickly leads to failure of multiple other organs. Many of these end-organ failures can be supported temporarily by drugs or medical devices, but the support is invariably short-lived if liver function is not restored. In most instances, liver function can only be restored by transplantation, although patients with acute disease have the potential to recover by regeneration ("spontaneous recovery"). Unfortunately, spontaneous recovery from acute liver failure is uncommon, so the two most important aspects of patient management are highly skilled intensive care and early recognition of patients in need of liver transplantation. Even under these circumstances, the mortality of liver failure remains high because we have no easy way of replacing liver function on demand and donor organs are becoming increasingly difficult to obtain in time. The development of techniques for liver assist offer the possibility that patients with liver failure will become a simple management problem, analogous to the options available in the treatment of acute and chronic renal failure.

Massive ascitic fluid loss and coagulation disturbances after liver transplantation

BACKGROUND & AIMS

A unique syndrome in which massive ascitic fluid loss developing 1-4 weeks after orthotopic liver transplantation (OLT) was associated with a hypercoagulable state and thrombotic complications is described. After OLT, severe coagulation abnormalities (international normalized ratio, 4.6) developed in a patient with ascitic losses of up to 12 L/day. The patient developed hypovolemia and severe systemic antithrombin III deficiency and venoocclusive disease in the graft. The aim of this study was to determine the prevalence of this syndrome after OLT.

METHODS

Coagulation studies were performed in 25 additional patients with large ascitic fluid losses after OLT and in 7 cirrhotic patients not undergoing transplantation.

RESULTS

All transplant recipients developed systemic deficiencies of multiple coagulation factors including antithrombin III. Markers of prothrombin activation were significantly elevated in both ascites and serum in all patients, and thrombotic complications subsequently developed in 5 patients. In the 7 cirrhotic patients, markers of prothrombin activation remained normal or minimally elevated and thrombotic complications were not found.

CONCLUSIONS

Massive ascitic losses after OLT may lead to a hypercoagulable state from unreplaced losses of plasma coagulation factors into ascites and accumulation of thrombin in the systemic circulation. Hypovolemia and major coagulation abnormalities should be corrected with fresh frozen plasma, which may prevent the development of thrombotic complications.