title: Risk factors for bleeding and clinical implications in patients undergoing liver transplantation.
abstract: BACKGROUND
  Advanced liver disease is characterized by prolonged global coagulation tests such as prothrombin time (PT). Using Model of End-stage Liver Disease (MELD) score-based allocation, many current transplant recipients show advanced end-stage liver disease with an elevated international normalized ratio (INR). The relationship between abnormalities in coagulation tests and the risk of bleeding has been recently challenged among liver disease patients. In this study we reassessed risk factors for bleeding and the clinical implications for patients who underwent orthotopic liver transplantation (OLT).
  
  
  METHODS
  We studied OLT patients between 2005 and 2011 excluding combined transplantations, retransplantations, or cases due to acute liver failure. We collected prospectively pre-OLT, during OLT, and post-OLT clinical and biochemical data to assess the risk for bleeding using linear regression models.
  
  
  RESULTS
  The strongest predictor of overall survival among 286 patients with a mean follow-up of 32 months was the number of blood transfusions (P = .005). The risk factor for bleeding during surgery investigated by multivariate analysis only showed the INR (P < .001) and the presence of ascites (P = .003) to independently correlate with the amount of blood transfusion. Receiver operation characteristics (ROC) analysis performed to determine the risk for massive blood transfusion (more than 6 units) revealed a cut-off value for INR ≥ 1.6. Appreciation of the operative field by the surgeon during the intervention as "wet" versus "dry", amounts of blood transfusion and fresh frozen plasma, and stay in the intensive care unit (ICU) and in the hospital were all significantly different (P < .001) for patients with INR <1.6 versus INR ≥ 1.6.
  
  
  CONCLUSIONS
  Bleeding during OLT affects the outcome. The risk is independently influenced by the presence of ascites (probably reflecting the degree portal hypertension) and an INR ≥ 1.6. To improve survival after OLT therapeutic interventions should be further explored to reduce the need for blood transfusions.
authors.affiliation: Department of Hepatology, University Hospital Gasthuisberg, KU Leuven, Belgium.
authors.forename: M
authors.initials: M
authors.lastname: Esmat Gamil
authors.forename: J
authors.initials: J
authors.lastname: Pirenne
authors.forename: H
authors.initials: H
authors.lastname: Van Malenstein
authors.forename: M
authors.initials: M
authors.lastname: Verhaegen
authors.forename: B
authors.initials: B
authors.lastname: Desschans
authors.forename: D
authors.initials: D
authors.lastname: Monbaliu
authors.forename: R
authors.initials: R
authors.lastname: Aerts
authors.forename: W
authors.initials: W
authors.lastname: Laleman
authors.forename: D
authors.initials: D
authors.lastname: Cassiman
authors.forename: C
authors.initials: C
authors.lastname: Verslype
authors.forename: W
authors.initials: W
authors.lastname: Van Steenbergen
authors.forename: J
authors.initials: J
authors.lastname: Van Pelt
authors.forename: F
authors.initials: F
authors.lastname: Nevens
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001201:Ascites / Q000209:etiology; D001778:Blood Coagulation Disorders / Q000097:blood / Q000150:complications* / Q000175:diagnosis / Q000401:mortality; D001780:Blood Coagulation Tests; D016063:Blood Loss, Surgical / Q000401:mortality / Q000517:prevention & control*; D001803:Blood Transfusion; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D016014:Linear Models; D008107:Liver Diseases / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D016031:Liver Transplantation / Q000009:adverse effects* / Q000401:mortality; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011446:Prospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult