title: Thrombocytopenia in cirrhosis: Impact of fibrinogen on bleeding risk.
abstract: OBJECTIVE
  To investigate the relationship between baseline platelet count, clauss fibrinogen, maximum amplitude (MA) on thromboelastography, and blood loss in orthotopic liver transplantation (OLT).
  
  
  METHODS
  A retrospective analysis of our OLT Database (2006-2015) was performed. Baseline haematological indices and intraoperative blood transfusion requirements, as a combination of cell salvage return and estimation of 300 mls/unit of allogenic blood, was noted as a surrogate for intraoperative bleeding. Two groups: Excessive transfusion (> 1200 mL returned) and No excessive transfusion (< 1200 mL returned) were analysed. All data analyses were conducted using IBM SPSS Statistics version 23.
  
  
  RESULTS
  Of 322 OLT patients, 77 were excluded due to fulminant disease; redo transplant or baseline haemoglobin (Hb) of < 80 g/L. One hundred and fourteen (46.3%) were classified into the excessive transfusion group, 132 (53.7%) in the no excessive transfusion group. Mean age and gender distribution were similar in both groups. Baseline Hb (P≤ 0.001), platelet count (P= 0.005), clauss fibrinogen (P= 0.004) and heparinase MA (P= 0.001) were all statistically significantly different. Univariate logistic regression with a cut-off of platelets < 50 × 109/L as the predictor and Haemorrhage as the outcome showed an odds ratio of 1.393 (95%CI: 0.758-2.563;P= 0.286). Review of receiver operating characteristic curves showed an area under the curve (AUC) for platelet count of 0.604 (95%CI: 0.534-0.675;P= 0.005) as compared with AUC for fibrinogen level, 0.678 (95%CI: 0.612-0.744;P≤ 0.001). A multivariate logistic regression shows United Kingdom model for End Stage Liver Disease (P= 0.006), Hb (P= 0.022) and Fibrinogen (P= 0.026) to be statistically significant, whereas Platelet count was not statistically significant.
  
  
  CONCLUSIONS
  Platelet count alone does not predict excessive transfusion. Additional investigations,e.g., clauss fibrinogen and viscoelastic tests, provide more robust assessment of bleeding-risk in thrombocytopenia and cirrhosis.
authors.affiliation: Sonali V Thakrar, Susan V Mallett, Royal Free Perioperative Research Group, Department of Anaesthesia, Royal Free London, London NW3 2QG, United Kingdom.
authors.forename: Sonali V
authors.initials: SV
authors.lastname: Thakrar
authors.affiliation: Sonali V Thakrar, Susan V Mallett, Royal Free Perioperative Research Group, Department of Anaesthesia, Royal Free London, London NW3 2QG, United Kingdom.
authors.forename: Susan V
authors.initials: SV
authors.lastname: Mallett
keywords: Cirrhosis; Fibrinogen; Haemostasis; Liver transplantation; Thrombocytopenia