Coagulation, hemostasis, and transfusion during liver transplantation

Liver disease is associated with complex disturbances of hemostasis that affect both the pro- and anticoagulant systems. This results in a "rebalanced" coagulation system that may result in bleeding diathesis or increased clot formation. Conventional coagulation models of coagulation such as the waterfall cascade model and conventional coagulation tests are not able to reflect these complex changes as they only account for deficiencies of the pro-coagulant system. Viscoelastic tests such as rotational thromboelastometry or thromboelastography may be more suitable to assess coagulation and guide transfusions in liver transplants. Specific recommendations for transfusion of platelets, fresh frozen plasma, cryoprecipitate, and fibrinogen as well as factor concentrates are discussed. In general transfusion should not only be guided by laboratory values but it also includes a clinical assessment of clot formation.