Fibrinolysis detected by thrombelastography in heterotopic, auxiliary liver transplantation: effect of tissue-type plasminogen activator

Orthotopic liver transplantation (OLT) is associated with haemostatic disturbances and a severe bleeding diathesis. Fibrinolytic activity may be increased, especially during the anhepatic phase and after graft-recirculation and this has been mentioned as a possible causative factor in the occurrence of uncontrollable bleeding. However, most studies were based on global assays and could not clarify the origin of the increased fibrinolysis. Recently, a programme of auxiliary liver transplantation (APLT) was started in Rotterdam. APLT is a surgically less traumatic procedure in which no anhepatic phase occurs. We examined fibrinolytic activity in the first 8 cases of APLT by thrombelastography (TEG), and also by measuring plasma levels of tissue-type plasminogen activator activity (t-PA-act) and antigen (t-PA-Ag) and its inhibition (PAI). Intraoperatively, in only two of the eight APLTs, a period of enhanced fibrinolytic activity was observed on TEG-recordings. This could be explained by an increase of t-PA-act (max. 8840 mIU/ml and 3760 mIU/ml) and t-PA-Ag (≥ 60 ng/ml). Both patients had signs of increased bleeding during these periods. Postoperatively in patients with a good graft function PAI levels decreased to normal values, whereas persistently elevated PAI levels (≥ 25 IU/ml) were found in cases with primary non-functioning liver grafts.