Hemocoagulative aspects of solid organ transplantation

Abstract

Transplantation has long been the standard of care for selected patients with end-stage organ disease not responsive to maximal medical treatment. Improvements in the clinical management have led to extremely high perioperative and postoperative survival rates even in the most difficult situations, even in older patients (older than 60 years), with increasing complexity both for the comorbidity burden and for the higher risk of perioperative complications. Among the many problems posed by solid organ transplant procedures, complex hemostatic problems are frequent: they result from defects associated with the preexisting systemic effects of the end-stage organ disease/failure, preoperative antiplatelet/anticoagulant medications, intraoperative bleeding related to surgical technical problems, use of extracorporeal circulation (cardiopulmonary bypass) in the case of thoracic transplant procedures or mechanical support devices used as a bridge to heart transplantation, metabolic changes during the various phases of the procedures, as in liver transplantation, hypothermic donor grafts, preservation injury, or ischemia reperfusion injury. Major perioperative hemostatic derangements during solid organ transplantation and their possible solutions are discussed: also included are the newer forms of hemostatic monitoring (thromboelastography/thromboelastometry), the most recent views on the rebalanced hemostatic system in liver-diseased patients, and the use of blood components, drugs, or both to manipulate the deranged hemostatic profiles in the perioperative period of the various solid organ transplant procedures.