Franklin A. Bontempo

Intraoperative Changes in Blood Coagulation and Thrombelastographic Monitoring in Liver Transplantation

The blood coagulation system of 66 consecutive patients undergoing consecutive liver transplantations was monitored by thrombelastograph and analytic coagulation profile. A poor preoperative coagulation state, decrease in levels of coagulation factors, progressive fibrinolysis, and whole blood clot lysis were observed during the preanhepatic and an-hepatic stages of surgery. A further general decrease in coagulation factors and platelets, activation of fibrinolysis, and abrupt decrease in levels of factors V and VIII occurred before and with reperfusion of the homograft. Recovery of blood coagulability began 30–60 min after reperfusion of the graft liver, and coagulability had returned toward baseline values 2 hr after reperfusion. A positive correlation was shown between the variables of thrornbelastography and those of the coagulation profile. Thrombelastography was shown to be a reliable and rapid monitoring system. Its use was associated with a 33% reduction of blood and fluid infusion volume, whereas blood coagulability was maintained without an increase in the number of blood product donors.

Epsilon-aminocaproic Acid for Treatment of Fibrinolysis during Liver Transplantation

In 97 adult patients receiving liver transplants, the coagulation system was monitored by thrombelastography and by coagulation profile including PT; aPTT; platelet count; level of factors I, II, V, VII, VIII, IX, X, XI, and XII; fibrin degradation products; ethanol gel test; protamine gel test; and euglobulin lysis time. Preoperatively, fibrinolysis defined as a whole blood clot lysis index of less than 80% was present in 29 patients (29.9%), and a euglobulin lysis time of less than 1 h was present in 13 patients. Fibrinolysis increased progressively during surgery in 80 patients (82.5%) and was most severe on reperfusion of the graft liver in 33 patients (34%). When whole blood clot lysis (F < 180 min) was observed during reperfusion of the graft liver, blood coagulability was tested by thrombelastography using both a blood sample treated in vitro with &epsis;-aminocaproic acid (0.09%) and an untreated sample. Blood treated with &epsis;-aminocaproic acid showed improved coagulation without fibrinolytic activity in all 74 tests. When whole blood clot lysis time was less than 120 min, generalized oozing occurred, and the effectiveness of &epsis;-aminocaproic acid was demonstrated in vitro during the pre-anhepatic and post-anhepatic stages, &epsis;-aminocaproic acid (1 g, single intravenous dose) was administered. In all 20 patients treated with &epsis;-aminocaproic acid, fibrinolytic activity disappeared; whole blood clot lysis was not seen on thrombelastography during a 5-h observation period, and whole blood clot lysis index improved from 28.5 ± 29.5% to 94.8 ± 7.4% (mean ± SD, P < 0.001). None of the treated patients had hemorrhagic or thrombotic complications. In patients undergoing liver transplantation, the judicious use of a small dose of &epsis;-aminocaproic acid, when its efficacy was confirmed in vitro, effectively treated the severe fibrinolysis without clinical thrombotic complications.

Liver transplantation in a hemophiliac.

To the Editor: A cure rather than a treatment has long been the goal of those caring for and those suffering from hemophilia. Encouraging results were obtained some years ago with the transplantation of normal livers into a dog with mild hemophilia 1,2 and into four others with severe hemophilia.3 Two dogs given transplants survived more than 100 days and produced coagulation factor VIII in quantities sufficient to maintain normal levels. The first “cure” in a human being appears to have been achieved, at least temporarily, in a 15-year-old boy with hemophilia and severe chronic active hepatitis, who received a liver from a 9-year-old “normal” donor on March 5, 1985. The patient was given the diagnosis of hemophilia A in early childhood and has been followed at the Hemophilia Center, Children’s Memorial Hospital, Northwestern School of Medicine, Chicago, by Dr. John Paul Scott. In 1969 he had severe hepatitis B; positivity for hepatitis B surface antigen and antibody to hepatitis B e has persisted. In addition, therapy-related non A,non B hepatitis may have contributed to his liver disease. About four months before liver transplantation, a splenectomy was performed for chronic thrombocytopenia, which resolved postoperatively, but a residual pancreaticogastrocutaneous fistula remained. Liver transplantation and repair of the fistula were accomplished with less than the average blood loss. Before, during, and for 18 hours after liver transplantation, the patient’s factor VIII level was maintained at 0.54 to 1.60 U per milliliter by intermittent infusions of heat-treated factor VIII concentrate. From 18 hours after operation to the time of this writing (April 17), his level has been sustained at 1.0 to 3.0 U per milliliter without exogenous treatment. The high postoperative levels of factor VIII are similar to those seen after transplantation in patients without hemophilia. Eight days after operation the patient underwent repair of a bile duct. There was no increased hemorrhage, and he required no factor VIII treatment. Although in this case, at least temporarily, internal production of factor VIII has been achieved by the implanted liver, liver transplantation cannot be recommended as a “cure” for hemophilia. This drastic operation is justified only for end-stage liver disease because of the risks of lifelong immunosuppressive therapy, rejection, infection, and recurrence of disease. The duration of production of factor VIII is unknown. This case suggests that the antihemophilic activity (factor VIII:C) of the large factor VIII complex, synthesized in endothelium.4,5 is acquired in the liver.

THE RELATION OF PREOPERATIVE COAGULATION FINDINGS TO DIAGNOSIS, BLOOD USAGE, AND SURVIVAL IN ADULT LIVER TRANSPLANTATION

A group of 70 adults with end-stage liver disease received 87 homologous liver transplants from 7/11/81 and 7/11/83. The recipients fell into the following diagnostic categories: postnecrotic cirrhosis (PNC) in 22, primary biliary cirrhosis (PBC) in 18, cancer or neoplasia (CA) in 11, sclerosing cholangitis (SC) in 8 and miscellaneous (MISC) in 11. Survival for six months or longer was 46%: survival by group was PBC=67%, CA=55%, PNC=45%, SC=25%, and MISC=18%. Preoperative coagulation profiles were evaluated on 64 of the 70 first transplant patients by assigning a score derived from one point per abnormality in each of 8 tests. Mean coagulation abnormality scores (CAS) were strikingly elevated in the PNC and MISC groups. Mean intraoperative blood product usage was 43 units of RBCs, 40 units of fresh frozen plasma (FFP), 21 units of platelets, and 9 bags of cryoprecipitate. Direct correlations were found between CAS and RBC usage (+0.454, P=<.001), CAS, and survival of 6 months or longer (-0.281, P=<.02), and RBC usage and survival (-0.408, P=<.001). These findings indicate that the degree of coagulation abnormality and the type of liver disease may be predictive of intraoperative blood usage and survival in liver transplantation in adults.

Hemostasis in liver transplantation

M ore than 25 yr ago, Starzl et al. (1) reported the first clinical application of orthotopic liver transplantation. The patient, who died of blood loss due to hemostatic disturbances, had complications that would become a serious problem in subsequent patients. Although the success rate has improved markedly in recent years, and orthotopic liver transplantation is now an accepted treatment for patients with an end-stage of chronic liver disease (2,3), massive blood loss is still a major problem (4-6). In the recently published First Report of the European Liver Transplant Registry (7)) bleeding complications were the most frequent (34%) cause of death intraoperatively and during the first postoperative week. Several investigators have demonstrated that large perioperative blood loss is correlated with a high mortality (8,9). Patients undergoing orthotopic liver transplantation who received ~30 U of red blood cells had a survival rate of 70%, whereas the survival rate decreased to about 14% in patients receiving 2 30 U (10). Disturbances in hemostasis appeared to be a major contributing factor to a high blood loss (8,ll) and surviving and nonsurviving cases of orthotopic liver transplantation can be partly classified by discriminant analysis of hemostasis parameters (12). Many studies have examined the pathogenesis of the hemorrhagic diathesis in orthotopic liver transplantation. Results of several studies, however, are contradictory. The use of different operation techniques and management procedures and variations in assay methods make comparison of the results difficult. In the last few years improvements in operative management, surgical techniques, and improved graft preservation have played an important role in reducing the intraoperative blood loss. Although these factors have undoubtedly contributed to lowering the intraoperative mortality, patients using >50 U of red blood cells are still no exception. Serious hemostatic disorders can still be found in patients undergoing orthotopic liver transplantation and they are often a diagnostic and therapeutic dilemma to many clinicians. We have surveyed the literature dealing with intraoperative changes in hemostasis found in clinical and experimental orthotopic liver transplantation and the underlying processes. In this paper the results of older studies will be discussed in the light of current experiences and insights regarding hemostasis in liver transplantation. In view of the renewed interest in the heterotopic transplantation of an auxiliary liver graft, the effects of auxiliary liver transplantation on hemostasis will be compared with those induced by orthotopic liver transplantation.

Association of a Common Interferon Regulatory Factor 5 (IRF5) Variant with Increased Risk of Systemic Lupus Erythematosus (SLE)

Interferon regulatory factor 5 (IRF5) belongs to a family of transcription factors that control the transactivation of type I interferon system‐related genes, as well as the expression of several other genes involved in immune response, cell signalling, cell cycle control and apoptosis. Two recent studies reported a significant association between the IRF5/rs2004640 T allele and systemic lupus erythematosus (SLE). The purpose of this study was to determine whether the reported rs2004640 T allele association could be replicated in our independent SLE case‐control sample. We genotyped DNA samples from 370 white SLE‐affected female subjects and 462 white healthy female controls using the TaqMan Assay‐on‐Demand for rs2004640, and performed a case‐control genetic association analysis. Frequency of the rs2004640 T allele was significantly higher in cases than in controls (56.5% vs. 50%; P= 0.008). The odds ratio for T allele carriers was 1.68 (95% CI: 1.20 – 2.34; P= 0.003). Our results in an independent case‐control sample confirm the robust association of the IRF5/rs2004640 T allele with SLE risk, and further support the relevance of the type I interferon system in the pathogenesis of SLE and autoimmunity.

Increase in Hepatitis C Virus Load in Hemophiliacs during Treatment with Highly Active Antiretroviral Therapy

The effect of highly active antiretroviral therapy (HAART) on liver function and viral load of hepatitis C virus (HCV) was studied in 21 hemophilic men coinfected with HCV and human immunodeficiency virus (HIV). HCV RNA polymerase chain reaction was measured by branched DNA Quantiplex assay on frozen plasma samples obtained at baseline and at 24, 48, and 96 weeks after initiation of HAART. HCV RNA increased at 48 and 96 weeks after initiation of HAART therapy (198x105 Eq/mL [P=.03] and 227x105 Eq/mL [P<.0001], respectively, compared with baseline [141x105 Eq/mL]). This increase was associated with an increase in CD4 cell count and reduction in HIV viral load but no change in hepatic transaminases. With discontinuation of HAART, HCV RNA decreased as HIV RNA rebounded. Further study is required to clarify the histopathologic significance of this finding.

Genetic Variation in Lectin-Like Oxidized Low-Density Lipoprotein Receptor 1 (LOX1) Gene and the Risk of Coronary Artery Disease

Background—We examined the association of 3 polymorphisms in the lectin-like oxidized LDL receptor-1 (LOX1 or OLR1) gene with coronary artery disease in the Women’s Ischemia Syndrome Evaluation (WISE) study population. Methods and Results—The WISE sample comprised 589 white and 122 black women who underwent angiography for suspected ischemia. The sample was divided into 3 groups: <20% stenosis (38.7%), 20% to 49% stenosis (24.9%), and ≥50% stenosis (35.3%). The three LOX1 polymorphisms (intron 4/G→A, intron 5/T→G, and 3′ UTR/T→C) were in linkage disequilibrium and thus behaved as a single polymorphism. The frequency of the 3′UTR/T allele was significantly higher in whites than blacks (49% versus 19%; P <0.0001). Among white women, the frequency of the 3′UTR/T allele carriers (TC+TT genotypes) increased gradually from 67.9% to 75.0% and 79.2% in the <20%, 20% to 49%, and ≥50% stenosis groups, respectively (&khgr;2 trend=6.23; P =0.013). Logistic regression analyses indicated that APOE (odds ratio, 1.90; P =0.007) and LOX1 (odds ratio, 1.67; P =0.025) genotypes were independently associated with the risk of disease and that there was no interaction between the two genes. The 3′UTR/T allele carriers also had significantly higher IgG anti-oxLDL levels than individuals carrying the CC genotype (0.94±0.20 versus 0.86±0.16; P =0.032). Furthermore, our electrophoretic mobility shift assay data show that the 3′UTR polymorphic sequence affects the binding of a putative transcription factor in an allele-specific manner. Conclusions—Our data suggest that common genetic variation in the LOX1 gene may be associated with the risk of coronary artery disease in white women.

The factor V Leiden mutation: spectrum of thrombotic events and laboratory evaluation.

PURPOSE This study aims to describe the spectrum of clinical thrombotic events and to compare the methods of laboratory evaluation for the newly described prothrombotic factor V Leiden mutation. METHODS Specimens from 1376 patients with thrombotic events or their relatives were tested for the factor V Leiden mutation by polymerase chain reaction plus restriction digest from Jan. 1, 1995, to Mar. 31, 1996. Activated protein C (APC) resistance test data was available for 554 of these patients. Clinical information was available for 166 patients with the mutation. RESULTS Of 1376 patients tested for factor V Leiden mutation, 270 (19.6%) were positive, with 12 homozygotes and 258 heterozygotes. Of 554 patients for whom APC resistance data was available, 221 (39.9%) had low APC resistance ratios (< or = 2.4); of these only 97 (43.9%) were factor V Leiden-positive. Among 333 samples with normal or elevated APC resistance ratios, 19 (5.7%) were later identified with the factor V Leiden mutation, despite the normal screening test. One hundred fourteen of 166 patients (68.7%) with the mutation had at least one thrombotic event, most commonly deep venous thrombosis and pulmonary embolus. Arterial cerebrovascular thrombotic events occurred in 11 patients (10%), and myocardial infarctions in eight (7%). The mean age of all patients with arterial thrombotic events was 45.4 years. CONCLUSIONS The factor V mutation is a common cause of venous thromboses but may also be associated with the early presentation of arterial thrombotic events. The APC resistance test is a sensitive screening assay but has limitations of its specificity in clinical practice.

JAK2 V617F mutation in patients with catastrophic intra-abdominal thromboses.

Catastrophic intra-abdominal thrombosis can result from a variety of prothrombotic states, including polycythemia vera and essential thrombocythemia, both of which are frequently associated with an acquired mutation (V617F) in the JAK2 gene. To assess the prevalence and clinical implications of this mutation in the setting of intra-abdominal thrombosis, JAK2 V617F genotyping was performed in 42 patients who had catastrophic intra-abdominal thromboses resulting in visceral transplants. The prevalence of V617F was compared with that of other prothrombotic states for which molecular testing is routinely performed. V617F mutations were detected in 7 patients (17%), who were not distinguishable on the basis of their peripheral blood cell counts. The median posttransplantation survival of V617F+ patients was 17.5 months, compared with 116.4 months for the V617F- patients (ratio, 6.6; 95% confidence interval, 6.3-7.0). These results highlight the diagnostic usefulness of JAK2 V617F testing in this setting and underscore the clinical significance of a positive result.