Fibrinogen: A Clinical Update on Liver Transplantation

• There is a scarcity of published controlled studies on hemostasis and coagulation management in liver transplantation surgery.
• A PubMed and Scopus search from 1990 to 2015 was conducted using the key words fibrinogen, liver transplantation, coagulation, and blood product replacement; most articles refer to expert opinion.
• Despite this lack of evidence, administration of fibrinogen when plasma levels decrease to 1.5 to 2 g/L has recently been incorporated into the European guidelines for surgery patients.
• On the other hand, there is evidence of a decrease in plasma fibrinogen level during the liver transplantation procedure and of the need for intraoperative fibrinogen reposition.
• No randomized, controlled trial has investigated the value of fibrinogen administration in liver transplantation.
• Future research should focus on determining the critical level of plasma fibrinogen or platelet free-clot firmness thromboelastometry value to guide fibrinogen replacement.

IntroductionHemostatic and coagulation disorders related to severe liver disease may cause massive bleeding beyond what can be expected from surgical trauma in liver transplantation. Fluid resuscitation and fibrinolysis may aggravate the problem, as plasma fibrinogen decreases in all patients. The objective of this review was to update the criteria for fibrinogen replacement in liver transplantation.MethodsA PubMed and Scopus search from 1990 to 2015 was made. The following key words were used: fibrinogen, liver transplantation, coagulation, and blood product replacement. Controlled trials and observational studies were selected on the basis of clinical relevance.ResultsThere is a scarcity of published controlled studies on perioperative fibrinogen replacement. Most articles refer to expert opinion; therefore, criteria for the administration of fibrinogen have been empirically established. The response to cryoprecipitate or fibrinogen concentrate administration in liver transplantation has not been established. Viscoelastic platelets free tests have been reported to have a good correlation with Clauss-measured plasma fibrinogen concentration. In surgical patients, the median increase in fibrinogen plasma level per gram injected has been determined in 0.2375 g/L. Alternatively, fibrinogen replacement can be guided based on viscoelastic hemostatic assays.ConclusionsIn liver transplantation, plasma fibrinogen levels are low in most patients during surgery. Fibrinogen administration to correct hypofibrinogenemia has a positive impact on surgical bleeding. However, there is a scarcity of literature about fibrinogen administration; therefore, administration should be adjusted to replace plasma fibrinogen levels in the range of normal and guided by thromboelastometry.