Predictive role of hepatic venous pressure gradient in bleeding events among patients with cirrhosis undergoing orthotopic liver transplantation
Mikhael Giabicani,
Pauline Joly,
Stéphanie Sigaut,
Clara Timsit,
Pauline Devauchelle,
Fédérica Dondero,
François Durand,
Pierre Antoine Froissant,
Myriam Lamamri,
Audrey Payancé,
Aymeric Restoux,
Olivier Roux,
Tristan Thibault-Sogorb,
Shantha Ram Valainathan,
Mickaël Lesurtel,
Pierre-Emmanuel Rautou,
Emmanuel Weiss
Affiliations
Mikhael Giabicani
Département d’anesthésie réanimation, AP-HP, Hôpital Beaujon, DMU PARABOL, Clichy, France; Université Paris-Cité, Paris, France
Pauline Joly
Département d’anesthésie réanimation, AP-HP, Hôpital Beaujon, DMU PARABOL, Clichy, France
Stéphanie Sigaut
Département d’anesthésie réanimation, AP-HP, Hôpital Beaujon, DMU PARABOL, Clichy, France
Clara Timsit
Département d’anesthésie réanimation, AP-HP, Hôpital Beaujon, DMU PARABOL, Clichy, France
Pauline Devauchelle
Département d’anesthésie réanimation, AP-HP, Hôpital Beaujon, DMU PARABOL, Clichy, France
Fédérica Dondero
Departement of HPB Surgery & Liver Transplantation, AP-HP, Beaujon Hospital, DMU DIGEST, Université Paris-Cité, Clichy, France
François Durand
Service d'Hépatologie, AP-HP, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France; Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
Pierre Antoine Froissant
Département d’anesthésie réanimation, AP-HP, Hôpital Beaujon, DMU PARABOL, Clichy, France
Myriam Lamamri
Département d’anesthésie réanimation, AP-HP, Hôpital Beaujon, DMU PARABOL, Clichy, France
Audrey Payancé
Service d'Hépatologie, AP-HP, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France; Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
Aymeric Restoux
Département d’anesthésie réanimation, AP-HP, Hôpital Beaujon, DMU PARABOL, Clichy, France
Olivier Roux
Service d'Hépatologie, AP-HP, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
Tristan Thibault-Sogorb
Département d’anesthésie réanimation, AP-HP, Hôpital Beaujon, DMU PARABOL, Clichy, France
Shantha Ram Valainathan
Service d'Hépatologie, AP-HP, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
Mickaël Lesurtel
Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France; Departement of HPB Surgery & Liver Transplantation, AP-HP, Beaujon Hospital, DMU DIGEST, Université Paris-Cité, Clichy, France
Pierre-Emmanuel Rautou
Service d'Hépatologie, AP-HP, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France; Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France; Corresponding author. Address: Service d’hépatologie; Hôpital Beaujon 100, Boulevard du Général Leclerc; 92110 Clichy, France; Tel.: +33.1.40.87.52.83, fax: +33.1.40.87.55.30.
Emmanuel Weiss
Département d’anesthésie réanimation, AP-HP, Hôpital Beaujon, DMU PARABOL, Clichy, France; Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
Background & Aims: Major bleeding events during orthotopic liver transplantation (OLT) are associated with poor outcomes. The proportion of this risk related to portal hypertension is unclear. Hepatic venous pressure gradient (HVPG) is the gold standard for estimating portal hypertension. The aim of this study was to analyze the ability of HVPG to predict intraoperative major bleeding events during OLT in patients with cirrhosis. Methods: We retrospectively analyzed a prospective database including all patients with cirrhosis who underwent OLT between 2010 and 2020 and had liver and right heart catheterizations as part of their pre-transplant assessment. The primary endpoint was the occurrence of an intraoperative major bleeding event. Results: The 468 included patients had a median HVPG of 17 mmHg [interquartile range, 13-22] and a median MELD on the day of OLT of 16 [11-24]. Intraoperative red blood cell transfusion was required in 72% of the patients (median 2 units transfused), with a median blood loss of 1,000 ml [575-1,500]. Major intraoperative bleeding occurred in 156 patients (33%) and was associated with HVPG, preoperative hemoglobin level, severity of cirrhosis at the time of OLT (MELD score, ascites, encephalopathy), hemostasis impairment (thrombocytopenia, lower fibrinogen levels), and complications of cirrhosis (sepsis, acute-on-chronic liver failure). By multivariable regression analysis with backward elimination, HVPG, preoperative hemoglobin level, MELD score, and tranexamic acid infusion were associated with the primary endpoint. Three categories of patients were identified according to HVPG: low-risk (HVPG <16 mmHg), high-risk (HVGP ≥16 mmHg), and very high-risk (HVPG ≥20 mmHg). Conclusions: HVPG predicted major bleeding events in patients with cirrhosis undergoing OLT. Including HVPG as part of pre-transplant assessment might enable better anticipation of the intraoperative course. Impact and implications: Major bleeding events during orthotopic liver transplantation (OLT) are associated with poor outcomes but the proportion of this risk related to portal hypertension is unclear. Our work shows that hepatic venous pressure gradient (HVPG), the gold standard for estimating portal hypertension, is a strong predictor of major bleeding events and blood loss volume in patients with cirrhosis undergoing OLT. Three groups of patients can be identified according to their risk of major bleeding events: low-risk patients with HVPG <16 mmHg, high-risk patients with HVPG ≥16 mmHg, and very high-risk patients with HVPG ≥20 mmHg. HVPG could be systematically included in the pre-transplant assessment to anticipate intraoperative course and tailor patient management.
