Giabicani Mikhael, Joly Pauline, Sigaut Stéphanie, Timsit Clara, Devauchelle Pauline, Dondero Fédérica, Durand François, Froissant Pierre Antoine, Lamamri Myriam, Payancé Audrey, Restoux Aymeric, Roux Olivier, Thibault-Sogorb Tristan, Valainathan Shantha Ram, Lesurtel Mickaël, Rautou Pierre-Emmanuel, Weiss Emmanuel
Département d'anesthésie réanimation, AP-HP, Hôpital Beaujon, DMU PARABOL, Clichy, France.
Université Paris-Cité, Paris, France.
JHEP Rep. 2024 Feb 28;6(6):101051. doi: 10.1016/j.jhepr.2024.101051. eCollection 2024 Jun.
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.
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.
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).
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.
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.
原位肝移植（OLT）期间的大出血事件与不良预后相关。这种风险中与门静脉高压相关的比例尚不清楚。肝静脉压力梯度（HVPG）是评估门静脉高压的金标准。本研究的目的是分析HVPG预测肝硬化患者OLT术中大出血事件的能力。
我们回顾性分析了一个前瞻性数据库，该数据库包括2010年至2020年间接受OLT的所有肝硬化患者，这些患者在移植前评估时进行了肝脏和右心导管检查。主要终点是术中大出血事件的发生。
纳入的468例患者的HVPG中位数为17 mmHg[四分位间距，13 - 22]，OLT当天的终末期肝病模型（MELD）中位数为16[11 - 24]。72%的患者术中需要输注红细胞（输注中位数为2单位），中位失血量为1000 ml[575 - 1500]。156例患者（33%）发生术中大出血，这与HVPG、术前血红蛋白水平、OLT时肝硬化的严重程度（MELD评分、腹水、肝性脑病）、止血功能受损（血小板减少、纤维蛋白原水平降低）以及肝硬化并发症（脓毒症、慢加急性肝衰竭）有关。通过逐步向后排除的多变量回归分析，HVPG、术前血红蛋白水平、MELD评分和氨甲环酸输注与主要终点相关。根据HVPG将患者分为三类：低风险（HVPG <16 mmHg）、高风险（HVGP≥16 mmHg）和极高风险（HVPG≥20 mmHg）。
HVPG可预测接受OLT的肝硬化患者的大出血事件。将HVPG纳入移植前评估的一部分可能有助于更好地预测术中过程。
原位肝移植（OLT）期间的大出血事件与不良预后相关，但这种风险中与门静脉高压相关的比例尚不清楚。我们的研究表明，评估门静脉高压的金标准——肝静脉压力梯度（HVPG），是接受OLT的肝硬化患者大出血事件和失血量的有力预测指标。根据大出血事件风险可将患者分为三组：HVPG <16 mmHg的低风险患者、HVPG≥16 mmHg的高风险患者和HVPG≥20 mmHg的极高风险患者。HVPG可系统地纳入移植前评估，以预测术中过程并调整患者管理。
