Fig. 1.

Spectrum of preoperative coagulopathy of liver transplantation. VET, viscoelastic testing; HCC, hepatocellular carcinoma; PSC, primary sclerosing cholangitis; PBC, primary biliary cirrhosis. Fig. 1 represents the spectrum of patients who can receive organ donation for transplantation. Those patients with acute liver decompensation are the sickest group of recipients and their coagulation system is not intact. VET testing in cirrhotic patients bleeding and at risk of bleeding have demonstrated major reductions in transfusion volumes over SLT, which is critical in this pretransplant population as they often have concurrent renal failure. However, transfusion triggers based on VET do not need to be corrected to a normal range. Repeated routine testing to manage coagulopathy is essential as liver function rarely recovers, and failure to address clotting derangements can result in complication making them ineligible for transplant. On the opposite end of the spectrum are living donors who come from home and are seen the week before transplant with time for coagulation assessment. These patients tend to have well-compensated liver disease and are more at risk of thrombotic complications than cadaveric organs due to small diameter vascular reconstructions during surgery. Most liver transplant patients fall in between these two spectrums and come from home after being called about an organ offer. Some of these patients may have increased risk for thrombosis based on their indication for liver transplant (cancer or inflammatory condition) and VET testing can help risk stratify them for postoperative thrombotic risk and guide a more permissive hypocoagulable strategy during surgery. Other patients coming from home may have harbor unappreciated advanced coagulopathy and have increased risk of massive transfusion. Identification of this cohort can allow the blood bank to prepare for anticipated large blood loss.