Abstract
Background
Bleeding is a common issue in pediatric living donor liver transplantation (LDLT). Coagulopathy related bleeding can lead to increased morbidity and mortality. There has been limited research on the use of coagulation factor complexes, specifically fibrinogen concentrate (FibC) and prothrombin complex concentrate (PCC), in pediatric LDLT.
Methods
Pediatric patients who underwent LDLT between March 2019 and December 2024 were identified. Patients who received FibC and PCC were assigned to the F group(n = 103), while those who did not receive these treatments were designated as the C group (n = 272). After 1:1 propensity score matching, 57 patients were included in each group for analysis. The primary endpoint was the need for red blood cell (RBC) transfusion in pediatric patients undergoing LDLT.
Results
There was no significant difference in the volume of RBC infusion between groups F and C (median [interquartile range]: 550.00 (400.00, 600.00) ml vs. 700.00 (400.00, 750.00) ml [p = 0.281]). In terms of plasma and intraoperative bleeding, group F demonstrated a trend toward lower levels compared to group C; however, there was no significant difference between the two groups. The two groups had no significant difference in intraperitoneal drainage volume or RBC infusion volume 24 h after surgery. Both groups also showed no difference in postoperative outcomes such as mechanical ventilation time, ICU stay, and hospital length of stay. Fibrinogen, PT, and INR levels post-surgery were significantly better in Group F than in Group C. Additionally, the groups had no notable differences in postoperative complications, including thromboses or embolism.
Conclusions
This study indicates that using FibC and PCC was linked to a trend of reducing intraoperative RBC administration and bleeding in pediatric patients undergoing LDLT, although no significant difference was observed. Coagulopathy management strategies emphasizing targeted factor replacement should be a focus for future research.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12871-025-03553-6.
Keywords: Living donor liver transplantation, Factor concentrates, Fibrinogen concentrate, Prothrombin complex concentrate, Haemostasis, Transfusion
Introduction
The liver produces a variety of pro- and anticoagulant proteins involved in regulating hemostasis. In children with end-stage liver disease (ESLD), both the quantity and quality of coagulation protein are altered [1, 2]. These children also frequently are thrombocytopenic, its effect balanced by increased von Willebrand factor, decreased coagulation factors and inhibitors, and preserved fibrinolytic pathway [3, 4]. This rebalanced hemostatic state is precarious and susceptible to decompensation towards a hypo- or hypercoagulable state due to a variety of factors [5, 6]. The interplay of a rebalanced hemostasis, surgical stress, hemodilution, hypothermia, and an anhepatic phase during surgery complicates coagulation management in living donor liver transplantation (LDLT) [7]. Blood loss during transplantation is a major concern, as transfusion is linked to higher mortality, multi-organ dysfunction, and lower graft survival [8]. Coagulation disorders significantly impact the management of anesthesia during LDLT.
Fibrinogen concentrate (FibC) contains purified fibrinogen as a lyophilized powder. Four-factor prothrombin complex concentrate (PCC) is a hemostatic agent that contains the coagulation factors required to promote thrombin generation. Both FibC and PCC are manufactured from human plasma and have the advantage of being able to be stored under ambient conditions, are immediate available, and are not blood group specific [9]. FibC and PCC can significantly enhance fibrinogen and vitamin K-dependent clotting factor levels without substantial fluid infusion. This reduces the risk of intraoperative transfusion-associated circulatory overload [10]. Research on FibC/PCC in pediatric patients has been focused principally in the areas of cardiopulmonary bypass, orthopedics, and trauma [11]. There is limited research on the use of FibC/PCC in pediatric LDLT. We retrospectively analyzed the data of pediatric patients who underwent LDLT at our hospital to explore the effectiveness and safety of FibC and PCC.
Methods
After approval by the hospital’s Clinical Research Ethics Committee, data between March 2019 and December 2024 were retrospectively analyzed. Due to its retrospective and observational nature, the institutional review board waived the requirement for informed consent.
Pediatric patients under 12 years old who underwent LDLT at our institution were retrospectively identified using the hospital’s electronic medical records. Patients were excluded if they met any of the following criteria: missing laboratory data, preoperative transfusion of cryoprecipitate or frozen plasma, congenital coagulation disorders, or the presence of severe comorbidities (such as renal insufficiency, severe cardiac or pulmonary disease).
The primary objective of this study was to evaluate the need for red blood cell (RBC) transfusion during hemostatic resuscitation in pediatric patients undergoing LDLT. Intraoperative indicators used for analysis included the volume of fresh frozen plasma (FFP), crystalloid and colloid transfused, blood loss, urine output, and the use of tranexamic acid. Additionally, the study assessed the volume of intraperitoneal drainage and RBC transfusion 24 h postoperatively, as well as the duration of postoperative mechanical ventilation, ICU and hospital length of stay, and the incidence of postoperative complications. Furthermore, the objectives included evaluating a variety of parameters at the end of the surgical procedure and again at the 24-hour postoperative mark including included fibrinogen levels, prothrombin time (PT), International Normalized Ratio (INR), hemoglobin levels, and platelet count.
Anesthesia was induced using midazolam, propofol, fentanyl, and vecuronium, and was maintained with propofol, remifentanil, and sevoflurane. The following monitoring equipment was utilized: radial or femoral artery catheter, electrocardiogram, pulse oximetry, and a central venous catheter. For fluid replacement, a 5% glucose solution, Ringer’s lactate, and 5% albumin solution were administered. Thromboelastography (TEG) and laboratory results, in combination with vital signs, guided the use of blood products, FFP, FibC and PCC. Intraoperative coagulation management was carried out following our institutional algorithm for perioperative coagulation management during LDLT (Table 1). TEG and laboratory tests were repeated 30 min after reperfusion in all patients, and additional tests were performed as needed whenever there was unexplained bleeding in the surgical field.
Table 1.
Intraoperative transfusion management
| Parameter | Intervention |
|---|---|
| Laboratory fibrinogen < 1.5 g/L | FibC 25–75 mg/kg |
|
INR > 2 PT/APTT > 1.5 x normal TEG R > 14 min |
PCC ≦ 25IU/kg or FFP 10-15mL/kg |
| TEG LY30 > 8% | Tranexamic acid 0.25–1 g |
Abbreviations: TEG thromboelastogram, FibC fibrinogen concentrate, INR international normalized ratio, PCC prothrombin complex concentrate, PT prothrombin time, APTT activated partial thromboplastin time, R reaction time, FFP fresh frozen plasma, TEG LY30 30 min amplitude attenuation rate after maximum amplitude
Data are presented as mean (standard deviation), median (interquartile range), or count (percentage) as appropriate. Propensity score matching was utilized to control for selection biases. Relevant baseline variables, specifically age, sex, body mass index (BMI), Pediatric End-Stage Liver Disease (PELD) score, hemoglobin levels, duration of surgery, length of anhepatic phase, platelet count, PT, fibrinogen levels, diagnosis, and the surgical group were entered into a logistic regression analysis with FibC and PCC treatment as the dependent variable. Covariates used for calculating propensity score were derived from previously published literature, expert opinion from experienced clinicians, and their association with outcomes. All patients were matched in a 1:1 ratio using the nearest neighbor method, with a caliper set at 0.05. To compare differences between groups, we employed independent two-sample t-tests or the Mann-Whitney U test for continuous variables, and Pearson’s chi-square or Fisher’s exact test for categorical variables. P < 0.05 was considered statistically significant. Statistical analyses were conducted using IBM SPSS software, version 27.0.
Results
We conducted a retrospective study of 411 pediatric patients under the age of 12 who underwent LDLT at our institution. We excluded children who had other serious medical conditions (n = 7) and those with incomplete perioperative laboratory data (n = 29), resulting in a final analysis population of 375 children. Out of this number, 103 received FibC and PCC during the procedure (F group), while 272 received only FFP (C group). Using propensity score matching, 57 children in the F group were matched with another 57 children in the C group (Fig. 1). In the F group, children received an average of 47.17(33.33, 74.63) (median, Q1, Q3) mg/kg of FibC. The amount of PCC administered was 22.47(13.43, 42.86) IU/kg.
Fig. 1.
Study flow chart
There were significant differences between the two groups with regard to bleeding-related risk factors and laboratory indicators. Before matching, Group F exhibited higher PELD scores, PT levels, longer surgery times, and longer anhepatic periods. Additionally, this group had lower levels of hemoglobin, platelets, and fibrinogen. After matching, these factors were balanced between the two groups resulting in no significant differences between groups. (Table 2)
Table 2.
Patient characteristics before and after propensity score matching
| Variable | Before propensity score matching | After propensity score matching | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Total (n = 375) | C (n = 272) | F (n = 103) | p | SMD | Total (n = 114) | C (n = 57) | F (n = 57) | p | SMD | |
| Age(years), M (Q₁, Q₃) | 1.00 (0.00, 1.00) | 1.00 (0.00, 1.00) | 1.00 (0.00, 1.00) | 0.572 | 0.023 | 1.00 (0.00, 1.00) | 1.00 (0.00, 1.00) | 1.00 (0.00, 1.00) | 0.09 | 0.02 |
| Gender, n (%) | 0.464 | 0.086 | 0.127 | 0.281 | ||||||
| Male | 157 (41.87) | 117 (43.01) | 40 (38.83) | 46 (40.35) | 19 (33.33) | 27 (47.37) | ||||
| Female | 218 (58.13) | 155 (56.99) | 63 (61.17) | 68 (59.65) | 38 (66.67) | 30 (52.63) | ||||
| BMI(kg/m²), M (Q₁, Q₃) | 16.14 (14.91, 17.50) | 16.12 (15.03, 17.45) | 16.42 (14.76, 17.65) | 0.642 | −0.01 | 16.37 (14.90, 17.61) | 16.12 (14.72, 17.30) | 16.42 (14.94, 17.86) | 0.378 | 0.079 |
| PELD, M (Q₁, Q₃) | 13.00 (7.00, 20.00) | 12.50 (6.00, 19.00) | 17.00 (10.00, 24.00) | < 0.001 | 0.381 | 16.00 (9.00, 22.00) | 14.00 (8.00, 20.00) | 17.00 (11.00, 23.00) | 0.336 | 0.039 |
| Hemoglobin(g/dL), M (Q₁, Q₃)/Mean ± SD | 9.40(8.30,10.80) | 9.80(8.80,11.10) | 8.00(7.00,9.20) | < 0.001 | 0.156 | 7.70 (7.00, 9.20) | 7.80 (6.90, 8.70) | 7.70 (7.00, 9.30) | 0.63 | 0.016 |
| Surgical duration (minutes), M (Q₁, Q₃) | 407.00 (355.00, 467.50) | 385.00 (347.25, 431.50) | 485.00 (425.50, 536.50) | < 0.001 | 1.200 | 453.50 (407.50, 491.25) | 457.00 (415.00, 489.00) | 448.00 (407.00, 492.00) | 0.687 | −0.104 |
| Anhepatic phase(minutes), M (Q₁, Q₃) | 48.00 (35.50, 57.00) | 46.00 (35.00, 55.00) | 51.00 (41.50, 58.50) | 0.005 | 0.300 | 50.00 (39.25, 59.00) | 50.00 (37.00, 59.00) | 50.00 (41.00, 59.00) | 0.753 | 0.010 |
| Platelet count(×109/L), M (Q₁, Q₃) | 204.00 (128.00, 318.50) | 223.00 (147.75, 319.25) | 139.00 (95.00, 309.50) | < 0.001 | −0.284 | 199.00 (128.00, 319.75) | 218.00 (156.00, 304.00) | 163.00 (107.00, 324.00) | 0.097 | −0.038 |
| PT(s), M (Q₁, Q₃) | 14.70 (13.20, 18.20) | 14.40 (13.10, 16.52) | 17.30 (13.85, 22.90) | < 0.001 | 0.457 | 15.80 (13.70, 19.32) | 15.00 (13.60, 17.30) | 17.30 (13.70, 20.20) | 0.067 | 0.043 |
| Fibrinogen(g/L), M (Q₁, Q₃) | 1.90 (1.34, 2.50) | 2.04 (1.52, 2.61) | 1.46 (0.83, 2.06) | < 0.001 | −0.543 | 1.66 (1.11, 2.30) | 1.80 (1.16, 2.38) | 1.57 (0.98, 2.23) | 0.211 | −0.103 |
| Diagnosis, n (%) | 0.061 | 0.119 | 0.735 | 0.012 | ||||||
| Biliary atresia | 315(84) | 233(85.66) | 82(79.61) | 94(82.46) | 49(85.96) | 45(78.95) | ||||
| Cirrhosis | 21(5.6) | 12(4.41) | 9(8.73) | 8(7.02) | 4(7.02) | 4(7.02) | ||||
| Alagille syndrome | 4(10.66) | 4(1.47) | 0 | 0 | 0 | 0 | ||||
| Ornithine transcarbamylase deficiency | 8(2.13) | 4(1.47) | 4(3.88) | 3(5.26) | 1(1.75) | 2(3.51) | ||||
| Gastrointestinal Bleeding | 6(1.6) | 4(1.47) | 2(1.94) | 1(0.88) | 0 | 1(1.75) | ||||
| Others | 21(5.6) | 15(5.51) | 6(5.82) | 8(7.02) | 3(5.26) | 5(8.77) | ||||
| The surgeons’ group, n (%) | 0.976 | 0.100 | 0.545 | 0.010 | ||||||
| 1 | 153(40.8) | 111(20.8) | 42(40.8) | 53(45.7) | 28(47.5) | 25(43.) | ||||
| 2 | 130(34.7) | 95(34.9) | 35(34.0) | 34(29.8) | 18(31.6) | 16(28.1) | ||||
| 3 | 92(24.5) | 66(24.3) | 26(25.2) | 27(23.7) | 11(19.3) | 16(28.1) | ||||
Abbreviations: BMI body mass index, ASA American Society of Anesthesiologists, PT prothrombin time
Among the matched pairs, Group F had a trend towards reduced RBC, FFP, and blood loss during surgery. However, using FibC and PCC did not result in significant differences between the groups. Intraoperative indicators, including urine output and colloid infusion volume, also showed no apparent difference between groups. Additionally, 24 h post-surgery, there was no significant difference in the volume of intraperitoneal drainage or RBC transfusion between groups. Furthermore, there were no significant differences in the mechanical ventilation time, ICU length of stay, or total postoperative hospital days. No thrombotic or thromboembolic events were noted in either group. (Table 3)
Table 3.
Perioperative characteristics of patients in matched analytic cohort
| Variable | Total (n = 114) | C (n = 57) | F (n = 57) | p |
|---|---|---|---|---|
| RBC volume (ml), M (Q₁, Q₃) | 600.00 (500.00, 800.00) | 700.00 (400.00, 750.00) | 550.00 (400.00, 600.00) | 0.281 |
| FFP infusion volume (ml), M (Q₁, Q₃) | 480.00 (285.00, 710.00) | 530.00 (330.00, 710.00) | 380.00 (220.00, 710.00) | 0.142 |
| Blood loss (ml), M (Q₁, Q₃) | 550.00 (400.00, 800.00) | 600.00 (400.00, 800.00) | 500.00 (400.00, 800.00) | 0.758 |
| Urine output (ml), M (Q₁, Q₃) | 490.00 (326.25, 681.25) | 550.00 (375.00, 750.00) | 450.00 (320.00, 600.00) | 0.084 |
| Crystal volume (ml), M (Q₁, Q₃) | 487.50 (350.00, 873.75) | 550.00 (450.00, 1000.00) | 400.00 (265.00, 650.00) | 0.01 |
| Colloidal volume(ml), M (Q₁, Q₃) | 250.00 (200.00, 500.00) | 250.00 (150.00, 550.00) | 250.00 (200.00, 400.00) | 0.423 |
| Tranexamic acid (g), M (Q₁, Q₃) | 0.00 (0.00, 0.10) | 0.00 (0.00, 0.00) | 0.00 (0.00, 0.10) | 0.001 |
| Intraperitoneal drainage postoperative 24 h (ml), M (Q₁, Q₃) | 330.00 (284.00, 492.00) | 381.00 (292.00, 530.00) | 310.00 (208.00, 476.00) | 0.577 |
| RBC volume postoperative 24 h (ml), M (Q₁, Q₃) | 0.00 (0.00, 0.00) | 0.00 (0.00, 100.00) | 0.00 (0.00, 0.00) | 0.274 |
| Mechanical ventilation (days), M (Q₁, Q₃) | 0.00 (0.00, 2.00) | 0.00 (0.00, 2.00) | 0.00 (0.00, 1.00) | 0.134 |
| ICU stay (days), M (Q₁, Q₃) | 6.00 (3.00, 10.00) | 6.00 (4.00, 11.00) | 5.00 (3.00, 9.00) | 0.186 |
| Postoperative hospitalization days (days) | 31.00 (22.00, 44.00) | 32.00 (22.00, 46.00) | 29.00 (24.00, 40.00) | 0.975 |
| Complicationsm, n(%) | ||||
| Thrombotic complications | 0 | 0 | 0 | |
| Hemorrhagic complications | 0 | 0 | 0 | |
| Hospital mortality | 1 (2.63) | 1 (1.75) | 0 | 0.315 |
Abbreviations: RBC red blood cell, FFP fresh frozen plasma, ICU intensive care unit
Postoperative fibrinogen and hemoglobin levels in group F were significantly higher than those in group C. However, this difference did not persist for more than 24 h after the surgery. There were no significant differences in perioperative INR, PT, or platelet count between groups. (Table 4)
Table 4.
Comparison of perioperative laboratory indicators
| Variable | Preoperative | Postoperative | Postoperative 24 h |
|---|---|---|---|
| INR, M (Q₁, Q₃) | |||
| C | 1.29 (1.19, 1.45) | 1.79 (1.48, 1.98) | 1.67 (1.51, 1.88) |
| F | 1.50 (1.20, 1.77) | 1.52 (1.37, 1.87) | 1.47 (1.52, 1.83) |
| p | 0.63 | 0.039 | 0.589 |
|
Fibrinogen(g/L), M (Q₁, Q₃) | |||
| C | 1.80 (1.16, 2.38) | 1.17 (0.76, 1.45) | 1.87 (1.35, 2.35) |
| F | 1.57 (0.98, 2.23) | 1.34 (1.03, 1.70) | 1.91 (1.62, 2.61) |
| p | 0.211 | 0.006 | 0.213 |
|
PT(s), M (Q₁, Q₃) | |||
| C | 15.00 (13.60, 17.30) | 20.50 (16.10, 22.40) | 18.60 (16.90, 20.60) |
| F | 17.30 (13.70, 20.20) | 18.30 (15.90, 20.60) | 18.40 (17.00, 20.70) |
| p | 0.067 | 0.048 | 0.593 |
|
Hemoglobin(g/dL), Mean ± SD/M (Q₁, Q₃) | |||
| C | 7.80 (6.90, 8.70) | 9.40 (8.70, 11.10) | 9.90 (8.60, 10.60) |
| F | 7.70 (7.00, 9.30) | 10.50 (9.20, 11.80) | 9.90 (8.70, 11.00) |
| p | 0.63 | 0.035 | 0.704 |
|
Platelet Count (×109/L), M (Q₁, Q₃) | |||
| C | 218.00 (156.00, 304.00) | 107.00 (60.00, 176.00) | 116.00 (69.00, 172.00) |
| F | 163.00 (107.00, 324.00) | 87.00 (61.00, 125.00) | 92.00 (62.00, 138.00) |
| p | 0.097 | 0.171 | 0.202 |
Abbreviations: PT prothrombin time, INR international normalized ratio
Discussion
This retrospective, single-center study found that administering FibC and PCC during surgery was linked to a trend toward reduced blood product usage and less bleeding in pediatric patients undergoing LDLT, although no significant difference was observed. The study group showed no advantages regarding mechanical ventilation duration, ICU and hospital length of stay, or in-hospital mortality. The study also highlighted that FibC and PCC did not increase the incidence of thromboembolic events.
The pediatric LDLT uses livers donated by relatives, helping to address the shortage of available organs and paving the way for the future of pediatric liver transplantation [12]. In two studies involving adult allogeneic liver transplantation, the authors found that patients receiving FibC/PCC had a significant decrease in the need for RBC and FFP transfusion although the dose of FibC or PCC were not included [13, 14]. Thorough preoperative surgical planning and preparation, along with a high-quality donor liver and optimal cold ischemia time, can help minimize complications such as perioperative bleeding in LDLT [15]. These factors may partly explain why the use of FibC/PCC in our study did not show a significant advantage. In a study of combined heart and liver transplantation in children, PCC was used for refractory post-cardiopulmonary bypass bleeding in 15/18 (83%) patients and fibrinogen concentrate in 9/18 (50%) patients [16]. The patients received an average of 38.0 (18.5, 44.1) mg/kg of FibC and 31.5 (12.5, 44) IU/kg of PCC. The authors reported a 30-day thromboembolism rate of 22%. The dosage of PCC used in the above study was higher than the dose observed in our research. In a study focused on pediatric cardiac surgery, the authors concluded that FibC/PCC can safely replace standard treatment with FFP [9]. Children in their study group received 52 (32, 83) mg/kg of FibC and 28 (12.5, 43.5) IU/kg of PCC, which is higher than our study’s drug dosage. Currently, there are no established recommendations for the optimal threshold to initiate fibrinogen replacement in pediatric surgery. There are also no guidelines on the appropriate dose needed to reach a target fibrinogen concentration or the dose of PCC required to achieve a target INR [17]. Further large randomized controlled trials are necessary to investigate the clinical efficacy and adverse reactions, such as embolism, of FibC/PCC at various doses. Additionally, ESLD-induced coagulopathy is a complex hemostatic disorder that involves interactions between coagulation factors, fibrinolysis, platelets, and the vascular endothelium. Thus, FibC/PCC administration is just one of many influencing factors.
Fibrinogen is an essential coagulation factor necessary for hemostasis. Hypofibrinogenemia is an important risk factor for bleeding in pediatric patients [18]. In children with hypofibrinogenemia, FibC acts quickly and effectively to raise fibrinogen levels [19]. Researchers concluded that FibC could be considered a viable alternative to cryoprecipitate for treating hypofibrinogenemia in infants experiencing bleeding after cardiopulmonary bypass [20]. A recent systematic review also indicated that FibC is beneficial for managing surgical bleeding [21]. The postoperative fibrinogen level in the FibC/PCC group in our study was markedly higher than in the non-FibC/PCC group, which is consistent with prior study findings. Although fibrinogen levels in the FibC/PCC group tended to be higher than those in the control group, this difference did not persist past 24 h postoperatively with the recovery of transplanted liver function.
PCC offers several benefits, such as rapid reconstitution, decreased immunogenicity, and a lower risk of pathogen transmission [22]. Research indicates that PCC effectively enhances thrombin generation and hemostatic function [23]. For reversing an elevated INR, the recommended dose of FFP is about 10–30 ml/kg. Conversely, PCC can achieve similar results at doses of 10–30 IU/kg, administered in volumes of 1–2 ml/kg [24]. PCCs are used off-label to manage acquired coagulopathy caused by perioperative bleeding, hemodilution, traumatic injury, and liver disease. In our study, the INR and PT levels in the FibC/PCC group were significantly lower post-surgery compared to the control group. A randomized controlled study on transfusion strategies for trauma related hemorrhage found that administering 4 F-PCC did not significantly reduce 24-hour blood product consumption [25], which is consistent with our study’s results. Researchers believe that both inhibitors and procoagulants were diminished due to trauma and tissue damage. This has resulted in a new hemostatic balance, which may clarify why thrombin production was preserved despite PT prolongation. This may be one reason why there was no significant difference in perioperative blood product administration and bleeding between the two groups in this study.
Due to the retrospective nature of this study, the effect of factor concentrates alone could not be identified because they were administered with FFP in our center. FFP transfusion can be associated with adverse effects such as fluid overload, transfusion-related acute lung injury, transfusion transmitted infections, and immunomodulatory side effects. Research indicates that factor-based strategies can lower the need for transfusion and enhance patient outcomes without the use of FFP [26–28]. The lack of significant differences in our study may result from the continued use of FFP which dilutes the potential benefits of FibC/PCC. Further investigation of FFP-free coagulation management regimens is needed to improve outcomes in LDLT.
There was no significant difference in mortality rates between the two groups. In the non-FibC/PCC group, one child died due to multiple organ dysfunction. In the study by Hartmann and colleagues involving 372 adult liver transplant patients, a ROTEM-guided coagulation management algorithm was used [29]. Multivariate analysis indicated that factor concentrates were not independent predictors of 30-day mortality. One child in our study in the control group underwent a second operation for a biliary fistula and another for an incisional hernia.
There is ongoing controversy regarding the risk of embolism associated with the use of FibC/PCC. In this study, there was no significant difference in postoperative thromboses or embolism between groups. In a meta-analysis of 17 studies involving 2,745 patients who underwent major surgery, including 156 adult patients who received liver transplantation, the use of PCC did not lead to an increased incidence of thromboembolic events [30]. However, in a study of 939 adult LT patients, the authors found that PCC and FibC administration was linked to early thrombosis in the hepatic artery, portal vein, or inferior vena cava within 30 days post-surgery [31]. Variations among studies may be the result of differences in coagulation management protocols and drug dosages used at various medical centers. In our institution, we managed coagulation during LDLT by TEG, laboratory tests, and clinical observations. Due to the higher risk of embolism in children, anesthesiologists tended to use factor concentrates more cautiously in pediatric cases.
The main limitation of our study is its retrospective design and the lack of objective indicators, such as clot hardness and platelet function, which would enhance our understanding of clotting behavior. The small sample size in our study is another concern, and as these procedures evolve, we hope future analyses will include larger samples. Despite using propensity score matching to address confounding factors, imbalances in baseline characteristics remain. Future research should gather more information for better matching and analysis, leading to more convincing results. Lastly, the effect of factor concentrates alone could not be identified because they were administered with FFP. The use of FFP may obscure the effectiveness of FibC/PCC, necessitating further research on targeted factor replacement without FFP.
In conclusion, although no significant difference was observed, this retrospective study suggests that the administration of FibC and PCC was associated with a trend toward reduced bleeding and intraoperative blood product administration in pediatric patients undergoing LDLT. The factor concentrates can improve coagulation function without increasing the risk of thrombosis. Future clinical studies should be performed to explore dosage, timing and safety of targeted factor replacement strategies and FFP-free coagulation management regimens to optimize outcomes in LDLT in larger groups of pediatric patients.
Supplementary Information
Acknowledgements
Not applicable.
Approval for publication
All authors have read and approved the final version of the manuscript and consent to its publication.
Authors’ contributions
Conceptualization: Zhiyong Hu, Patrick M. McQuillan. Data curation: Mi Wang, Fuquan Fang. Methodology: Yuhan Hu, Diansan Su. Validation: Jun Li, Xinghua Qian. Investigation: Mi Wang, Fuquan Fang, Yuhan Hu. Writing - original draft: Mi Wang, Fuquan Fang. Writing - review & editing: Zhiyong Hu, Diansan Su.
Funding
National Natural Science Foundation of China (Nos. 82171260, 81641042, 81471240), Natural Science Foundation of Zhejiang Province (Nos. LZ22H090002, 2014C33170).
Data availability
Data is provided within the manuscript or supplementary information files.
Declarations
Ethics approval and consent to participate
The First Affiliated Hospital of Zhejiang University School of Medicine Ethics Committee (No: IIT20240416A) granted ethical permission for this study in April 2024 and complies with the revised declaration of Helsinki. Due to its retrospective and observational nature, the institutional review board waived the requirement for informed consent.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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