Evaluation of low fibrinolytic activity by rotational thromboelastometry and outcomes in liver transplantation: A single-center prospective study

Liver transplantation (LT) is a critical treatment for end-stage liver disease (ESLD) and is often complicated by hemostatic disturbances, including low fibrinolytic activity (LFA). LFA has been linked to adverse outcomes such as splanchnic thrombosis and increased perioperative mortality. This study aimed to evaluate the incidence of LFA during LT, its association with thrombotic and clinical outcomes, and its predictive value for the 28-day mortality. This prospective observational study included 222 ESLD patients who underwent LT at the University of Pisa. Rotational thromboelastometry (ROTEM) analyses were performed at 4 time points: baseline (T 0 ), anhepatic phase (T 1 ), neohepatic phase (T 2 ), and 24 hours post-LT (T 3 ). LFA was defined as a maximum lysis (ML) < 3.5% in EXTEM and confirmed by FIBTEM to exclude platelet clot retraction. Outcomes assessed included postransplant splanchnic thrombosis, 28-day mortality, post-reperfusion syndrome (PRS), re-LT, and massive blood transfusion (MBT). Statistical analyses included chi-squared tests, ORs, and ROC curve assessments. LFA occurred in 27.5% of patients at one or more time points. LFA was strongly associated with splanchnic thrombosis (OR=32.7, 95% CI: 14.7-72.7, p< 0.001) and 28-day mortality (OR=8.7, 95% CI: 1.7-44.2, p =0.002). ROC curve analysis demonstrated excellent predictive accuracy for splanchnic thrombosis (AUC=0.84) and good accuracy for 28-day mortality (AUC=0.75). Significant associations were also observed between the LFA and PRS (OR=6.1, p< 0.001), re-LT (OR=5.7, p< 0.001), and MBT (OR=3.8, p< 0.001). LFA was not associated with MELD score or HCC. LFA identified using ROTEM is a significant predictor of adverse outcomes, including splanchnic thrombosis and 28-day mortality, in LT patients. The real-time diagnostic capability of ROTEM offers critical prognostic insights and may guide therapeutic interventions to mitigate the thrombotic risk. These findings highlight the need for further multicenter studies to confirm the utility of ROTEM in LT and investigate the molecular mechanisms underlying LFA.