*Purpose: Hepatobiliary malignancies have been associated with hyper-coagulability. However, the impact of hepatocellular carcinoma (HCC) on coagulation during liver transplantation remains less clear. We hypothesize that patients with HCC have a distinct perioperative coagulation profile compared to patient’ with nonmalignant disease during liver transplantation.

*Methods: Liver transplant recipients underwent serial perioperative blood samples [pre-op, hepatectomy, anhepatic, early reperfusion (30 min), late reperfusion (120 min), and post operative day 1 (POD-1)]. Blood was analyzed with thrombelastography (TEG) to quantify clot strength (MA) and fibrinolysis (LY30). Patients were dichotomized on HCC status. Coagulation variables and blood products were compared between cohorts with a Mann Whitney U test.

*Results: 100 patients were included (24% HCC). HCC patients had lower MELDs (11 vs 24 p<0.001) decreased INR (1.4 vs 2.1 p<0.001) and higher platelet counts (74 vs 54 p<0.092). HCC patients had increased clot strength at baseline and through the anhepatic phase of surgery (P<0.006 for all Panel A), but clot strength was not significant after graft reperfusion. Fibrinolytic activity was decreased in patients with HCC at the anhepatic phase of surgery (p=0.026) but became markedly increased during early reperfusion (p=0.003 Figure Panel B). Red blood cell transfusions ([RBC (panel C)] were reduced in patients with HCC until reperfusion (p<0.000 all) which equated to 5X less transfusions during this time (2 vs 10 units p<0.001). RBC transfusions inversley correlated with clot strength (Spearman’s Rho -0.336 p<0.001). When controlling for INR and platelet count, HCC persisted as a predictor of lower blood product utilization prior to graft implantation (p=0.020) but lost significance after graft reperfusion (p=0.115).

*Conclusions: HCC was associated with a higher clot strength than patients with non-malignant liver disease, which persisted until early graft reperfusion. While HCC was associated with less severe liver disease, red blood cell transfusions were 5-fold lower and remained significant after adjusting for conventional coagulation assays. Ongoing investigation is warranted to determine if increasing clot strength in nonmalignant liver disease prior to reperfusion to the level of patients with HCC can reduce blood loss without risking thrombotic complications.

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