*Purpose: In order to determine the efficacy of post-liver transplant (LT) anticoagulation protocols in reducing the occurrence of arterial thrombosis (HAT) and other vascular complications in children, we compared the rate of thrombotic complications after LT and the incidence of bleeding complications associated with both prophylactic and therapeutic post LT anticoagulation protocols.

*Methods: A retrospective review of our prospectively collected LT database was performed over a 5-year period (2014-2018). At our institution, heparin is used in all patients after LT but therapeutic dosing is used only when a patient has had a thrombotic event during or after LT or had less than ideal hepatic artery or portal venous flow at the end of the LT. Results were compared between prophylactic (Ppx) vs. therapeutic (Tx) heparin groups. Independent t-test and Chi-square test were used for statistical analysis (p<0.05 considered significant).

*Results: 69 patients received 73 LT. Median age and weight at LT were 2.3 years (40 days-18.9 years) and 13.4 kg (3.3-88.9). The Ppx protocol was used in 52/73 (71.2%) LT. Heparin was stopped in 10/52 patients in the Ppx group (19.2%) due to bleeding compared to 8/21 (38.1%) in the Tx group (Ppx vs. Tx, p=0.090). Within the first 72 hours after LT, the blood transfusion requirements were similar in both groups (Ppx 25.5±42.3 cc/kg vs. Tx 37.0±43.2 cc/kg, p=0.30). The number of patients requiring massive transfusion within 72 hours post LT was not significantly different (Ppx 4/52 7.7% vs. Tx 4/21 19.0%, p=0.16). Patients from the Tx group were taken back to the operating room (OR) more frequently for complications related to bleeding (Ppx 7/52, 13.5%, vs. Tx 10/21, 47.6%, p=0.002). Patients in the Ppx group were taken back to the OR for bleeding significantly sooner after LT (Ppx 1.7±1.6 vs. Tx 4.2±2.0 days, p=0.015). Overall, 4/73 transplants had HAT (5.5%): 1/52 (1.9%) in the Ppx vs. 3/21 (14.3%) in the Tx group (p=0.036). 3 HAT occurred in patients already on Tx protocol due to concerns with hepatic artery flow or thrombosis at the time of LT. Portal vein thrombosis (PVT) occurred in 5 occasions (5/73, 6.8%). All PVT occurred in patients from the Tx group (Ppx 0/52, 0%, vs. Tx 5/21, 23.8%, p<0.001). There were no hepatic venous outflow obstruction events. Median follow-up was 2.3 years (15 days-5.6 years). Overall patient (Ppx 96.2% vs. Tx 95.2%, p=0.86) and graft (Ppx 92.3% vs. Tx 81.0%, p=0.16) survival were not statistically different between groups.

*Conclusions: The use of an anticoagulation protocol after pediatric liver transplantation was associated with a low rate of hepatic artery and portal vein thrombosis. Therapeutic anticoagulation was associated with more bleeding complications, but without adversely affecting patient or graft survival.

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