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Open Access Study protocol

Prothrombin complex concentrate in the reduction of blood loss during orthotopic liver transplantation: PROTON-trial

Freeha Arshad1, Brigitte Ickx2, Rachel T van Beem3, Wojciech Polak4, Frank Grüne5, Frederik Nevens6, Minna Ilmakunnas7, Anna-Maria Koivusalo7, Helena Isoniemi8, Paul FW Strengers3, Henk Groen9, Herman GD Hendriks10, Ton Lisman1, Jacques Pirenne11 and Robert J Porte1*

Author Affiliations

1 Department of Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands

2 Department of Anaesthesiology, Hospital Erasme Brussels, Free University of Brussels, Brussels, Belgium

3 Sanquin Blood Supply Foundation, Amsterdam, The Netherlands

4 Department of Transplantation Surgery, Erasmus Medical Center Rotterdam, Erasmus University Rotterdam, Rotterdam, The Netherlands

5 Department of Anesthesiology, Erasmus Medical Center Rotterdam, Erasmus University Rotterdam, Rotterdam, The Netherlands

6 Department of Hepatology, University Hospital Leuven, Catholic University Leuven, Leuven, Belgium

7 Department of Anaesthesiology and Intensive Care, Hospital District of Helsinki and Uusimaa, Helsinki, Finland

8 Department of Transplantation and Liver Surgery, Hospital District of Helsinki and Uusimaa, Helsinki, Finland

9 Department of Epidemiology, University Medical Center Groningen, Groningen, The Netherlands

10 Department of Anaesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands

11 Department of Abdominal Transplant Surgery, University Hospital Leuven, Catholic University Leuven, Leuven, Belgium

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BMC Surgery 2013, 13:22  doi:10.1186/1471-2482-13-22

Published: 1 July 2013

Abstract

Background

In patients with cirrhosis, the synthesis of coagulation factors can fall short, reflected by a prolonged prothrombin time. Although anticoagulants factors are decreased as well, blood loss during orthotopic liver transplantation can still be excessive. Blood loss during orthotopic liver transplantation is currently managed by transfusion of red blood cell concentrates, platelet concentrates, fresh frozen plasma, and fibrinogen concentrate. Transfusion of these products may paradoxically result in an increased bleeding tendency due to aggravated portal hypertension. The hemostatic effect of these products may therefore be overshadowed by bleeding complications due to volume overload.

In contrast to these transfusion products, prothrombin complex concentrate is a low-volume highly purified concentrate, containing the four vitamin K dependent coagulation factors. Previous studies have suggested that administration of prothrombin complex concentrate is an effective method to normalize a prolonged prothrombin time in patients with liver cirrhosis. We aim to investigate whether the pre-operative administration of prothrombin complex concentrate in patients undergoing liver transplantation for end-stage liver cirrhosis, is a safe and effective method to reduce perioperative blood loss and transfusion requirements.

Methods/Design

This is a double blind, multicenter, placebo-controlled randomized trial.

Cirrhotic patients with a prolonged INR (≥1.5) undergoing liver transplantation will be randomized between placebo or prothrombin complex concentrate administration prior to surgery. Demographic, surgical and transfusion data will be recorded. The primary outcome of this study is RBC transfusion requirements.

Discussion

Patients with advanced cirrhosis have reduced plasma levels of both pro- and anticoagulant coagulation proteins. Prothrombin complex concentrate is a low-volume plasma product that contains both procoagulant and anticoagulant proteins and transfusion will not affect the volume status prior to the surgical procedure. We hypothesize that administration of prothrombin complex concentrate will result in a reduction of perioperative blood loss and transfusion requirements. Theoretically, the administration of prothrombin complex concentrate may be associated with a higher risk of thromboembolic complications. Therefore, thromboembolic complications are an important secondary endpoint and the occurrence of this type of complication will be closely monitored during the study.

Trial registration

The trial is registered at http://www.trialregister.nl webcite with number NTR3174. This registry is accepted by the ICMJE.

Keywords:
Orthotopic Liver Transplantation; Prothrombin Complex Concentrate; Haemostatis; Bleeding; Blood Loss; Transfusion Requirements; Cirrhosis