Predictive Role of Hepatic Venous Pressure Gradient in Bleeding Events Among Cirrhotic Patients Undergoing Orthotopic Liver Transplantation

Background and aims Major bleeding events during orthotopic liver transplantation (OLT) are associated with poor outcomes. The proportion of this risk related to portal hypertension is unclear. Hepatic venous pressure gradient (HVPG) is the gold standard for estimating portal hypertension. The aim of this study was to analyze the ability of HVPG to predict intraoperative major bleeding events during OLT in patients with cirrhosis. Methods We retrospectively analyzed a prospective database including all patients with cirrhosis who underwent liver transplantation between 2010 and 2020 and had liver and right heart catheterizations as part of their pre-transplant assessment. The primary endpoint was the occurrence of an intraoperative major bleeding event. Results The 468 included patients had a median HVPG of 17 mmHg [interquartile range, 13-22] and a median MELD on the day of OLT of 16 11-24. Intraoperative red blood cell transfusion was required in 72% of the patients (median 2 units transfused), with a median blood loss of 1000 mL [575-1500]. Major intraoperative bleeding occurred in 156 patients (33%) and was associated with HVPG, preoperative hemoglobin level, severity of cirrhosis at the time of OLT (MELD score, ascites, encephalopathy), hemostasis impairment (thrombocytopenia, lower fibrinogen levels), and complications of cirrhosis (sepsis, ACLF). By multivariable regression analysis with backward elimination, HVPG, preoperative hemoglobin level, MELD score, and tranexamic acid infusion were associated with the primary endpoint. Three categories of patients according to HVPG were identified: low-risk (HVPG<16 mmHg), high-risk (HVGP≥16 mmHg), and very high-risk (HVPG≥20 mmHg). Conclusions HVPG predicted major bleeding events in patients with cirrhosis undergoing OLT. Including HVPG as part of pre-transplant assessment might allow better anticipation of the intraoperative course. Impact and implications Major bleeding events during orthotopic liver transplantation (OLT) are associated with poor outcomes but the proportion of this risk related to portal hypertension is unclear. Our work shows that hepatic venous pressure gradient (HVPG), the gold standard for estimating portal hypertension, is a strong predictor of major bleeding events and blood loss volume in patients with cirrhosis undergoing OLT. Three groups of patients can be identified according to their risk of major bleeding event: low-risk patients with HVPG<16 mm Hg, high-risk patients with HVPG≥16 mm Hg, and very high-risk patients with HVPG≥20 mm Hg. HVPG could be systematically included in the pre-transplant assessment to anticipate intraoperative course and tailor patient management.