Introduction: End stage liver disease (ESLD) is characterized by a precarious imbalance of hemostasis. Detrimental consequences of hypofibrinolysis, also known as fibrinolytic shutdown, have been recently demonstrated, and its significance in visceral transplant remains unknown.

Method: To fill this gap, following IRB approval, this retrospective study included 49 adult recipients of visceral allografts (14 without the liver, 35 multivisceral (MVT) with the liver) transplanted between 2010-2018 in a single university hospital, and for whom pre-incisional thromboelastography was available. Based on % clot lysis 30 min after maximal amplitude, patients were stratified into 3 fibrinolysis phenotypes: fibrinolytic shutdown, physiologic fibrinolysis, and hyperfibrinolysis.

Results: Fibrinolytic shutdown occurred in 57% of patients, with higher incidence in recipients of multivisceral (69%), compared to visceral (29%) allografts (P=.04). Of the 35 MVT, 26% had normal liver function, 46% had parenteral nutrition-associated liver disease and 28% had severe ESLD with extensive portal vein thrombosis. Fibrinolytic shutdown was statistically associated with ESLD, as incidence of fibrinolytic shutdown in the presence or absence of ESLD was 73% versus 39% (P=0.02). Intraoperative thrombosis (18%) occurred only with MVT, and accounted for 36% of in-hospital mortality. Intraoperative thrombosis occurred solely in recipients with an abnormal fibrinolytic phenotype (fibrinolysis shutdown- 8/9 and hyperfibrinolysis- 1/9). A clinically meaningful reduction in incidence of intraoperative thrombosis was noted in recipients who received iv heparin thromboprophylaxis. Logistic regression identified pretransplant platelet count as a risk factor for fibrinolytic shutdown [OR 0.992, 95%CI (0.984-0.998); χ2=7.8, P=0.005).

Conclusions: This study highlights fibrinolytic shutdown as a dominant and clinically important feature of the hemostatic imbalance in recipients undergoing visceral transplantation.