2026 FSA Podium and Poster Abstracts

Introduction: Coagulopathy is common in patients undergoing orthotopic liver transplantation (OLT) and contributes to significant blood loss and transfusion requirements. In end-stage liver disease, there is reduced hepatic synthesis of both procoagulant factors (intrinsic and extrinsic pathway factors) and anticoagulant factors (protein C, protein S, and antithrombin), creating a delicate balance between bleeding and clotting. Concurrent thrombocytopenia further increases the risk of both hemorrhage and thrombosis during OLT, producing a thrombotic-hemorrhagic “tightrope”.

To manage this intraoperatively, Prothrombin Complex Concentrate (PCC) is administered to correct the International Normalized Ratio (INR) resulting from clotting factor deficiencies and reduce fresh frozen plasma (FFP) administration, as FFP introduces a substantial volume burden that may adversely affect graft function and postoperative outcomes. Because intraoperative bleeding contributes to postoperative anemia, hemoglobin levels are routinely monitored in the perioperative period to detect anemia resulting from surgical blood loss and coagulation abnormalities. Importantly, early postoperative anemia within six months following liver transplantation has been significantly associated with long-term mortality or graft failure.

Since approval by the Food and Drug Administration in April 2013, PCC has been used intraoperatively, but standardized dosing parameters in OLT remain undefined, with typical clinical doses ranging from 20-60 IU/kg. Prior studies have primarily focused on the association between PCC dose and perioperative thrombotic complications, while its relationship with postoperative hemoglobin has not been well characterized. Accordingly, this study aimed to evaluate the relationship between intraoperative PCC dose and postoperative hemoglobin in adult liver transplant recipients.

Methods: This retrospective cohort study included 56 adult liver transplant recipients who received intraoperative PCC at University of Florida Health Shands Hospital, identified from 931 liver transplants performed between April 2013 and December 2024. Adult liver transplant recipients receiving intraoperative PCC between 20-60 IU/kg were included. Collected perioperative variables included PCC dosing and postoperative hemoglobin values. Postoperative hemoglobin was defined as the first hemoglobin value recorded on postoperative day 0. 

Results: Analysis included 56 adult liver transplant recipients who received intraoperative PCC at doses between 20-60 IU/kg. The mean PCC dose was 30.39±9.5 IU/kg. Mean postoperative day 0 hemoglobin was 9.50±1.69 g/dL. Higher intraoperative PCC doses demonstrated a weak but statistically significant positive correlation with postoperative hemoglobin (Figure 1; r = 0.28, p = 0.039). 

Discussion/Conclusion: Higher intraoperative PCC dosing demonstrated a weak but statistically significant positive association with postoperative hemoglobin on postoperative day 0 in adult liver transplant recipients. This finding possibly reflects intraoperative bleeding control as a result of PCC administration. Given the known association between postoperative anemia and adverse outcomes following liver transplantation, higher early postoperative hemoglobin may have clinical significance in this population. Although modest, higher postoperative hemoglobin may reduce postoperative transfusion requirements, which may improve postoperative recovery. These findings support further investigation of optimal PCC dosing strategies in liver transplantation. The single-center retrospective design and limited sample size restrict the generalizability of these findings, suggesting the need for larger multicenter studies.