Associação do diagnóstico etiológico, classificação de child, presença ou não de ascite e coagulograma com o perfil tromboelastográfico pré-operatório de pacientes submetidos a transplante hepático

Abstract

A cross-sectional clinical trial was conducted at the University Hospital of the Federal University of Minas Gerais (HC-UFMG), Alfa Institute of Gastroenterology Transplant Group, between September 2001 and June 2004 in order to investigate possible associations of clinical (etiological diagnosis of the liver cirrhosis, severity of the hepatic insufficiency according to the Child classification, and the presence or absence of clinically evident ascites) and laboratory (conventional coagulogram) characteristics of patients submitted to liver transplantation with the immediate preoperative thromboelastographic profile. A total of 113 patients were included prospectively in the study. Associations were analyzed by chi-square test and Fischer`s exact test. The odds ratio was used to determine the direction of the association. The level of significance was set at 5%. Forty-one (36.3%) of the 113patients were females and 72 (63.7%) were males. Age ranged from 1 to 75 years, with a mean of 45.1 years (SD ± 16.6) and a median of 49 years. Using the Child classification, 16 (14.2%) patients were classified as Child A, 72 (63%) as Child B, and 25 (22.1%) as Child C. Eighty-five (75.2%) patients presented no clinically evident ascites at the immediatepreoperative period, whereas ascites was easily detected upon preoperative clinical examination in 28 (24.8%). The patients were distributed into groups according to the etiological diagnosis of liver disease: postnecrotic cirrhosis, 77 patients (68.1%); bile ductdisease, 15 (13.3%); autoimmune hepatitis, seven (6.2%); retransplantation, three (2.7%); fulminant hepatitis, five (4.4%), and others, six (5.3%). Activated partial thromboplastin time (APTT) was not recovered for analysis in six (5.3%) of the 113 patients, was abnormalin 47 (41.6%), and normal in 60 (53.1%). The international normalized ratio (INR) was not recovered for analysis in five (4.4%) patients, was abnormal in 81 (71.7%), and normal in xiii 27 (23.9%). Analysis of the immediate preoperative thromboelastographic profiles revealeda hypocoagulable profile in 53 (46.9%) patients, a normal profile in 19 (16.8%), and a hypercoagulable profile in 41 (36.3%). An association was observed between the thromboelastogram (TEG) patterns and the etiological diagnosis of postnecrotic cirrhosis and bile duct disease (p = 0.0301). Patients included in the second group more frequentlypresented the hypercoagulable profile, whereas the hypocoagulable profile was more frequent in the group with postnecrotic cirrhosis. No significant association was observed between TEG patterns and Child classification (p = 0.1045) or the presence or absence of clinically evident ascites (p = 0.1694). There was an association between TEG patterns and INR (p = 0.0372) and APTT (p = 0.0247). Patients with both altered APTT and INR more frequently presented the hypocoagulable profile. The same associations were investigated in the group with postnecrotic cirrhosis. No association was observed between the TEG patterns and severity of the hepatic insufficiency according to the Child classification (p = 0.6354), presence or absence of clinically detectable ascites (p = 0.1310) or INR (p = 0.0815). However, there was an association between TEG patterns and APTT (p = 0.0216), with the hypocoagulable profile being more frequent in the patients with altered APTT. In conclusion, the hemostatic equilibrium is extremely variable when evaluated bythromboelastography during the immediate pretransplant period in patients with hepatic insufficiency. The following associations were observed: postnecrotic cirrhosis and hypocoagulable thromboelastographic profile, bile duct disease and hypercoagulableprofile, altered APTT and hypocoagulable profile, and altered INR and hypocoagulable profile only when the group was studied as a whole. This association was not observed when the postnecrotic cirrhosis group was sole evaluated.