Use of prothrombin complex concentrates in liver transplantation: a systematic review and meta-analysis

Background: Liver transplantation (LT) can be a high transfusion procedure. Frozen plasma (FP) is widely used despite mixed efficacy and safety data. Several centres perform LT with no or low volume of FP by using prothrombin complex concentrate (PCC). This systematic review and meta-analysis characterises the existing efficacy and safety data of PCC use in LT. Methods: This review was registered (PROSPERO CRD#42024561866). MEDLINE, Embase, Cochrane, and ClinicalTrials.gov were searched from inception to 30 May 2024. Studies in adults undergoing LT where PCC exposure was reported in relation to clinical outcomes were included. Random effects models were used to obtain pooled effect estimates. Results: All studies were retrospective, with seven reporting the number of patients receiving PCC [392/1901 (21%)], and one grouping patients receiving different factor concentrates together [576/939 (61%)]. Patients receiving PCC had worse preoperative coagulopathy, model for end-stage liver disease scores, and comorbidities. Patients exposed to PCC had a comparable mean number of red blood cell (RBC), plasma, or platelet units transfused. Use of viscoelastic testing-based algorithms incorporating PCC compared with usual care was associated with reduced odds of RBC exposure (odds ratio [OR]: 0.53, 95% confidence interval [CI]: 0.32–0.86, I²=0%) and FP exposure (OR: 0.35, 95% CI: 0.13–0.92, I²=50%), but not platelets. Safety outcomes were driven by one large study using PCC as rescue therapy. Conclusions: Although there are no randomised trials comparing use of PCC vs FP in LT, their efficacy and safety appear comparable. Higher-quality studies are needed to assess PCC use for coagulopathic bleeding in LT.