Use of prothrombin complex concentrates in liver transplantation: a systematic review and meta-analysis.
Kojundzic, I., et al.Br J Anaesth. 2025 Nov;135(5):1172-1192.
Aims
A systematic review and meta-analysis to assess efficacy and safety of prothrombin complex concentrate (PCC) use during liver transplant (LT) compared with usual care (often fresh frozen plasma (FFP) based) and/or algorithms incorporating PCC, focusing on transfusion requirements and thromboembolic and other complications.
Interventions
Systematic review/meta-analysis of retrospective studies comparing PCC exposure vs no PCC; and/or implementation of Viscoelastic (VET – e.g. ROTEM, TEG) guided algorithms incorporating PCC vs prior usual care.
Participants
Eight studies, totalling 2840 LT recipients, seven reported explicit PCC exposure counts (392/1901, 21%) and one grouped factor concentrates (PCC +/- fibrinogen) 576/939 (61%).
Outcomes
The primary outcomes assessed was transfusion efficacy, reducing RBC exposure without increased morbidity/mortality. Safety outcomes were also looked at, thrombosis, AKI and dialysis.
Follow-up
N/A
CET Conclusions
They conduct a comprehensive systematic review and meta-analysis looking at the limited number of studies in the field which contains no randomised trials. Across the available retrospective data, PCC, especially within VET-guided, goal-directed algorithms appears to reduce RBC/FP transfusion with comparable short-term safety to FFP when dosed judiciously. There are reduced odds of RBC exposure (OR 0.53, 95% CI 0.32–0.86) and reduced FFP exposure (OR 0.35, 95% CI 0.13–0.92), with platelets unchanged. In propensity-matched cohorts using protocolised PCC (often 15–25 IU/kg), several studies showed lower RBC/FFP use without increases in morbidity/mortality. It’s worth noting that patients given PCC typically had worse baseline coagulopathy and higher MELD. Safety concerns (splanchnic thrombosis) are largely observed in rescue-therapy contexts with more unwell patients and high cumulative doses, limiting causal inference. Post-op AKI and new haemodialysis were not higher with PCC, one study reported less new dialysis with PCC. Overall, the evidence quality is low to moderate with: no RCTs, heterogeneity in dosing, algorithms, and co-interventions. Clinically, centres already using VET-guided haemostatic management may reasonably integrate PCC as a factor-replacement option to minimise FFP exposure, while closely monitoring for thrombotic events and standardising dosing/indications. That being said, there is no high-quality RCT in LT which is needed to define efficacy, optimal dosing, and safety vs FFP.
Trial registration
PROSPERO - CRD42024561866