# Persisting thrombomodulin resistance at 3 months after liver transplantation in children with cirrhosis

## TL;DR

This study shows that children with cirrhosis have a rebalanced coagulation system before liver transplant, but some clotting issues persist three months after surgery.

## Contribution

The study is one of the few to investigate coagulation recovery in pediatric cirrhosis patients after liver transplantation.

## Key findings

- Coagulation in cirrhotic children is rebalanced before liver transplantation, similar to controls.
- Three months after transplantation, thrombomodulin resistance persists in most patients.
- High interpatient variability in coagulation parameters was observed.

## Abstract

The coagulation cascade in pediatric cirrhotic patients appears rebalanced, similar to adults, with few true hemostasis-related bleeds or thromboembolic events before liver transplantation. Vascular thrombosis is an important post–liver transplantation complication. Few papers have addressed the recovery of the coagulation cascade after liver transplantation.

We aimed to assess the coagulation cascade, with both measurement of individual factors and a global hemostasis assay, before living donor liver transplantation and to investigate its recovery 3 months after transplantation, when liver function has normalized.

From January 2022 to July 2023, pediatric cirrhotic patients were prospectively enrolled 1 day before liver transplantation. An age-matched control group was included for comparison. Routine hemostasis tests, levels of coagulation factors and natural anticoagulants, and thrombomodulin-modified thrombin generation were determined on automated coagulation analyzers at inclusion and 3 months after liver transplantation.

Twenty-seven pediatric patients with cirrhosis, primarily of cholestatic origin, and 10 controls were enrolled. Sixteen patients were sampled 3 months after liver transplantation. Pediatric end-stage liver disease scores ranged from −10 to 44. A rebalanced coagulation cascade was confirmed in cirrhotic children, indicated by a thrombomodulin-modified thrombin generation assay similar to controls, although with higher interpatient variability. Interestingly, 3 months posttransplant, coagulation was not completely normalized. In the majority of patients resistance to thrombomodulin persisted.

This study confirmed a rebalanced coagulation system in pediatric cirrhotic patients before liver transplantation. Three months posttransplant thrombomodulin resistance persisted. Whereas this contributes to thrombotic complications observed after liver transplantation, remains to be elucidated.

•Limited literature on coagulation recovery after liver transplant (LT) in pediatric cirrhosis.•Evaluation of coagulation factors and a global hemostasis assay before and after LT.•Rebalanced coagulation confirmed, but with high variability among patients.•Persisting thrombomodulin resistance 3 months after LT.

Limited literature on coagulation recovery after liver transplant (LT) in pediatric cirrhosis.

Evaluation of coagulation factors and a global hemostasis assay before and after LT.

Rebalanced coagulation confirmed, but with high variability among patients.

Persisting thrombomodulin resistance 3 months after LT.