Preoperative fibrinogen level and blood transfusions in liver transplantation: A systematic review

Transplant Rev (Orlando). 2023 Dec;37(4):100797. doi: 10.1016/j.trre.2023.100797. Epub 2023 Sep 26.


Background: Orthotopic liver transplantation (OLT) is a major surgery often associated with significant bleeding. We conducted a systematic review to explore the association between preoperative fibrinogen level and intraoperative blood products transfusion, blood loss and clinical outcomes in patients undergoing OLT.

Methods: We included observational studies conducted in patients undergoing an OLT mostly for end-stage liver disease that reported an association between the preoperative fibrinogen level and our outcomes of interest. Our primary outcome was the intraoperative red blood cell (RBC) transfusion requirements. Our secondary outcomes were intraoperative blood loss, intraoperative transfusion of any blood product, postoperative RBC transfusion, postoperative thrombotic or hemorrhagic complications, and mortality. We used a standardized search strategy. We reported our results mostly descriptively but conducted meta-analyses using random-effect models when judged feasible.

Results: We selected 24 cohort studies reporting at least one of our outcomes. We found that a high preoperative fibrinogen level was associated with fewer intraoperative RBC and other blood products transfusions, and lower blood loss. We also found a lower overall survival in patients with a higher fibrinogen level (pooled hazard ratio [95% CI] of 1.50 [1.23 to 1.84]; 5 studies, n = 1012, I2 = 48%). Only one study formally explored a fibrinogen level threshold effect. Overall, reporting was heterogeneous, and risk of bias was variable mostly because of uncontrolled confounding.

Conclusion: A higher preoperative fibrinogen level was associated with fewer intraoperative RBC and other blood products transfusions, lower blood loss, and higher mortality. Further studies may help clarify observed associations and inform guidelines.

Keywords: Blood loss; Blood transfusion; Fibrinogen level; Orthotopic liver transplantation; Postoperative outcomes.

Publication types

  • Systematic Review
  • Review

MeSH terms

  • Blood Transfusion
  • End Stage Liver Disease*
  • Erythrocyte Transfusion / adverse effects
  • Fibrinogen
  • Humans
  • Liver Transplantation* / adverse effects
  • Liver Transplantation* / methods


  • Fibrinogen