Liver transplantation has now become standard practice in persons with haemophilia who have an indication for this procedure. This requires close collaboration between liver surgeon, hepatologist, anaesthesiologist and haematologist. Practical recommendations for liver transplantation: In our centre, we formulate a plan for factor substitution before patients are placed on the waiting list. This plan is available to all team members, in the electronic patient file. An inhibitor this website is excluded at this time point, with repeat measurements at least every 6 months (in low risk patients with generally >1000 exposure days). Shortly before transplantation, FVIII or FIX concentrate is infused, aiming for levels of 100 and

80% respectively. After this initial bolus, a continuous

infusion of 4 units per kg bodyweight per hour is started. A FVIII or FIX level is measured before the start of surgery. During transplantation, laboratory staff is available for repeat measures if surgery is complicated or haemostasis is insufficient. At the end of surgery and at least daily afterwards, factor levels are again monitored. Decrease of substitution is guided by these measurements. Palliative options with proven efficacy (increased survival) are limited to trans-catheter arterial chemoembolization (TACE) and sorafenib. The AASLD recommends TACE in BCLC intermediate (B) stage HCC, and sorafenib in advanced (C) stage. In TACE, chemotherapy (either doxorubicin or cisplatin in lipiodol emulsion) is infused directly in the hepatic artery. Subsequently, the blood vessel is embolized using small particles, RAD001 thus combining cytotoxic and ischaemic damage to the tumour. A recent advance is combining both steps in the use of embolic

particles that elute cytotoxic drugs [42]. Extensive tumour necrosis is seen after TACE in most patients, with objective responses in 20–60% and very rare complete responses. Necrosis causes fever, abdominal pain and ileus, from which patients normally recover in 2 days. TACE has been shown to improve survival, but the size of the gain depends heavily on patient characteristics. In patients with more advanced disease (i.e., BCLC stage only C, especially those with portal invasion) the benefits do not outweigh the risk of complications [42]. Evidence in haemophilia.  Four cases of TACE in persons with haemophilia have been described in the same paper quoted earlier for PEI [46]. Here too, substitution was used for 2 days after the procedure. Moreover, no early complications were seen but 2/4 patients had late gastrointestinal bleeding. We have used TACE twice, in a single patient with severe haemophilia A who had a longstanding inhibitor. He was treated with recombinant factor VIIa, 90 μg kg−1, for 3 days. During the procedure and the first 12 h afterwards, dosing was every 2 h. Afterwards, we decreased the interval between doses. The procedure was uncomplicated.