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Tomić Mahečić T, Baronica R, Mrzljak A, Boban A, Hanžek I, Karmelić D, Babić A, Mihaljević S, Meier J. Individualized Management of Coagulopathy in Patients with End-Stage Liver Disease. Diagnostics (Basel) 2022; 12:diagnostics12123172. [PMID: 36553179 PMCID: PMC9777026 DOI: 10.3390/diagnostics12123172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 12/02/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022] Open
Abstract
Over the last decades, individualized approaches and a better understanding of coagulopathy complexity in end-stage liver disease (ESLD) patients has evolved. The risk of both thrombosis and bleeding during minimally invasive interventions or surgery is associated with a worse outcome in this patient population. Despite deranged quantitative and qualitative coagulation laboratory parameters, prophylactic coagulation management is unnecessary for patients who do not bleed. Transfusion of red blood cells (RBCs) and blood products carries independent risks for morbidity and mortality, including modulation of the immune system with increased risk for nosocomial infections. Optimal coagulation management in these complex patients should be based on the analysis of standard coagulation tests (SCTs) and viscoelastic tests (VETs). VETs represent an individualized approach to patients and can provide information about coagulation dynamics in a concise period of time. This narrative review will deliver the pathophysiology of deranged hemostasis in ESLD, explore the difficulties of evaluating the coagulopathies in liver disease patients, and examine the use of VET assays and management of coagulopathy using coagulation factors. Methods: A selective literature search with PubMed as the central database was performed with the following.
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Affiliation(s)
- Tina Tomić Mahečić
- Clinic of Anesthesiology, Reanimatology and Intensive Care Medicine, and Pain Treatment, University Hospital Center Zagreb, 10000 Zagreb, Croatia
- Correspondence: ; Tel.: +385-98-457-189
| | - Robert Baronica
- Clinic of Anesthesiology, Reanimatology and Intensive Care Medicine, and Pain Treatment, University Hospital Center Zagreb, 10000 Zagreb, Croatia
- School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
| | - Anna Mrzljak
- School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
- Liver Transplant Center, Department of Gastroenterology and Hepatology, University Hospital Center Zagreb, 10000 Zagreb, Croatia
| | - Ana Boban
- School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
- Department of Hematology, University Hospital Center Zagreb, 10000 Zagreb, Croatia
| | - Ivona Hanžek
- Clinic of Anesthesiology, Reanimatology and Intensive Care Medicine, and Pain Treatment, University Hospital Center Zagreb, 10000 Zagreb, Croatia
| | - Dora Karmelić
- Clinic of Anesthesiology, Reanimatology and Intensive Care Medicine, and Pain Treatment, University Hospital Center Zagreb, 10000 Zagreb, Croatia
| | - Anđela Babić
- Clinic of Anesthesiology, Reanimatology and Intensive Care Medicine, and Pain Treatment, University Hospital Center Zagreb, 10000 Zagreb, Croatia
| | - Slobodan Mihaljević
- Clinic of Anesthesiology, Reanimatology and Intensive Care Medicine, and Pain Treatment, University Hospital Center Zagreb, 10000 Zagreb, Croatia
- School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
| | - Jens Meier
- Clinic of Anesthesiology and Intensive Care Medicine, Kepler University Clinic, Johannes Kepler University, 4040 Linz, Austria
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Impact of liver disease severity on outcomes of patients undergoing endourological procedures for urolithiasis. Curr Urol 2022; 16:20-24. [PMID: 35633855 PMCID: PMC9132189 DOI: 10.1097/cu9.0000000000000088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 12/08/2020] [Indexed: 11/26/2022] Open
Abstract
Objectives: This study is aimed to determine the impact of liver disease severity on the outcome of patients undergoing endourological procedures for urolithiasis, and to understand the factors that are helpful in improving the outcome. Materials and methods: We retrospectively analyzed the records of patients with chronic liver disease who underwent endourological procedures between January 2014 and February 2020. Inpatient records and charts were assessed for age, sex, height, weight, body mass index, model for end-stage liver disease (MELD) score, Child-Turcotte-Pugh score, type of procedure and anesthesia, intensive care unit (ICU) stay, duration of hospitalization, number, size, and position of stones, and postoperative complications such as hematuria, sepsis, and secondary procedures. Data are presented as mean ± standard deviation or frequency. The chi-square test was applied to determine the exact association between categorical data and Student t-test or Mann-Whitney U test as appropriate for continuous data. Statistical significance was set at p < 0.05. Results: Hospital and ICU stay as well as administration of different blood products were significantly longer in the Child C than in the Child A and B categories (p < 0.001). Two patients in the Child C category died, while 3 left the hospital against medical advice. The duration of ICU stay and blood products administered increased with augmenting MELD scores. The durations of hospitalization and blood product administration were significantly higher in patients with an MELD score ≥20 than in the group with MELD score <20. Conclusions: Hospital and ICU stay and blood product administration were significantly higher in Child C than in Child A and B class patients. Hospitalization duration and blood product administration were significantly higher in patients with an MELD score ≥20.
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Adam EH, Möhlmann M, Herrmann E, Schneider S, Zacharowski K, Zeuzem S, Weber CF, Weiler N. Assessment of hemostatic profile in patients with mild to advanced liver cirrhosis. World J Gastroenterol 2020; 26:2097-2110. [PMID: 32536777 PMCID: PMC7267688 DOI: 10.3748/wjg.v26.i17.2097] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 03/26/2020] [Accepted: 04/24/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Hemostasis of patients suffering from liver cirrhosis is challenging due to both, pro- and anticoagulatory disorders leading to hemostatic alterations with distinct abnormalities of coagulation. Pathological changes in conventional coagulation analysis and platelet count are common manifestations of decreased liver synthesis of coagulation factors and reduced platelet count in these patients. However, conventional coagulation analysis and platelet count do not reflect in-vivo coagulation status or platelet function. The purpose of this present observational study was therefore to assess the haemostatic profile including plasmatic coagulation using thrombelastometry and impedance aggregometry for platelet function in patients suffering from liver cirrhosis.
AIM To assess the hemostatic profile of cirrhotic patients according to model for end-stage liver disease (MELD) score.
METHODS Our study included both in- and outpatients suffering from liver cirrhosis attending the out- and inpatient care of the department of hepatology. Demographic and biochemical data as well as medical history including cause of liver cirrhosis, end stage kidney failure and medication with anticoagulants were recorded. To assess the hemostatic profile, platelet function was analyzed by multiple electrode aggregometry (MEA) using Multiplate® (ADP-, ASPI- and TRAP-test) and thrombelastometry using ROTEM® (EXTEM, INTEM, FIBTEM). Data were compared using Mann-Whitney U- or χ2-test. Spearman correlation was performed to analyze the association between MELD Score and results of thrombelastometry and MEA.
RESULTS A total of 68 patients attending the out- and inpatient care suffering from liver cirrhosis were screened. Of these, 50 patients were included and assigned to groups according to MELD score 6 to 11 (n = 25) or ≥ 17 (n = 25). Baseline patient characteristics revealed significant differences for MELD score (8 vs 22, P < 0.0001) and underlying laboratory parameters (international normalized ratio, bilirubine, creatinine) as well as fibrinogen level (275 mg/dL vs 209 mg/dL, P = 0.006) and aPTT (30 s vs 35 s, P = 0.047). MEA showed a moderately impaired platelet function (medians: AUCADP = 43U, AUCASPI = 71U, AUCTRAP = 92U) but no significant differences between both groups. Thrombelastometry using ROTEM® (EXTEM, INTEM, FIBTEM) revealed values within normal range in both groups. No significant correlation was observed between MELD score and results of MEA/thrombelastometry.
CONCLUSION Our data demonstrate a partially impaired hemostatic profile in liver cirrhosis patients unrelated to MELD score. An individual assessment of a potential coagulopathy should therefore be considered.
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Affiliation(s)
- Elisabeth Hannah Adam
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Frankfurt 60590, Germany
| | - Madara Möhlmann
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Frankfurt 60590, Germany
| | - Eva Herrmann
- Department of Biostatistics and mathematical modeling, University Hospital Frankfurt, Goethe-University Frankfurt, Frankfurt 60590, Germany
| | - Sonia Schneider
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Frankfurt 60590, Germany
| | - Kai Zacharowski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Frankfurt 60590, Germany
| | - Stefan Zeuzem
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University Hospital Frankfurt, Goethe-University Frankfurt, Frankfurt 60590, Germany
| | - Christian Friedrich Weber
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Frankfurt 60590, Germany
- Department of Anaesthesiology, Intensive Care Medicine and Emergency Medicine, Asklepios Clinics Hamburg, Hamburg 22043, Germany
| | - Nina Weiler
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University Hospital Frankfurt, Goethe-University Frankfurt, Frankfurt 60590, Germany
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Wang H, Liu W, Tian M, Tang Z, Jiang X, Zhou P, Ding Z, Peng Y, Dai Z, Qiu S, Zhou J, Fan J, Shi Y. Coagulopathy associated with poor prognosis in intrahepatic cholangiocarcinoma patients after curative resection. Biosci Trends 2017; 11:469-474. [DOI: 10.5582/bst.2017.01080] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Han Wang
- Department of Liver Surgery, Liver Cancer Institute, Zhongshan Hospital, Fudan University; Key Laboratory of Carcinogenesis and Cancer Invasion of Ministry of Education
| | - Weiren Liu
- Department of Liver Surgery, Liver Cancer Institute, Zhongshan Hospital, Fudan University; Key Laboratory of Carcinogenesis and Cancer Invasion of Ministry of Education
| | - Mengxin Tian
- Department of Liver Surgery, Liver Cancer Institute, Zhongshan Hospital, Fudan University; Key Laboratory of Carcinogenesis and Cancer Invasion of Ministry of Education
| | - Zheng Tang
- Department of Liver Surgery, Liver Cancer Institute, Zhongshan Hospital, Fudan University; Key Laboratory of Carcinogenesis and Cancer Invasion of Ministry of Education
| | - Xifei Jiang
- Department of Liver Surgery, Liver Cancer Institute, Zhongshan Hospital, Fudan University; Key Laboratory of Carcinogenesis and Cancer Invasion of Ministry of Education
| | - Peiyun Zhou
- Department of Liver Surgery, Liver Cancer Institute, Zhongshan Hospital, Fudan University; Key Laboratory of Carcinogenesis and Cancer Invasion of Ministry of Education
| | - Zhenbin Ding
- Department of Liver Surgery, Liver Cancer Institute, Zhongshan Hospital, Fudan University; Key Laboratory of Carcinogenesis and Cancer Invasion of Ministry of Education
| | - Yuanfei Peng
- Department of Liver Surgery, Liver Cancer Institute, Zhongshan Hospital, Fudan University; Key Laboratory of Carcinogenesis and Cancer Invasion of Ministry of Education
| | - Zhi Dai
- Department of Liver Surgery, Liver Cancer Institute, Zhongshan Hospital, Fudan University; Key Laboratory of Carcinogenesis and Cancer Invasion of Ministry of Education
| | - Shuangjian Qiu
- Department of Liver Surgery, Liver Cancer Institute, Zhongshan Hospital, Fudan University; Key Laboratory of Carcinogenesis and Cancer Invasion of Ministry of Education
| | - Jian Zhou
- Department of Liver Surgery, Liver Cancer Institute, Zhongshan Hospital, Fudan University; Key Laboratory of Carcinogenesis and Cancer Invasion of Ministry of Education
- Institutes of Biomedical Sciences, Fudan University
| | - Jia Fan
- Department of Liver Surgery, Liver Cancer Institute, Zhongshan Hospital, Fudan University; Key Laboratory of Carcinogenesis and Cancer Invasion of Ministry of Education
- Institutes of Biomedical Sciences, Fudan University
| | - Yinghong Shi
- Department of Liver Surgery, Liver Cancer Institute, Zhongshan Hospital, Fudan University; Key Laboratory of Carcinogenesis and Cancer Invasion of Ministry of Education
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Saner FH, Kirchner C. Monitoring and Treatment of Coagulation Disorders in End-Stage Liver Disease. Visc Med 2016; 32:241-248. [PMID: 27722160 DOI: 10.1159/000446304] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Patients with end-stage liver disease (ESLD) are assumed to be at high risk of bleeding when undergoing any kind of invasive intervention (any kind of operation, including transplantation or minimally invasive interventions). Both bleeding and thrombosis are associated with a poor outcome. METHODS A selective literature research was conducted with the following key words: 'cirrhosis', 'coagulation', 'bleeding', 'INR' (international normalized ratio), 'aPTT' (activated partial thromboplastin time), and 'thrombocytopenia'. PubMed was used as the basic database. RESULTS Pathological values of standard laboratory tests (SLT) and thrombocytopenia have traditionally been regarded as indicators of a high risk for bleeding in all patients, and especially in those with ESLD. However, this approach has been challenged in recent years. The conventional approach in assessing a bleeding risk was based on pathological values of SLT. A 1.5-fold increase of INR or aPTT or platelets < 50/nl is assumed as pathological. The traditional approach of reducing the risk of excessive bleeding during an invasive procedure was to transfuse fresh frozen plasma (FFP) or platelet concentrates in order to improve hemostasis and to avoid bleeding complications. In the recent 20 years, several studies have provided us with a basis for questioning this approach. Their results indicated that SLT were not able to predict hypocoagulation and bleeding complications. Moreover, transfusion of various blood products has been associated with an increased risk for acute lung injury, transfusion-associated circulation overload, bacterial infections, and modulation of the immune system with increased numbers of nosocomial infections. Furthermore, a high volume overload, which is required to correct a hemostasis disorder if FFP are being used in ESLD patients, may increase portal venous pressure. This might significantly increase bleeding in these ESLD patients. Although the first publication about the successful use of a viscoelastic test (VET) in liver transplantation dates back to 1985, physicians are still very reluctant to use VETs (Thrombelastography™ and/or ROTEM™) for the perioperative optimization of hemostasis. However, some very recent studies demonstrated that the use of VETs for assessing the risk of bleeding avoids futile transfusion with a similar safety profile. The implementation of ROTEM-based coagulation management and the use of coagulation factors (prothrombin complex, fibrinogen concentrate) have led to a highly significant reduction of FFP and red blood cell transfusions, without an increased incidence of thrombosis or bleeding. CONCLUSION Patients with ESLD often show pathological values of conventional parameters used to analyze coagulation hemostasis. Without overt signs of excessive bleeding, however, they do not require coagulation treatment. The use of FFP, which is associated with fluid overload and increase in portal venous pressure, should be avoided. The preferable coagulation treatment should be based on VET-guided administration of coagulation factor concentrates.
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Affiliation(s)
- Fuat H Saner
- Department of General, Visceral and Transplant Surgery, University Hospital, University Duisburg-Essen, Essen, Germany
| | - Carmen Kirchner
- Department of General, Visceral and Transplant Surgery, University Hospital, University Duisburg-Essen, Essen, Germany
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[Rotational thromboelastometry for the diagnosis of coagulation disorders]. Med Klin Intensivmed Notfmed 2016; 113:542-551. [PMID: 27405939 DOI: 10.1007/s00063-016-0194-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 04/22/2016] [Accepted: 05/01/2016] [Indexed: 01/19/2023]
Abstract
BACKGROUND Compared to conventional coagulation assays, as prothrombin time (PT) or activated partial thromboplastin time (aPTT), viscoelastic methods of coagulation analysis, including rotational thromboelastometry (ROTEM®, Tem International GmbH, Munich, Germany), yield prognostic benefits. Results of ROTEM® in citrated whole blood could be generated within 10-12 min and allow for a qualitative and semiquantitative characterisation of clot kinetics. Based on ROTEM® results, the switch between empiric approaches of treating coagulopathy to a goal-directed approach could be accelerated. Introduction of ROTEM® reduces transfusion requirements and the need for single factor concentrates. Thus, ROTEM® reduces transfusion-related adverse events, and additionally implement therapeutic cost effectiveness. OBJECTIVES This review provides a short introduction in the methodology of ROTEM®, showing how the combination of assays with different commercially available ROTEM® reagents allows for rapid differential diagnosis of common coagulopathies in clinical practice. Furthermore, prognostic benefits and limitations of ROTEM® diagnostics are described. Finally, we discuss the potential fields of ROTEM® application in different surgical settings. CONCLUSION ROTEM® appears to be a contemporary, applicable and effective method in diagnosing coagulopathy and for subsequent algorithm-based goal-directed therapy.
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