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Drolz A. [Bleeding in liver diseases]. Med Klin Intensivmed Notfmed 2024; 119:458-464. [PMID: 39138654 DOI: 10.1007/s00063-024-01167-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Accepted: 07/08/2024] [Indexed: 08/15/2024]
Abstract
Bleeding events are feared complications in patients with advanced liver diseases and are associated with morbidity and mortality. In this context, gastrointestinal bleeding, particularly upper gastrointestinal bleeding, has a special clinical importance. In addition to endoscopic measures for hemostasis, reducing portal pressure in particular is a key component of treatment. Although the standard coagulation parameters are often altered in patients with liver diseases, optimizing coagulation plays a secondary role. Typically, a bundle of measures are employed in patients with portal hypertensive bleeding, which nowadays in most cases can halt the bleeding and stabilize the situation. The measures include endoscopy, antibiotic treatment, vasopressor treatment and, if necessary, shunt placement (transjugular intrahepatic portosystemic shunt).
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Affiliation(s)
- Andreas Drolz
- I. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland.
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2
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Balaceanu LA, Dina I. D-dimers in advanced liver cirrhosis: Useful biomarker or not? Am J Med Sci 2024:S0002-9629(24)01264-3. [PMID: 38788925 DOI: 10.1016/j.amjms.2024.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 02/03/2024] [Accepted: 05/20/2024] [Indexed: 05/26/2024]
Abstract
In clinical practice, the d-dimer levels rule out venous thromboembolism and diagnose disseminated intravascular coagulation. d-dimers increase in both physiological and pathological conditions. Liver cirrhosis, especially in the final stages, is characterized by complex coagulation and fibrinolysis factor disorders. Multiple mechanisms tried to explain the increased d-dimer levels in patients with liver cirrhosis and ascites. The d-dimer cut-off level used to rule out venous thromboembolism in cirrhosis is higher than that used to confirm the diagnosis of VTE or DIC in noncirrhotic patients. The cut-off d-dimer level used for the prognosis of thrombotic events is not standardized in advanced liver cirrhosis. Thus, it is necessary to update the clinical guidelines regarding the usefulness of d-dimer testing in advanced liver cirrhosis and the cut-off d-dimer levels, which should vary based on the detection method.
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Affiliation(s)
- Lavinia Alice Balaceanu
- Internal Medicine Department, "Carol Davila" University of Medicine and Pharmacy, Emergency Clinical Hospital "Sf. Ioan," Bucharest, Romania.
| | - Ion Dina
- Gastroenterology Department, "Carol Davila" University of Medicine and Pharmacy, Emergency Clinical Hospital "Sf. Ioan," Bucharest, Romania
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3
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Huang X, Abougergi MS, Sun C, Murphy D, Sondhi V, Chen B, Zheng X, Chen S, Wang Y. Incidence and outcomes of thromboembolic and bleeding events in patients with liver cirrhosis in the USA. Liver Int 2023; 43:434-441. [PMID: 35635760 DOI: 10.1111/liv.15325] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 05/11/2022] [Accepted: 05/26/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND & AIMS Understanding the epidemiology of bleeding and thromboembolism (clotting) in liver cirrhosis provides important data for future studies and policymaking; however, head-to-head comparisons of bleeding and clotting remain limited. METHODS This is a populational retrospective cohort study using the US National Readmission Database of 2018 to compare the incidence and outcomes of bleeding and clotting events in patients with liver cirrhosis. The primary outcomes were the 11-month incidence proportion of bleeding and clotting events. RESULTS Of 1 304 815 participants, 26 569 had liver cirrhosis (45.0% women, mean age 57.2 [SD, 12.7] years). During the 11-month follow-up, in patients with cirrhosis, for bleeding and clotting events, the incidence proportions was 15.3% and 6.6%; the risk-standardized all-cause mortality rates were 2.4% and 1.0%; the rates of intensive care intervention were 4.1% and 1.9%; the rates of rehabilitation transfer were .2% and .2%; the cumulative length of stays were 45 100 and 23 566 days; total hospital costs were 147 and 84 million US dollars; total hospital charges were 620 and 365 million US dollars. Compared to non-cirrhosis, liver cirrhosis was associated with higher rates of bleeding (adjusted hazard ratio, 3.02 [95% CI, 2.85-3.20]) and portal vein thrombosis (PVT) (18.46 [14.86-22.92]), and slightly lower risks of other non-PVT venous thromboembolic events (.82 [.75-.89]). CONCLUSIONS Bleeding is more common than thromboembolism in patients with liver cirrhosis, causes higher morbidity, mortality and resource utilization. Liver cirrhosis is an independent risk factor for bleeding and PVT, but not non-PVT thromboembolism including venous thromboembolism, acute myocardial infarction and ischemic stroke.
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Affiliation(s)
- Xiaoquan Huang
- Department of Gastroenterology and Hepatology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Marwan S Abougergi
- Division of Gastroenterology, Department of Internal Medicine, University of South Carolina School of Medicine, Columbia, South Carolina, USA.,Catalyst Medical Consulting, Simpsonville, South Carolina, USA
| | - Chenyu Sun
- AMITA Health Saint Joseph Hospital Chicago, Chicago, Illinois, USA
| | - Dermot Murphy
- Mercy Internal Medicine Service, Trinity Health of New England, Springfield, Massachusetts, USA
| | - Vikram Sondhi
- Mercy Internal Medicine Service, Trinity Health of New England, Springfield, Massachusetts, USA
| | - Bing Chen
- Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Xin Zheng
- Division of Gastroenterology, Department of Medicine, Loma Linda University, Loma Linda, California, USA
| | - Shiyao Chen
- Department of Gastroenterology and Hepatology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yichen Wang
- Mercy Internal Medicine Service, Trinity Health of New England, Springfield, Massachusetts, USA
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4
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Latona A, Hill K, Connelly A, Stuart K, Wood P. Prothrombinex®-VF in chronic liver disease: Friend or foe? Emerg Med Australas 2023; 35:89-96. [PMID: 35993256 PMCID: PMC10087488 DOI: 10.1111/1742-6723.14058] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 05/11/2022] [Accepted: 07/28/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Management of coagulopathy in chronic liver disease (CLD) poses a challenge for critical care physicians. Prothrombinex®-VF is a low-volume product with rapid onset of action. Evidence for its efficacy and safety in CLD is limited and cases of acute intravascular coagulation and fibrinolysis (AICF) and/or disseminated intravascular coagulation (DIC) have been reported. Our objective was to evaluate the role of Prothrombinex®-VF in reversal of coagulopathy and the incidence AICF/DIC, thromboembolic events and mortality. METHODS This was a retrospective, multi-centre study of Prothrombinex®-VF use in CLD across 11 hospitals over a 2-year period, excluding those on therapeutic anticoagulation. Patients were subclassified into acute on chronic liver failure (ACLF), acute decompensation (ADC) and compensated cirrhosis. Reversal of coagulopathy was defined as international normalised ratio (INR) <1.5× upper limit normal (ULN), prothrombin time <1.5× ULN, activated partial thromboplastin time <1.5× ULN and fibrinogen >1 g/L. Markers of AICF/DIC were recorded. RESULTS Thirty CLD patients were included, and the median model for end-stage liver disease score was 23.5. Acute bleeding was the most common indication for Prothrombinex®-VF (60%). All had baseline coagulopathy and the majority did not achieve reversal. Key indicators of AICF/DIC were mainly observed in those with ACLF; bleeding from mucosa or lines (53%), worsening hypofibrinogenaemia (60%), worsening thrombocytopaenia (60%). The ADC and compensated cirrhosis groups were relatively unaffected. Incidence of venous thromboembolism was 6%. Overall mortality was 43% and 70% in ACLF. CONCLUSION Prothrombinex®-VF did not lead to meaningful reversal of coagulopathy and should be used with caution in CLD. Patients with ACLF were more likely to develop AICF/DIC following Prothrombinex®-VF, although the association is uncertain. Further studies are needed to evaluate the safety and efficacy of Prothrombinex®-VF use in CLD.
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Affiliation(s)
- Akmez Latona
- Department of Emergency Medicine, Ipswich Hospital, Ipswich, Queensland, Australia.,Department of Emergency Medicine, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Department of Emergency Medicine, St Vincent's Private Hospital, Toowoomba, Queensland, Australia.,The University of Queensland, Brisbane, Queensland, Australia
| | - Kate Hill
- Department of Haematology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Griffith University, Brisbane, Queensland, Australia
| | - Aurelia Connelly
- Department of Emergency Medicine, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Katherine Stuart
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Peter Wood
- Department of Haematology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Department of Haematology, Calderdale and Huddersfield NHS Foundation Trust, Huddersfield, England
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5
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Gallo P, Terracciani F, Di Pasquale G, Esposito M, Picardi A, Vespasiani-Gentilucci U. Thrombocytopenia in chronic liver disease: Physiopathology and new therapeutic strategies before invasive procedures. World J Gastroenterol 2022; 28:4061-4074. [PMID: 36157107 PMCID: PMC9403422 DOI: 10.3748/wjg.v28.i30.4061] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 04/21/2022] [Accepted: 07/18/2022] [Indexed: 02/06/2023] Open
Abstract
Chronic liver disease is characterized by several hematological derangements resulting in a complex and barely rebalanced haemostatic environment. Thrombocytopenia is the most common abnormality observed in these patients and recent advances have led to researchers focus the attention on the multifactorial origin of thrombocytopenia and on the key role of thrombopoietin (TPO) in its physiopathology. Severe thrombocytopenia (platelet count < 50000/μL) complicates the management of patients with chronic liver disease by increasing the potential risk of bleeding for invasive procedures, which may be therefore delayed or canceled even if lifesaving. In the very last years, the development of new drugs which exceed the limits of the current standard of care (platelet transfusions, either immediately before or during the procedure) paves the way to a new scenario in the management of this population of patients. Novel agents, such as the TPO-receptor agonists avatrombopag and lusutrombopag, have been developed in order to increase platelet production as an alternative to platelet transfusions. These agents have demonstrated a good profile in terms of efficacy and safety and will hopefully allow reducing limitations and risks associated with platelet transfusion, without any delay in scheduled interventions. Altogether, it is expected that patients with chronic liver disease will be able to face invasive procedures with one more string in their bow.
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Affiliation(s)
- Paolo Gallo
- Clinical Medicine and Hepatology Unit, Campus Bio-Medico University, Roma 00128, Italy
| | - Francesca Terracciani
- Clinical Medicine and Hepatology Unit, Campus Bio-Medico University, Roma 00128, Italy
| | - Giulia Di Pasquale
- Clinical Medicine and Hepatology Unit, Campus Bio-Medico University, Roma 00128, Italy
| | - Matteo Esposito
- Clinical Medicine and Hepatology Unit, Campus Bio-Medico University, Roma 00128, Italy
| | - Antonio Picardi
- Clinical Medicine and Hepatology Unit, Campus Bio-Medico University, Roma 00128, Italy
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Garcia-Saenz-de-Sicilia M, Al-Obaid L, Hughes DL, Duarte-Rojo A. Mastering Core Recommendations during HEPAtology ROUNDS in Patients with Advanced Chronic Liver Disease. Semin Liver Dis 2022; 42:341-361. [PMID: 35764316 DOI: 10.1055/a-1886-5909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Efficient and thorough care of hospitalized patients with advanced chronic liver disease is of utter importance to improve outcomes and optimize quality of life. This requires understanding current evidence and best practices. To facilitate focus on up-to-date knowledge and a practical approach, we have created the HEPA-ROUNDS mnemonic while outlining a practical review of the literature with critical appraisal for the busy clinician. The HEPA-ROUNDS mnemonic provides a structured approach that incorporates critical concepts in terms of prevention, management, and prognostication of the most common complications frequently encountered in patients with advanced chronic liver disease. In addition, implementing the HEPA-ROUNDS mnemonic can facilitate education for trainees and staff caring for patients with advanced chronic liver disease.
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Affiliation(s)
| | - Lolwa Al-Obaid
- Division of Gastroenterology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Dempsey L Hughes
- Division of Gastroenterology, Hepatology and Nutrition, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Andrés Duarte-Rojo
- Division of Gastroenterology, Hepatology and Nutrition, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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7
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Islam R, Kundu S, Jha SB, Rivera AP, Flores Monar GV, Islam H, Puttagunta SM, Sange I. Cirrhosis and Coagulopathy: Mechanisms of Hemostasis Changes in Liver Failure and Their Management. Cureus 2022; 14:e23785. [PMID: 35518552 PMCID: PMC9063731 DOI: 10.7759/cureus.23785] [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] [Accepted: 04/03/2022] [Indexed: 11/20/2022] Open
Abstract
Cirrhosis is an end-stage liver disease that can cause changes in any component of the hemostatic system. The net effects of the complicated hemostatic changes have long been unknown due to concurrent changes in pro-and antihemostatic drivers. Coagulation disorders are caused by various factors, including decreased clotting and inhibitor factor synthesis, reduced clearance of activated factors, quantitative and qualitative platelet defects, hyperfibrinolysis, and increased intravascular coagulation. This review discusses the pathogenesis of coagulopathy and multiple studies related to its clinical presentations. This article also highlights an additional problem in the diagnostic and therapeutic approach to this group of patients: the fact that traditional coagulation tests and transfusional strategies may not be reliable for assessing and managing bleeding or thrombotic risks. Hence, multiple management options have been assessed for bleeding and thrombosis in liver disease.
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8
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Kreimeyer H, Buechter M, Best J, Gieseler RK, Katsounas A, Sowa JP, Gerken G, Canbay A, Manka P, Bechmann LP. Performance of the Liver Maximum Function Capacity Test, Fibrinogen, and Transient Elastography in Patients with Acute Liver Injury. Dig Dis 2022; 41:259-267. [PMID: 35193135 DOI: 10.1159/000523696] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 02/14/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Acute liver failure (ALF) occurs as a rare, sudden, extensive loss of liver function in a previously healthy liver. In advanced cases, ALF may require liver transplantation (LT). Available prognostic parameters have limited accuracy to decide, which patient to consider for LT. The liver maximum function capacity test (LiMAx) can accurately determine liver function and was assessed as predictor of survival, along with coagulation parameters and liver stiffness in nonacetaminophen-induced ALF. METHODS Various liver function tests, including LiMAx measurements, coagulation factors, and transient elastography (TE), were analyzed retrospectively for associations with clinical outcome in 34 patients with ALF or acute hepatitis (AH). Data were compared between patients with spontaneous recovery (SR) and non-SR (3-month mortality/LT; NSR). RESULTS The analysis included 34 patients (22 ALF, 12 AH; 19 males, 15 females; age 36.7 ± 14.6 years) with drug-induced liver injury (DILI) (n = 12), autoimmune hepatitis (AIH; n = 13), AIH-DILI overlap (n = 1), viral (n = 9), or cryptogenic liver failure (n = 1). Thirty-one patients recovered spontaneously, 2 patients died, and 1 patient underwent LT. The LiMAx was 197.6 (±68.4) for SR versus 92.33 (±65.0) for NSR (p = 0.0157). Fibrinogen was significantly lower in patients with NSR than in SR patients (209.0 vs. 106.3; p = 0.02). Mean liver stiffness measured by TE was 39.3 for NSR and 17.3 for SR (p = 0.26). KCC was fulfilled in only 4 patients (3 SR, 1 NSR). LiMAx results correlated positively with serum fibrinogen and antithrombin III concentrations and correlated negatively with liver stiffness. No other analyzed factor could differentiate between SR and NSR. CONCLUSION Decision-making in ALF remains challenging. LiMAx and fibrinogen might predict the prognosis in patients with nonacetaminophen-induced ALF and in combination could be feasible tools to decide if LT is necessary.
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Affiliation(s)
- Henriette Kreimeyer
- Department of Medicine, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, Bochum, Germany
| | - Matthias Buechter
- Department of Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany
| | - Jan Best
- Department of Medicine, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, Bochum, Germany
| | - Robert K Gieseler
- Department of Medicine, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, Bochum, Germany
| | - Antonios Katsounas
- Department of Medicine, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, Bochum, Germany
| | - Jan-Peter Sowa
- Department of Medicine, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, Bochum, Germany
| | - Guido Gerken
- Department of Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany
| | - Ali Canbay
- Department of Medicine, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, Bochum, Germany,
| | - Paul Manka
- Department of Medicine, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, Bochum, Germany
| | - Lars P Bechmann
- Department of Medicine, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, Bochum, Germany
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Zhang X, Han J, Qi X, Zhang Y, Zhou P, Liu X, Ying Y, Zhang W, Zhang J, Huang Y. DIC Score Combined With CLIF-C OF Score Is More Effective in Predicting Prognosis in Patients With Hepatitis B Virus Acute-on-Chronic Liver Failure. Front Med (Lausanne) 2022; 9:815580. [PMID: 35223914 PMCID: PMC8878906 DOI: 10.3389/fmed.2022.815580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 01/18/2022] [Indexed: 11/13/2022] Open
Abstract
Coagulation and fibrinolysis disorders are major prognostic factors in hepatitis B virus-related acute-on-chronic liver failure (HBV-ACLF) patients. Here, we aimed to clarify the role of disseminated intravascular coagulation (DIC) scores in predicting HBV-ACLF patient prognosis. We assessed the DIC score from HBV-ACLF patients at Huashan Hospital in Shanghai, China from June 2013 to May 2021 and evaluated it in relation to short-term mortality, clinical course, and infection. A novel prognostic scoring model was proposed based on DIC scores. A total of 163 transplant-free HBV-ACLF patients were enrolled. DIC scores were higher in non-survivors than survivors (6 vs. 4, P = 0.000) and were independently associated with short-term mortality [hazard ratio (HR): 1.397, 95% confidence interval (95% CI): 1.040–1.875, P = 0.026]. DIC scores were associated with ACLF grade, clinical course, and infection. Moreover, they were correlated with model for end-stage liver disease (MELD) scores (r = 0.521, P < 0.001). The area under the receiver operating curve (auROC) of CLIF-C OF-DICs [a novel prognostic score based on age, DIC score, and Chronic liver failure-consortium organ function score (CLIF-C OFs)] for 90-day mortality was 0.936, which was higher than six other generic prognostic scoring models. These results were confirmed in a validation cohort (n = 82). In conclusion, elevated DIC score is associated with poor prognosis in HBV-ACLF patients, and can be used jointly with CLIF-C OFs to improve the accuracy of prognosis prediction.
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Affiliation(s)
- Xueyun Zhang
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Jiajia Han
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Xun Qi
- Department of Hepatology, Shanghai Public Health Clinical Center, Fudan University, Shanghai, China
| | - Yao Zhang
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Pu Zhou
- Huashan Worldwide Medical Center, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiaoqin Liu
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Yue Ying
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Wenhong Zhang
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Jiming Zhang
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
- Key Laboratory of Medical Molecular Virology (MOE/MOH), Shanghai Institute of Infectious Diseases and Biosecurity, Shanghai Medical College, Fudan University, Shanghai, China
- Department of Infectious Diseases, Jing'an Branch of Huashan Hospital, Fudan University, Shanghai, China
- Jiming Zhang
| | - Yuxian Huang
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
- Department of Hepatology, Shanghai Public Health Clinical Center, Fudan University, Shanghai, China
- *Correspondence: Yuxian Huang
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10
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Ostojic Z, Ostojic A, Bulum J, Mrzljak A. Safety and efficacy of dual antiplatelet therapy after percutaneous coronary interventions in patients with end-stage liver disease. World J Cardiol 2021; 13:599-607. [PMID: 34909126 PMCID: PMC8641002 DOI: 10.4330/wjc.v13.i11.599] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 08/06/2021] [Accepted: 10/25/2021] [Indexed: 02/06/2023] Open
Abstract
The prevalence of coronary artery disease (CAD) increases in patients with end-stage liver disease, with part of them receiving the percutaneous coronary intervention (PCI) as a treatment option. Dual antiplatelet therapy (DAPT), a standard of care after PCI, could result in catastrophic consequences in this population. Before PCI and the start of DAPT, it is recommended to assess patient bleeding risk. Based on novel findings, liver cirrhosis does not necessarily lead to a significant increase in bleeding complications. Furthermore, conventional methods, such as the international normalized ratio, might not be appropriate in assessing individual bleeding risk. The highest bleeding risk among cirrhotic patients has a subgroup with severe thrombocytopenia (< 50 × 109/L) and elevated portal pressure. Therefore, every effort should be made to maintain thrombocyte count above > 50 × 109/L and prevent variceal bleeding. There is no solid evidence for DAPT in patients with cirrhosis. However, randomized trials investigating short (one month) DAPT duration after PCI with new drug-eluting stents (DES) in a high bleeding risk patient population can be implemented in patients with cirrhosis. Based on retrospective studies (with older stents and protocols), PCI and DAPT appear to be safe but with a higher risk of bleeding complications with longer DAPT usage. Finally, novel methods in assessing CAD severity should be performed to avoid unnecessary PCI and potential risks associated with DAPT. When indicated, PCI should be performed over radial artery using contemporary DES. Complementary medical therapy, such as proton pump inhibitors and beta-blockers, should be prescribed for lower bleeding risk patients. Novel approaches, such as thromboelastography and “preventive” upper endoscopies in PCI circumstances, warn clinical confirmation.
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Affiliation(s)
- Zvonimir Ostojic
- Department of Cardiology, University Clinical Hospital Zagreb, Zagreb 10000, Croatia
| | - Ana Ostojic
- Department of Gastroenterology and Hepatology, University Hospital Center, Zagreb 10000, Croatia
| | - Josko Bulum
- Department of Cardiovascular Diseases, University Hospital Center Zagreb, University Clinical Hospital Zagreb, Zagreb 10000, Croatia
- School of Medicine, University of Zagreb, Zagreb 10000, Croatia
| | - Anna Mrzljak
- Department of Gastroenterology and Hepatology, University Hospital Center, Zagreb 10000, Croatia
- School of Medicine, University of Zagreb, Zagreb 10000, Croatia
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11
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Perez I, Bolte FJ, Bigelow W, Dickson Z, Shah NL. Step by Step: Managing the Complications of Cirrhosis. Hepat Med 2021; 13:45-57. [PMID: 34079394 PMCID: PMC8164676 DOI: 10.2147/hmer.s278032] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 04/24/2021] [Indexed: 12/12/2022] Open
Abstract
According to the Centers for Disease Control and Prevention, chronic liver disease and cirrhosis is the 11th leading cause of death in the United States. Common causes of chronic liver disease include alcohol, viral hepatitis, and non-alcoholic steatohepatitis (NASH). Inflammation is a critical driver in the progression of liver disease to liver fibrosis and ultimately cirrhosis. While the severity of chronic liver disease extends over a continuum, the management is more easily differentiated between compensated and decompensated cirrhosis. In this review, we discuss pathophysiology, clinical features and management of common complications of liver cirrhosis based on literature review and the current clinical practice guidelines of the American Association for the Study of Liver Diseases (AASLD).
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Affiliation(s)
- Irene Perez
- Department of Internal Medicine, University of Virginia, Charlottesville, VA, USA
| | - Fabian J Bolte
- Department of Internal Medicine, University of Virginia, Charlottesville, VA, USA
| | - William Bigelow
- Department of Internal Medicine, University of Virginia, Charlottesville, VA, USA
| | - Zachary Dickson
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA, USA
| | - Neeral L Shah
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA, USA
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12
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Abstract
Patients with liver disease acquire complex changes in their hemostatic system. Historically, these patients were considered to have a bleeding tendency related, in part, to a hyperfibrinolytic state. However, studies using more modern fibrinolysis tests have questioned the presence of a hyperfibrinolytic state in patients with liver disease and its association with bleeding risk. It may be that the sickest patients with liver disease do have fibrinolytic abnormalities. However, the debate on the fibrinolytic state of patients with (decompensated) cirrhosis or critically ill liver disease is complicated by the fact that hypo- and hyperfibrinolysis have been poorly defined. This could, in part, be explained by the lack of reliable tests that assess a patient's fibrinolytic status. Moreover, large clinical studies on the relationship between bleeding and fibrinolysis in patients with liver disease are scarce. Here, we provide an overview of the current knowledge on fibrinolysis in various types of liver diseases and possible implications as a target for therapeutic strategies in liver disease. As antifibrinolytic therapy has been shown to be safe and effective during liver transplantation, it could potentially be of use in patients with (either laboratory-established or suspected) hyperfibrinolysis-related bleeding.
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Affiliation(s)
- Fien A von Meijenfeldt
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Surgical Research Laboratory, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ton Lisman
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Surgical Research Laboratory, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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13
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Kovalic AJ, Majeed CN, Samji NS, Thuluvath PJ, Satapathy SK. Systematic review with meta-analysis: abnormalities in the international normalised ratio do not correlate with periprocedural bleeding events among patients with cirrhosis. Aliment Pharmacol Ther 2020; 52:1298-1310. [PMID: 33105981 DOI: 10.1111/apt.16078] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 06/03/2020] [Accepted: 08/17/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Cirrhotic coagulopathy is a delicate interplay comprising deficiencies of both procoagulant and anticoagulant factors. AIM To identify the relationship between international normalised ratio [INR] with periprocedural bleeding risk among patients with cirrhosis. METHODS Following a thorough database search of the primary literature, 29 studies were targeted for analysis, including 13 276 patients with cirrhosis undergoing indicated procedures. RESULTS There was no significant association between periprocedural bleeding events and pre-procedural INR [pooled odds ratio 1.52; 95% CI 0.99, 2.33; P = 0.06]. Furthermore, there was no significant difference in mean INR [pooled mean difference 0.05; 95% CI -0.03, 0.13; P = 0.23] upon comparison of patients who either did or did not experience a periprocedural bleeding event. Significant heterogeneity among some studies was primarily fuelled by significant subgroup effects of both specific procedure types performed. Additionally, there were markedly inconsistent transfusion practices across studies. CONCLUSIONS INR fails to serve as a significant correlate for periprocedural bleeding events among patients with cirrhosis. Ideally, these new findings will help serve as a springboard for future studies, as well as to minimize transfusion of blood products, which command a myriad of adverse effects among patients with cirrhosis.
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Affiliation(s)
- Alexander J Kovalic
- Department of Internal Medicine, Novant Forsyth Medical Center, Winston Salem, NC, USA
| | - Chaudry Nasir Majeed
- Department of Internal Medicine, Section on Hospital Medicine, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Naga Swetha Samji
- Department of Internal Medicine, Tenova Cleveland Hospital, Cleveland, TN, USA
| | - Paul J Thuluvath
- Institute of Digestive Health & Liver Diseases, Mercy Medical Center, Baltimore, MD, USA
| | - Sanjaya K Satapathy
- Department of Internal Medicine, Division of Hepatology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Hempstead, NY, USA.,Department of Internal Medicine, Division of Hepatology, Sandra Atlas Bass Center for Liver Diseases & Transplantation, North Shore University Hospital, Northwell Health, Manhasset, NY, USA
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14
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Abstract
Disorders of the mesenteric, portal, and hepatic veins and mesenteric and hepatic arteries have important clinical consequences and may lead to acute liver failure, chronic liver disease, noncirrhotic portal hypertension, cirrhosis, and hepatocellular carcinoma. Although literature in the field of vascular liver disorders is scant, these disorders are common in clinical practice, and general practitioners, gastroenterologists, and hepatologists may benefit from expert guidance and recommendations for management of these conditions. These guidelines represent the official practice recommendations of the American College of Gastroenterology. Key concept statements based on author expert opinion and review of literature and specific recommendations based on PICO/GRADE analysis have been developed to aid in the management of vascular liver disorders. These recommendations and guidelines should be tailored to individual patients and circumstances in routine clinical practice.
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15
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O'Leary JG, Greenberg CS, Patton HM, Caldwell SH. AGA Clinical Practice Update: Coagulation in Cirrhosis. Gastroenterology 2019; 157:34-43.e1. [PMID: 30986390 DOI: 10.1053/j.gastro.2019.03.070] [Citation(s) in RCA: 243] [Impact Index Per Article: 48.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 03/19/2019] [Accepted: 03/22/2019] [Indexed: 12/12/2022]
Abstract
DESCRIPTION This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership. The intent is to evaluate the current data on mechanism of altered coagulation in patients with cirrhosis, provide guidance on the use of currently available testing of the coagulation cascade, and help practitioners use anticoagulation and pro-coagulants appropriately in patients with cirrhosis. METHODS This review is framed around the best practice points, which were derived from the most impactful publications in the area of coagulation in cirrhosis and agreed to by all authors. BEST PRACTICE ADVICE 1: Global tests of clot formation, such as rotational thromboelastometry, thromboelastography, sonorheometry, and thrombin generation, may eventually have a role in the evaluation of clotting in patients with cirrhosis, but currently lack validated target levels. BEST PRACTICE ADVICE 2: In general, clinicians should not routinely correct thrombocytopenia and coagulopathy before low-risk therapeutic paracentesis, thoracentesis, and routine upper endoscopy for variceal ligation in patients with hepatic synthetic dysfunction-induced coagulation abnormalities. BEST PRACTICE ADVICE 3: Blood products should be used sparingly because they increase portal pressure and carry a risk of transfusion-associated circulatory overload, transfusion-related acute lung injury, infection transmission, alloimmunization, and/or transfusion reactions. BEST PRACTICE ADVICE 4: The following transfusion thresholds for management of active bleeding or high-risk procedures may optimize clot formation in advanced liver disease: hematocrit ≥25%, platelet count >50,000, and fibrinogen >120 mg/dL. Commonly utilized thresholds for international normalized ratio correction are not supported by evidence. BEST PRACTICE ADVICE 5: Thrombopoietin agonists are a good alternative to platelet transfusion, but require time (about 10 days) to elevate platelet levels. BEST PRACTICE ADVICE 6: The large volume of fresh frozen plasma required to reach an arbitrary international normalized ratio target, limitations of the usual target, minimal effect on thrombin generation, and adverse effects on portal pressure limit the utility of this agent significantly. BEST PRACTICE ADVICE 7: The 4-factor prothrombin complex concentrate contains both pro- and anticoagulant factors that offer an attractive low-volume therapeutic to rebalance a disturbed hemostatic system. However, dosage is, in part, based on international normalized ratio, which is problematic in cirrhosis, and published experience in liver disease is limited. BEST PRACTICE ADVICE 8: Anti-fibrinolytic therapy may be considered in patients with persistent bleeding from mucosal oozing or puncture wound bleeding consistent with impaired clot integrity. Both ε-aminocaproic acid and tranexamic acid inhibit clot dissolution. Neither is believed to generate a hypercoagulable state, although both may exacerbate pre-existing thrombi. BEST PRACTICE ADVICE 9: Desmopressin releases von Willebrand factor as its primary hemostatic mechanism. As this factor is usually elevated in cirrhosis, the agent lacks a sound evidence-based foundation, but may be useful in patients with concomitant renal failure. BEST PRACTICE ADVICE 10: Systemic heparin infusion is recommended for symptomatic deep vein thrombosis and portal and mesenteric vein thrombosis, but there are unresolved issues regarding monitoring with both the anti-Xa assay and the partial thromboplastin time due to cirrhosis-related antithrombin deficiency (heparin cofactor). BEST PRACTICE ADVICE 11: Treatment of incidental portal and mesenteric vein thrombosis depends on estimated impact on transplantation surgical complexity vs risks of bleeding and falls. Therapy with low-molecular-weight heparin, vitamin K antagonists, and direct-acting anticoagulants improve portal vein repermeation vs observation alone. BEST PRACTICE ADVICE 12: Direct-acting anticoagulants, such as the factor Xa and thrombin inhibitors, are relatively safe and effective in stable cirrhotic patients, but are in need of further study in patients with more advanced liver disease.
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Affiliation(s)
| | | | - Heather M Patton
- Southern California Permanente Medical Group-San Diego, San Diego, California
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16
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Harwood M, Robinson C, Wood P. Too much of a good thing: two cases of disseminated intravascular coagulation‐like coagulopathy in patients with decompensated cirrhosis after administration of Prothrombinex‐VF. Intern Med J 2019; 49:679-680. [DOI: 10.1111/imj.14272] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 07/29/2018] [Accepted: 07/30/2018] [Indexed: 01/28/2023]
Affiliation(s)
- Matthew Harwood
- Haematology DepartmentPrincess Alexandra Hospital Brisbane Queensland Australia
- School of MedicineThe University of Queensland Brisbane Queensland Australia
| | - Claire Robinson
- Haematology DepartmentPrincess Alexandra Hospital Brisbane Queensland Australia
- School of MedicineThe University of Queensland Brisbane Queensland Australia
| | - Peter Wood
- Haematology DepartmentPrincess Alexandra Hospital Brisbane Queensland Australia
- School of MedicineThe University of Queensland Brisbane Queensland Australia
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17
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Thrombogenesis and thrombotic disorders based on 'two-path unifying theory of hemostasis': philosophical, physiological, and phenotypical interpretation. Blood Coagul Fibrinolysis 2019; 29:585-595. [PMID: 30234545 DOI: 10.1097/mbc.0000000000000769] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
: Hemostasis, endowed to human to protect lives, is a process of logical blood clotting system to prevent blood loss in vascular injury. However, the notion that deadly thrombosis occurs as a result of normal hemostasis in intravascular injury could encounter with conceptual skepticism because the term 'thrombosis' automatically conjures up as serious disease. According to 'two-path unifying theory', normal hemostasis is initiated only by vascular injury through activated unusually large von Willebrand factor (ULVWF) path and/or activated tissue factor (TF) path. When these two equally important paths are unified in normal hemostasis, clotting at external bodily injury site is initiated for wound healing, but in intravascular injury 'blood clots' is formed to produce a disease called 'thrombosis'. As microthrombi from ULVWF path and fibrin clots from TF path become unified, macrothrombus would be formed via thrombogenesis. However, if ULVWF path and TF path cannot be unified due to lone ULVWF path activation, partial hemostasis produces only microthrombi seen in endotheliopathy-associated vascular microthrombotic disease. In real life, in-vivo fibrin clot cannot be formed alone via normal hemostasis because bleeding vascular injury always activates both ULVWF and TF paths. Without vascular injury, microthrombi due to activated ULVWF path occur in ADAMTS13 deficiency in thrombotic thrombocytopenic purpura, and fibrin clots due to activated TF path occur in acute promyelocytic leukemia. These two conditions can be called pathologic hemostasis. Three thrombogenic pathways produce three thrombotic disorders, which include macrothrombosis, microthrombosis and true DIC through macrothrombogenesis, microthrombogenesis and fibrinogenesis in both physiologic and pathological hemostasis.
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18
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Intagliata NM, Argo CK, Stine JG, Lisman T, Caldwell SH, Violi F. Concepts and Controversies in Haemostasis and Thrombosis Associated with Liver Disease: Proceedings of the 7th International Coagulation in Liver Disease Conference. Thromb Haemost 2018; 118:1491-1506. [PMID: 30060258 PMCID: PMC6202935 DOI: 10.1055/s-0038-1666861] [Citation(s) in RCA: 117] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 05/17/2018] [Indexed: 12/12/2022]
Affiliation(s)
- N. M. Intagliata
- Department of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, United States
| | - C. K. Argo
- Department of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, United States
| | - J. G. Stine
- Department of Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, United States
| | - T. Lisman
- Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - S. H. Caldwell
- Department of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, United States
| | - F. Violi
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
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19
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Abstract
Acute and chronic liver failure are associated with numerous alterations in different features of the coagulation system. Consequently, there is widespread confusion regarding the potential for both bleeding and thrombosis in patients with liver disease. The risk of bleeding is related to the hemodynamic changes in portal pressures and venous congestion whereas the thrombotic risk stems from changes in the coagulation system. Antithrombotic prophylaxis and treatment of patients with hemorrhage and thrombosis requires careful assessment, interpretation of laboratory workup, and attention to coexistent morbidities. A framework for the management of these conditions is presented for clinicians.
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Affiliation(s)
- Michael G Allison
- Critical Care Medicine, St. Agnes Hospital, 900 South Caton Avenue, Box 062, Baltimore, MD 21229, USA.
| | - Carl B Shanholtz
- Medical Intensive Care Unit, Division of Pulmonary and Critical Care, University of Maryland School of Medicine, 110 South Paca Street, 2nd Floor, Baltimore, MD 21201, USA
| | - Ashutosh Sachdeva
- Interventional Pulmonary Program, Division of Pulmonary and Critical Care, University of Maryland School of Medicine, 110 South Paca Street, 2nd Floor, Baltimore, MD 21201, USA
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20
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DeAngelis GA, Khot R, Haskal ZJ, Maitland HS, Northup PG, Shah NL, Caldwell SH. Reply to: "Bleeding Risk and Management in Interventional Procedures in Chronic Liver Disease". J Vasc Interv Radiol 2017; 28:922-923. [PMID: 28532752 DOI: 10.1016/j.jvir.2017.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 03/30/2017] [Accepted: 04/01/2017] [Indexed: 12/17/2022] Open
Affiliation(s)
- Gia A DeAngelis
- Department of Radiology and Medical Imaging, Division of Hematology/Oncology, University of Virginia Health System, Box 800170, Charlottesville, VA 22908
| | - Rachita Khot
- Department of Radiology and Medical Imaging, Division of Hematology/Oncology, University of Virginia Health System, Box 800170, Charlottesville, VA 22908
| | - Ziv J Haskal
- Department of Radiology and Medical Imaging, Division of Hematology/Oncology, University of Virginia Health System, Box 800170, Charlottesville, VA 22908
| | - Hillary S Maitland
- Department of Medicine, University of Virginia Health System, Box 800170, Charlottesville, VA 22908
| | - Patrick G Northup
- Coagulation in Liver Disease Study Group Division of Gastroenterology and Hepatology Department of Medicine, University of Virginia Health System, Box 800170, Charlottesville, VA 22908
| | - Neeral L Shah
- Coagulation in Liver Disease Study Group Division of Gastroenterology and Hepatology Department of Medicine, University of Virginia Health System, Box 800170, Charlottesville, VA 22908
| | - Stephen H Caldwell
- Coagulation in Liver Disease Study Group Division of Gastroenterology and Hepatology Department of Medicine, University of Virginia Health System, Box 800170, Charlottesville, VA 22908
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21
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Stephen C, Nicolas I. A Summary of The 6th International Conference on Coagulation in Liver Disease: Discussion, Debate, Deliberations. Ann Hepatol 2017; 16:12-15. [PMID: 28051789 DOI: 10.5604/16652681.1226811] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Caldwell Stephen
- Division of Gastroenterology & Hepatology, University of Virginia, Charlottesville, Virginia, USA
| | - Intagliata Nicolas
- Division of Gastroenterology & Hepatology, University of Virginia, Charlottesville, Virginia, USA
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22
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Abstract
The state of clinical art of the coagulopathy of cirrhosis changed considerably over the last decade. Until 2005, cirrhosis was considered as the epitome of the hemorrhagic coagulopathies and the abnormal hemostasis tests associated with the disease were corrected with infusion of fresh frozen plasma or platelets to minimize the risk of bleeding. Since that time, a great deal of work has been done and there is now a change of paradigm. The prothrombin time once considered as an isolated measure of bleeding risk was rejected, and cirrhosis shifted from a purely hemorrhagic construct to a mixed and thrombosis-prone paradigm. In this article we examine the interesting history of how these conceptual changes came about.
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23
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Drolz A, Horvatits T, Roedl K, Rutter K, Staufer K, Kneidinger N, Holzinger U, Zauner C, Schellongowski P, Heinz G, Perkmann T, Kluge S, Trauner M, Fuhrmann V. Coagulation parameters and major bleeding in critically ill patients with cirrhosis. Hepatology 2016; 64:556-68. [PMID: 27124745 DOI: 10.1002/hep.28628] [Citation(s) in RCA: 123] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 03/22/2016] [Accepted: 04/27/2016] [Indexed: 12/15/2022]
Abstract
UNLABELLED Disturbances of coagulation and hemostasis are common in patients with liver cirrhosis. The typical laboratory pattern mimics disseminated intravascular coagulation (DIC). The aim of this study was to assess the impact of routine coagulation parameters in critically ill cirrhosis patients with regard to new onset of major bleeding and outcome. A total of 1,493 critically ill patients were studied prospectively. Routine coagulation parameters were assessed, and the DIC score was calculated based on platelets, fibrinogen, d-dimer, and prothrombin index. New onset of major bleeding during the stay at the intensive care unit and mortality were assessed. Patients were followed for 1 year. Two hundred eleven patients of the cohort had liver cirrhosis. Platelets, fibrinogen, prothrombin index, activated partial thromboplastin time, and d-dimer as well as the DIC score differed significantly between patients with and without cirrhosis (P < 0.001 for all). Moreover, fibrinogen, platelets, and activated partial thromboplastin time (but not prothrombin index) differed significantly between cirrhosis patients with and without major bleeding (P < 0.01 for all). Bleeding on admission, platelet count <30 < 10(9) /L, fibrinogen level <60 mg/dL, and activated partial thromboplastin time values >100 seconds were the strongest independent predictors for new onset of major bleeding in multivariate regression analysis. One-year mortality in cirrhosis patients with and without major bleeding was 89% and 68%, respectively (P < 0.05 between groups). CONCLUSION Abnormal coagulation parameters and high DIC scores (primarily due to fibrinogen and platelets) correspond to increased bleeding risk in patients with liver cirrhosis in the intensive care unit, and fibrinogen and platelet count were identified as the best routine coagulation parameters for prediction of new onset of major bleeding; however, further studies are required to evaluate the potential therapeutic implications of these findings. (Hepatology 2016;64:556-568).
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Affiliation(s)
- Andreas Drolz
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Horvatits
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kevin Roedl
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Karoline Rutter
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Katharina Staufer
- Division of Transplantation, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Nikolaus Kneidinger
- Department of Internal Medicine V, Comprehensive Pneumology Center, Member of the German Center for Lung Research, University of Munich, Munich, Germany
| | - Ulrike Holzinger
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Christian Zauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Peter Schellongowski
- Division of Oncology and Infectious Diseases, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Gottfried Heinz
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Thomas Perkmann
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Valentin Fuhrmann
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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24
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Blasi A. Coagulopathy in liver disease: Lack of an assessment tool. World J Gastroenterol 2015; 21:10062-10071. [PMID: 26401071 PMCID: PMC4572787 DOI: 10.3748/wjg.v21.i35.10062] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2015] [Revised: 05/29/2015] [Accepted: 08/25/2015] [Indexed: 02/06/2023] Open
Abstract
There is a discrepancy between the information from clotting tests which have routinely been used in clinical practice and evidence regarding thrombotic and bleeding events in patients with liver disease. This discrepancy leads us to rely on other variables which have been shown to be involved in haemostasis in these patients and/or to extrapolate the behaviour of these patients to other settings in order to decide the best clinical approach. The aims of the present review are as follows: (1) to present the information provided by clotting tests in cirrhotic patients; (2) to present the factors that may influence clotting in these patients; (3) to review the clinical evidence; and (4) to put forward a clinical approach based on the first 3 points.
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25
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Peck-Radosavljevic M, Angeli P, Cordoba J, Farges O, Valla D. Managing complications in cirrhotic patients. United European Gastroenterol J 2015; 3:80-94. [PMID: 25653862 DOI: 10.1177/2050640614560452] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 10/21/2014] [Indexed: 12/13/2022] Open
Abstract
Liver cirrhosis is a serious and potentially life-threatening condition. This life-threatening condition usually arises from complications of cirrhosis. While variceal bleeding is the most acute and probably best studied, several other complications of liver cirrhosis are more insidious in their onset but nevertheless more important for the long-term management and outcome of these patients. This review summarizes the topics discussed during the UEG-EASL Hepatology postgraduate course of the United European Gastroenterology Week 2013 and discusses emergency surgical conditions in cirrhotic patients, the management of hepatic encephalopathy, ascites and hepatorenal syndrome, coagulation disorders, and liver cancer.
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Affiliation(s)
| | - Paolo Angeli
- Unit of Hepatic Emergencies and Liver Transplantation, Department of Medicine, University of Padova, Italy
| | - Juan Cordoba
- Liver Unit, Hospital Valld'Hebron, Barcelona, Spain
| | - Oliver Farges
- Department of HPB surgery HôpitalBeaujon, AP-HP, Université Paris-Diderot, Clichy-la-Garenne, France
| | - Dominique Valla
- Service d'Hépatologie, HôpitalBeaujon, AP-HP, Université Paris-Diderot, Clichy-la-Garenne, France
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26
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Abstract
In patients with cirrhosis, routine laboratory tests for primary hemostasis and coagulation usually show anomalies that are associated with excess bleeding in other settings, in particular low platelet counts and prolonged prothrombin time. However, under conditions similar to those in vivo, primary hemostasis and thrombin production do not appear to be decreased in patients with cirrhosis, particularly when the platelet count is above 75,000/μl. Furthermore, there is laboratory and epidemiological evidence of a mild procoagulant and prothrombotic state in patients with cirrhosis. Bleeding is mainly because of portal hypertension rather than defective hemostasis. There is some evidence that anticoagulation therapy is not associated with an excess of severe bleeding and that it could improve the outcome in patients without portal vein thrombosis. At present, there is no clear evidence that portal vein thrombosis is responsible for the progression of liver disease and that anticoagulation therapy would improve the outcome of patients with portal vein thrombosis.
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Affiliation(s)
- Dominique-C Valla
- DHU UNITY, Service d'Hépatologie, Hôpital Beaujon, AP-HP, Clichy-la-Garenne, France; INSERM, U1149, CRI, Université Paris-Diderot, Paris, France
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27
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Fernandez AP, Wolfson A, Ahn E, Maldonad JC, Alonso-Llamazares J. Kasabach-Merritt phenomenon in an adult man with a tufted angioma and cirrhosis responding to radiation, bevacizumab, and prednisone. Int J Dermatol 2014; 53:1165-76. [DOI: 10.1111/ijd.12319] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Anthony P. Fernandez
- Departments of Dermatology and Anatomic Pathology; Cleveland Clinic; Cleveland OH USA
| | - Aaron Wolfson
- Department of Radiation Oncology; University of Miami Miller School of Medicine; Miami FL USA
| | - Eugene Ahn
- Department of Hematology/Oncology; Sylvester Comprehensive Cancer Center and Miami VA Medical Center; Miami FL USA
| | - Jennifer C. Maldonad
- Department of Hematology/Oncology; Sylvester Comprehensive Cancer Center and Miami VA Medical Center; Miami FL USA
| | - Javier Alonso-Llamazares
- Department of Dermatology; Bruce W. Carter VA Medical Center and University of Miami Miller School of Medicine; Miami FL USA
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28
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Alkim H, Ayaz S, Sasmaz N, Oguz P, Sahin B. Hemostatic Abnormalities in Cirrhosis and Tumor-Related Portal Vein Thrombosis. Clin Appl Thromb Hemost 2011; 18:409-15. [DOI: 10.1177/1076029611427900] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Affiliation(s)
- Huseyin Alkim
- Gastroenterology Department, Bakırkoy Dr Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Selime Ayaz
- Hematology Department, Turkey High Specialty Hospital, Ankara, Turkey
| | - Nurgul Sasmaz
- Gastroenterology Department, Turkey High Specialty Hospital, Ankara, Turkey
| | - Perihan Oguz
- Gastroenterology Department, Turkey High Specialty Hospital, Ankara, Turkey
| | - Burhan Sahin
- Gastroenterology Department, Turkey High Specialty Hospital, Ankara, Turkey
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29
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Basili S, Raparelli V, Violi F. The coagulopathy of chronic liver disease: is there a causal relationship with bleeding? Yes. Eur J Intern Med 2010; 21:62-4. [PMID: 20206871 DOI: 10.1016/j.ejim.2010.01.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2009] [Revised: 01/08/2010] [Accepted: 01/12/2010] [Indexed: 12/29/2022]
Abstract
Variceal hemorrhage is a major cause of death in patients with cirrhosis. Much still could be performed in clinical practice to reduce the risk for bleeding in cirrhotic patients and accurate predictive rules should be provided for early recognition of high-risk patients. Liver cirrhosis patients present a complex hemostatic dysfunction with prolongation of bleeding time, chronic coagulation activation, and secondary hyperfibrinolysis. Therefore, liver failure determines an acquired coagulopathy that has been considered to be one potential underlying mechanism of bleeding. Endotoxemia may play a pivotal role in activating clotting system in portal and systemic circulation and it could represent a common mechanism accounting for portal vein thrombosis, systemic hyperfibrinolysis and eventually gastrointestinal bleeding. Nevertheless, clinical trials should also be planned to investigate the causal relationship between acquired coagulopathy and bleeding in patients with chronic liver disease.
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30
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31
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Viral cirrhosis: an overview of haemostatic alterations and clinical consequences. Mediterr J Hematol Infect Dis 2009; 1:e2009033. [PMID: 21415961 PMCID: PMC3033129 DOI: 10.4084/mjhid.2009.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2009] [Accepted: 12/27/2009] [Indexed: 12/13/2022] Open
Abstract
Viral hepatitis is a major health problem worldwide, the principal cause of cirrhosis and hepatocarcinoma. Once cirrhosis occurs, the consequences of liver dysfunction and portal hypertension become evident and, sometimes, life threatening for patients. Among the various complications of liver cirrhosis, the alteration of haemostatic balance is often a hard challenge for the clinician, since it is capable to predispose both to bleeding or thrombosis. In this review, we analyze the principal aspects of procoagulant, anticoagulant and fibrinolytic capacity of cirrhotic patients, which appears to be variably altered in all these aspects, not only in the direction of a tendency to bleeding. Laboratory investigations, at present, may provide only a partial representation of this condition, because of the impossibility to obtain a test capable to furnish a global overview of the haemostatic system and to reproduce in vivo conditions. Furthermore, we describe the pathophysiological mechanisms underlying bleeding manifestations and thrombosis development in cirrhotic patients, which should be considered not only as obvious consequences of the advanced liver disease but, rather, as the result of a complex interaction between inherited and acquired factors.
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Abstract
This article reviews the variety of coagulation testing abnormalities identified and the evidence demonstrating their lack of correlation with hemostasis and inability to predict bleeding for patients with liver disease. The article discusses the historical and incorrect evolution of the commonly used "1.5x" prothrombin time/international normalized ratio "threshold" for fresh frozen plasma/frozen plasma (FFP/FP) administration. Finally, this article reviews why FFP/FP cannot correct minimally prolonged clotting times in patients with liver disease, nor provide adequate prophylaxis against bleeding from percutaneous liver biopsy.
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Affiliation(s)
- Valerie L Ng
- Clinical Laboratory, Highland General Hospital, 1411 East 31st Street, Oakland, CA 94602, USA.
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33
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Al-Ruzzeh S, Navia JL. The “Off-Label” Role of Recombinant Factor VIIa in Surgery: Is the Problem Deficient Evidence or Defective Concept? J Am Coll Surg 2009; 209:659-67. [DOI: 10.1016/j.jamcollsurg.2009.07.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2009] [Revised: 07/20/2009] [Accepted: 07/22/2009] [Indexed: 01/31/2023]
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34
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Abstract
The incidence of hyperfibrinolysis in patients with cirrhosis is still debated. The reasons for this uncertainty probably lie in the lack of appropriate laboratory tests for its evaluation. There is a relative consensus, however, that hyperfibrinolysis can complicate the clinical course of liver cirrhosis, especially in cases of moderate to severe liver failure. Hyperfibrinolysis correlates positively with the severity of underlying liver disease, and low-grade systemic fibrinolysis is found in 30% to 46% of patients who have end-stage liver disease. Accelerated intravascular coagulation with secondary hyperfibrinolysis has been reported in patients who have liver failure. Hyperfibrinolysis may delay primary hemostasis, thereby aggravating variceal bleeding and facilitating recurrence.
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Affiliation(s)
- Domenico Ferro
- Department of Experimental Medicine, University of Rome, "La Sapienza", Rome, Italy; Institute of Clinical Medicine I, University of Rome, "La Sapienza", Policlinico Umberto I, 00181 Rome, Italy.
| | - Andrea Celestini
- Institute of Clinical Medicine I, University of Rome, "La Sapienza", Policlinico Umberto I, 00181 Rome, Italy
| | - Francesco Violi
- Institute of Clinical Medicine I, University of Rome, "La Sapienza", Policlinico Umberto I, 00181 Rome, Italy
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35
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Impact of neutrophil apoptosis on haemostatic activation in chronic liver disease patients. Blood Coagul Fibrinolysis 2008; 19:535-42. [PMID: 18685437 DOI: 10.1097/mbc.0b013e3283079e15] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Recent studies suggest the impact of apoptosis on the mechanisms leading to hypercoagulability. We aimed to clarify the potential role of neutrophil apoptosis in neutropenia and hypercoagulable state encountered in chronic liver disease patients. This study was conducted on 15 normal controls and 45 patients with chronic liver disease classified according to modified Child Pugh classification into, Child A, B and C groups (15 cases each). Haemostatic parameters studied include, prothrombin time, partial thromboplastin time, tissue factor, protein C antigen, protein S antigen, and markers of haemostatic activation [prothrombin fragment 1+2 (F1+2), thrombus precursor protein (TpP) and D-dimer]. Flowcytometric study was done for quantitative assay of neutrophil apoptotic subpopulations to detect the percentage of early and late apoptotic, and necrotic neutrophils using Annexin V-FITC/propidium iodide dye. Semiquantitative assay of apoptotic neutrophils showing DNA fragmentation was performed on neutrophil culture using terminal deoxynucleotidyl transferase mediated deoxyuridine triphosphate nick end labelling test. In addition to enzyme-linked immunosorbent assay for soluble Fas (APO-1/CD95) in culture supernatant. The results revealed a rise in the neutrophil apoptotic and necrotic markers with progression of the disease, and they were inversely correlated with the absolute neutrophil count. The apoptotic neutrophil cells showed a significant positive correlation with several haemostatic parameters (tissue factor, prothrombin fragment 1+2, thrombus precursor protein and D-dimer). Regression analysis proved that apoptotic parameters are independent determinants of prothrombotic markers, which further incriminate the apoptotic mechanisms in the hypercoagulable state encountered in this clinical setting.
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36
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Aytac S, Turkay C, Bavbek N, Kosar A. Hemostasis and global fibrinolytic capacity in chronic liver disease. Blood Coagul Fibrinolysis 2007; 18:623-6. [PMID: 17890949 DOI: 10.1097/mbc.0b013e328285d80e] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Accelerated fibrinolysis associated with liver disease can be demonstrated by various tests that are either nonspecific in liver disease or that demonstrate only an extrinsic pathway. In the present study we used a new method to assess the global fibrinolytic capacity (GFC) of both the intrinsic and extrinsic pathways in patients with chronic liver disease. Forty patients with the diagnosis of chronic liver disease were included in the study. Seventeen age-matched and gender-matched healthy control individuals were enrolled as a control group. The GFC was studied with semiquantitative macrolatex agglutination. The study population consisted of 40 patients with chronic liver disease (group 1, patients with chronic hepatitis; group 2, patients with cirrhosis; group 3, patients with hepatocellular carcinoma), mean age 53.3 +/- 13 years, and a control group (group 4) consisting of 17 healthy individuals (mean age 55 +/- 12.2 years). The GFC was significantly higher in patients than in control individuals (13.8 +/- 9 microg/ml, 13.6 +/- 11 microg/ml, 14.1 +/- 14 microg/ml, 1.9 +/- 2.2 microg/ml, respectively; P < 0.05). There was no difference between the patient groups (P > 0.05). There was a significant positive relationship between the GFC and the prothrombin time and activated partial thromboplastin time values (P < 0.05). A negative correlation was also observed between the GFC and thrombocyte counts (P < 0.05). In conclusion, our results suggest that patients with chronic liver disease have hyperfibrinolysis, as reflected by the increased GFC. Elucidation of the GFC in chronic liver disease can reflect the net fibrinolytic capacity of those patients who are prone to hyperfibrinolysis resulting in bleeding tendencies and hemorrhages.
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Affiliation(s)
- Sirin Aytac
- Department of Gastroenterology, Guven Hospital, Ankara, Turkey
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37
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Abstract
BACKGROUND The liver is the site for synthesis of the vast majority of proteins that play a central role in maintaining hemostasis, by participating in the regulation of coagulation and fibrinolysis. AIM To summarize the available data on the impact of coagulation disorders in patients with chronic liver disease. RESULTS Hepatocellular damage in patients with severe liver disease can lead to abnormalities in the production and function of coagulation and fibrinolytic factors, disrupting the balance between coagulation and anticoagulation systems. CONCLUSIONS Hemostatic abnormalities (eg. impaired synthesis of clotting factors, heightened fibrinolysis, disseminated intravascular coagulation, thrombocytopenia, and platelet dysfunction) can increase the risk of bleeding in cirrhotic patients.
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Affiliation(s)
- M Peck-Radosavljevic
- Department of Gastroenterology and Hepatology, Medizinische Universität & AKH Wien, Vienna, Austria.
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38
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Senzolo M, Burra P, Cholongitas E, Burroughs AK. New insights into the coagulopathy of liver disease and liver transplantation. World J Gastroenterol 2006; 12:7725-36. [PMID: 17203512 PMCID: PMC4087534 DOI: 10.3748/wjg.v12.i48.7725] [Citation(s) in RCA: 108] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The liver is an essential player in the pathway of coagulation in both primary and secondary haemostasis. Only von Willebrand factor is not synthetised by the liver, thus liver failure is associated with impairment of coagulation. However, recently it has been shown that the delicate balance between pro and antithrombotic factors synthetised by the liver might be reset to a lower level in patients with chronic liver disease. Therefore, these patients might not be really anticoagulated in stable condition and bleeding may be caused only when additional factors, such as infections, supervene. Portal hypertension plays an important role in coagulopathy in liver disease, reducing the number of circulating platelets, but platelet function and secretion of thrombopoietin have been also shown to be impaired in patients with liver disease. Vitamin K deficiency may coexist, so that abnormal clotting factors are produced due to lack of gamma carboxylation. Moreover during liver failure, there is a reduced capacity to clear activated haemostatic proteins and protein inhibitor complexes from the circulation. Usually therapy for coagulation disorders in liver disease is needed only during bleeding or before invasive procedures. When end stage liver disease occurs, liver transplantation is the only treatment available, which can restore normal haemostasis, and correct genetic clotting defects, such as haemophilia or factor V Leiden mutation. During liver transplantation haemorrage may occur due to the pre-existing hypocoagulable state, the collateral circulation caused by portal hypertension and increased fibrinolysis which occurs during this surgery.
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Affiliation(s)
- M Senzolo
- Department of Surgical and Gastroenterological Sciences, University Hospital of Padua, Padua, Italy.
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Caldwell SH, Hoffman M, Lisman T, Macik BG, Northup PG, Reddy KR, Tripodi A, Sanyal AJ. Coagulation disorders and hemostasis in liver disease: pathophysiology and critical assessment of current management. Hepatology 2006; 44:1039-46. [PMID: 17006940 DOI: 10.1002/hep.21303] [Citation(s) in RCA: 331] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Normal coagulation has classically been conceptualized as a Y-shaped pathway, with distinct "intrinsic" and "extrinsic" components initiated by factor XII or factor VIIa/tissue factor, respectively, and converging in a "common" pathway at the level of the FXa/FVa (prothrombinase) complex. Until recently, the lack of an established alternative concept of hemostasis has meant that most physicians view the "cascade" as a model of physiology. This view has been reinforced by the fact that screening coagulation tests (APTT, prothrombin time--INR) are often used as though they are generally predictive of clinical bleeding. The shortcomings of this older model of normal coagulation are nowhere more apparent than in its clinical application to the complex coagulation disorders of acute and chronic liver disease. In this condition, the clotting cascade is heavily influenced by numerous currents and counter-currents resulting in a mixture of pro- and anticoagulant forces that are themselves further subject to change with altered physiological stress such as super-imposed infection or renal failure. This report represents a summary of a recent multidisciplinary symposium held in Charlottesville, VA. We present an overview of the coagulation system in liver disease with emphasis on the limitations of the current clinical paradigm and the need for a critical re-evaluation of the current tenets governing clinical practice. With the realization that there is often limited or conflicting data, we have attempted to represent diverse opinion and experience from the perspectives of both hepatology and hematology beginning with a brief update on the physiology of normal coagulation.
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Affiliation(s)
- Stephen H Caldwell
- University of Virginia, Digestive Health Center of Excellence, GI/Hepatology Division, Charlottesville, VA 22908-0705, USA.
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40
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Reverter JC. Abnormal hemostasis tests and bleeding in chronic liver disease: are they related? Yes. J Thromb Haemost 2006; 4:717-20. [PMID: 16634734 DOI: 10.1111/j.1538-7836.2006.01887.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- J C Reverter
- Haemotherapy and Haemostasis Department, Hospital Clínic, University of Barcelona, Barcelona, Spain.
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41
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Abstract
Liver transplantation offers patients with liver disease an optimal chance for long-term survival. Current indications, preoperative assessment, patient selection, intraoperative anesthetic management and outcomes are described. The management of special situations, including retransplantation, pediatric transplantation, and fulminant hepatic failure are also reviewed. The success of liver transplantation has led to increased demand. This demand, coupled with a nonexpanding supply of deceased donor organs, has resulted in a shortage of grafts and prolonged waiting times. Novel solutions using segmental liver grafts from living donors, and the challenges associated with this approach, are discussed.
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Affiliation(s)
- Randolph H Steadman
- Department of Anesthesiology, David Geffen School of Medicine, University of California at Los Angeles, CA 90095-1778, USA.
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42
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McCormick PA, Murphy KM. Splenomegaly, hypersplenism and coagulation abnormalities in liver disease. Best Pract Res Clin Gastroenterol 2000; 14:1009-31. [PMID: 11139352 DOI: 10.1053/bega.2000.0144] [Citation(s) in RCA: 100] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Splenomegaly is a frequent finding in patients with liver disease. It is usually asymptomatic but may cause hypersplenism. Thrombocytopenia is the most frequent manifestation of hypersplenism and may contribute to portal hypertension related bleeding. A number of therapies are available for treating thrombocytopenia due to hypersplenism including splenectomy, partial splenectomy, partial splenic embolization, TIPS etc. None is entirely satisfactory. Hypersplenism usually improves following liver transplantation. Therapy with cytokines such as thrombopoietin may offer hope for the future. Patients with liver disease also have abnormalities in coagulation. This is not surprising as all coagulation proteins (except for von willebrand factor vWF) and most inhibitors of coagulation are synthesized in the liver. Genetic or acquired abnormalities of coagulation may predispose to thrombosis of the hepatic or portal veins with significant clinical sequelae. An understanding of the mechanisms involved in coagulation and thrombosis is valuable in choosing from the increasing treatment options available. These include clotting factors, haemeostatic drugs and newer therapies such as recombinant factor VIIa. Splenic artery aneurysms are the most common visceral artery aneurysms in man. Rupture is frequently catastrophic. These aneurysms are being increasingly recognized in liver transplant patients and require treatment before or during transplant surgery.
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Affiliation(s)
- P A McCormick
- St Vincent's University Hospital, Elm Park, Dublin, 4, Ireland
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