Liver cirrhosis, ascites, and hyperfibrinolysis

Analysis of Ascites-Challenged Blood in Patients with Liver Cirrhosis Using Rotational Thromboelastometry: How Robust Is the Evidence on Ascites-Attributed Fibrinolysis?

INTRODUCTION

For over 30 years, ascites has been postulated to facilitate fibrinolysis in patients with liver cirrhosis. In contrast to previous research employing conventional coagulation tests, this study aimed to characterize hemostatic interactions between blood and ascites using the rotational thromboelastometry (ROTEM).

METHODS

Blood samples - pure or mixed with ascites in a ratio of 1:1 - from cirrhotic patients (n = 10) were subjected to ROTEM analysis. In addition, a negative control group was built with cirrhotic patients (n = 10) whose blood was mixed with physiologic sodium chloride (0.9% NaCl) solution in a ratio of 1:1. Subsequently, ROTEM measurements were subjected to statistical analysis.

RESULTS

During ascites challenge, clotting time (CT, measured in seconds) was significantly prolonged in EXTEM (blood: 70.40 ± 20.40 vs. ascites/blood: 109.8 ± 47.7) and APTEM (blood: 66.50 ± 14.55 vs. ascites/blood: 138.7 ± 105.8), likely reflecting a dilution effect. However, CT in INTEM remained unchanged, suggesting a sustained intrinsic pathway function. Maximal clot firmness (measured in millimeters) in FIBTEM decreased significantly (blood: 14.70 ± 9.55 vs. ascites/blood: 6.00 ± 5.66), thus indicating depletion of fibrinogen in ascites. Strikingly, maximum lysis (measured in %) significantly decreased in EXTEM (blood: 9.30 ± 2.79 vs. ascites/blood: 5.50 ± 2.84), APTEM (blood: 8.50 ± 3.10 vs. ascites/blood: 5.60 ± 2.88), and INTEM (blood: 7.50 ± 2.27 vs. ascites/blood: 5.10 ± 3.48).

CONCLUSIONS

ROTEM provided new evidence that ascites may not primarily induce fibrinolysis in cirrhotic patients. This finding seems to be of significant importance for the clinical management of cirrhotic patients experiencing complications, for example, abdominal hemorrhage after liver biopsy or paracentesis; here, replacement of prothrombin complex concentrates and/or fibrinogen concentrates may prove more beneficial than the use of fresh frozen plasma or antifibrinolytic drugs.

Antifibrinolytic amino acids for upper gastrointestinal bleeding in people with acute or chronic liver disease

BACKGROUND

Upper gastrointestinal bleeding is one of the most frequent causes of morbidity and mortality in the course of liver cirrhosis. People with liver disease frequently have haemostatic abnormalities such as hyperfibrinolysis. Therefore, antifibrinolytic amino acids have been proposed to be used as supplementary interventions alongside any of the primary treatments for upper gastrointestinal bleeding in people with liver diseases. This is an update of this Cochrane review.

OBJECTIVES

To assess the beneficial and harmful effects of antifibrinolytic amino acids for upper gastrointestinal bleeding in people with acute or chronic liver disease.

SEARCH METHODS

We searched The Cochrane Hepato-Biliary Controlled Trials Register (February 2015), Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 2 of 12, 2015), MEDLINE (Ovid SP) (1946 to February 2015), EMBASE (Ovid SP) (1974 to February 2015), Science Citation Index EXPANDED (1900 to February 2015), LILACS (1982 to February 2015), World Health Organization Clinical Trials Search Portal (accessed 26 February 2015), and the metaRegister of Controlled Trials (accessed 26 February 2015). We scrutinised the reference lists of the retrieved publications.

SELECTION CRITERIA

Randomised clinical trials irrespective of blinding, language, or publication status for assessment of benefits and harms. Observational studies for assessment of harms.

DATA COLLECTION AND ANALYSIS

We planned to summarise data from randomised clinical trials using standard Cochrane methodologies and assessed according to the GRADE approach.

MAIN RESULTS

We found no randomised clinical trials assessing antifibrinolytic amino acids for treating upper gastrointestinal bleeding in people with acute or chronic liver disease. We did not identify quasi-randomised, historically controlled, or observational studies in which we could assess harms.

AUTHORS' CONCLUSIONS

This updated Cochrane review identified no randomised clinical trials assessing the benefits and harms of antifibrinolytic amino acids for upper gastrointestinal bleeding in people with acute or chronic liver disease. The benefits and harms of antifibrinolytic amino acids need to be tested in randomised clinical trials. Unless randomised clinical trials are conducted to assess the trade-off between benefits and harms, we cannot recommend or refute antifibrinolytic amino acids for upper gastrointestinal bleeding in people with acute or chronic liver diseases.

Antifibrinolytic amino acids for upper gastrointestinal bleeding in patients with acute or chronic liver disease

BACKGROUND

Upper gastrointestinal bleeding is one of the most frequent causes of morbidity and mortality in the course of liver cirrhosis. Patients with liver disease frequently have haemostatic abnormalities like hyperfibrinolysis. Therefore, antifibrinolytic amino acids have been proposed to be used as supplementary interventions alongside any of the primary treatments for upper gastrointestinal bleeding in patients with liver diseases.

OBJECTIVES

To assess the beneficial and harmful effects of antifibrinolytic amino acids for upper gastrointestinal bleeding in patients with acute or chronic liver disease.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register (11 June 2012), Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (2012, Issue 5 of 12), MEDLINE (Ovid SP) (1946 to June 2012), EMBASE (Ovid SP) (1974 to June 2012), Science Citation Index EXPANDED (1900 to June 2012), LILACS (1982 to June 2012), Clinical Trials Search Portal of the WHO (accessed June 18, 2012), and the Metaregister of Controlled Trials (accessed June 18, 2012). We scrutinised the reference lists of the retrieved publications.

SELECTION CRITERIA

Randomised clinical trials irrespective of blinding, language, or publication status for assessment of benefits and harms. Observational studies for assessment of harms.

DATA COLLECTION AND ANALYSIS

Data from randomised clinical trials were to be summarised by standard Cochrane Collaboration methodologies.

MAIN RESULTS

We could not find any randomised clinical trials assessing antifibrinolytic amino acids for treating upper gastrointestinal bleeding in patients with acute or chronic liver disease. We could not identify quasi-randomised, historically controlled, or observational studies in which we could assess harms.

AUTHORS' CONCLUSIONS

No randomised clinical trials assessing the benefits and harms of antifibrinolytic amino acids for upper gastrointestinal bleeding in patients with acute or chronic liver disease were identified. The benefits and harms of antifibrinolytic amino acids need to be tested in randomised clinical trials. Unless randomised clinical trials are conducted to assess the trade off between benefits and harms, we cannot recommend nor refute antifibrinolytic amino acids for upper gastrointestinal bleeding in patients with acute or chronic liver diseases.

High circulating D-dimers are associated with ascites and hepatocellular carcinoma in liver cirrhosis

AIM: To measure plasma D-dimer levels in cirrhotic patients with and without ascites, assessing the effect of ascites resolution in D-dimer concentration.

METHODS: Seventy consecutive cirrhotic patients (M = 44, F = 26, mean age 65 years, SD ± 13), observed from October 2005 to March 2006 were enrolled. Circulating D-dimer levels were measured using a latex-enhanced, immunoturbidimetric test. In patients with ascites (n = 42) the test was repeated after ascites resolution.

RESULTS: Ascites was present in 42 patients (group A) and absent in 28 (group B). Group A patients had more advanced liver disease. Hepatocellular carcinoma (HCC) was diagnosed in 14 patients and was more frequent in group B. Above normal range D-dimers were found in 45/70 patients. High D-dimers were more frequent in group A than in group B (P = 0.001). High D-dimers were associated with presence of HCC (P = 0.048) only in group B. After ascites resolution, obtained in all patients, mean D-dimer values decreased in those 34 patients with high basal levels (P = 0.007), returning to normal in 17.

CONCLUSION: In patients with liver cirrhosis, ascites and HCC are the main factors associated with increased fibrinolytic activity.

Antifibrinolytic amino acids for acquired coagulation disorders in patients with liver disease

BACKGROUND

Upper gastrointestinal bleeding is one of the most frequent causes of morbidity and mortality in the course of liver cirrhosis. Patients with liver disease frequently have haemostatic abnormalities, which include accelerated fibrinolysis. Several primary treatments are used for upper gastrointestinal bleeding in patients with liver diseases. Supplementary interventions are often used as well. One of them could be antifibrinolytic amino acids administration.

OBJECTIVES

To assess the beneficial and harmful effects of antifibrinolytic amino acids for upper gastrointestinal bleeding in patients with acute or chronic liver disease plus acquired coagulation disorders.

SEARCH STRATEGY

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register (March 2006), the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 1, 2006), MEDLINE (1950 to March 2006), EMBASE (1980 to March 2006), Science Citation Index EXPANDED (1945 to March 2006), LILACS (1982 to March 2006), ClinicalTrials.gov (at www.clinicaltrials.gov) (accessed August 2006), ISI Web of Science (April 2006), and the International Standard Randomised Controlled Trial Number Register (at http://controlled-trials.com/isrctn/search.asp) (accessed August 2006). We also checked the reference lists of all the trials identified by the above methods.

SELECTION CRITERIA

We searched for randomised clinical trials irrespective of blinding, language, or publication status.

DATA COLLECTION AND ANALYSIS

We intended to summarise data by standard Cochrane Collaboration methodologies.

MAIN RESULTS

We could not find any randomised clinical trials with antifibrinolytic amino acids for upper gastrointestinal bleeding in patients with acute or chronic liver disease plus acquired coagulation disorders.

AUTHORS' CONCLUSIONS

We were unable to identify randomised clinical trials on the safety and efficacy of antifibrinolytic amino acids for upper gastrointestinal bleeding in patients with liver disease (acute or chronic) plus acquired coagulation disorders. The effects of antifibrinolytic amino acids has to be tested in randomised clinical trials.