New insights into the coagulopathy of liver disease and liver transplantation

New under the sun: ClotPro's ECA-test detects hyperfibrinolysis in a higher number of patients, more frequently and 9 min earlier

Liver diseases result in a re-balanced state of the haemostatic system with decreased haemostatic reserves. Increased fibrinolytic activity is commonly seen during liver transplants. The aim of this study was to assess whether ClotPro's ECA-test is able to detect hyperfibrinolysis earlier and with higher frequency than ClotPro's conventional viscoelastic assays for the intrinsic and the extrinsic coagulation pathway. From 25 liver transplant recipients, systemic blood samples were collected during surgery. Viscoelastic haemostatic assays with ClotPro's IN-test, EX-test and ECA-test were performed simultaneously from each blood sample. Hyperfibrinolysis was defined on the basis of the manufacturer's prespecified threshold value (maximal lysis >15%). The incidence of hyperfibrinolysis detected with each test was compared with the McNemar test. For each assay, lysis detection time (LDT) was calculated and analysed with the nonparametric Kruskal-Wallis test. A total of 125 tests were performed simultaneously. Compared with the IN-test and the EX-test, the ECA-test detected hyperfibrinolysis in significantly ( P  < 0.001) higher number of patients (9; 11; 14, respectively) and in more measurement points (14; 18; 28, respectively). The analysis of LDT values revealed significant superiority of the ECA-test to the IN-test ( P  = 0.046) and to the EX-test ( P  = 0.035), indicating the profibrinolytic state of the haemostasis 8.9 ± 0.65 and 8.7 ± 0.17 min earlier, respectively. These are preliminary results of the study NCT0424637. ClotPro's ECA-test appeared to detect fibrinolysis in a higher number of patients, more frequently, and the mean time of detection was 9 min earlier than that of the IN-test and the EX-test.

Impact of cardiac and noncardiac cirrhosis on coronary revascularization outcomes from the National Inpatient Sample, 2016 to 2018

Data on coronary revascularization in patients with cirrhosis are scarce because it is often deferred in the setting of significant comorbidities and coagulopathies. It is unknown whether patients with cardiac cirrhosis have a worse prognosis. The National Inpatient Sample was surveyed to identify patients who underwent percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) for acute coronary syndrome (ACS) from 2016 to 2018. Those with and without liver cirrhosis were propensity score-matched and compared within the PCI and CABG cohorts. Primary outcome was in-hospital mortality. Patients with cirrhosis were further classified into cardiac and noncardiac cirrhosis and their in-hospital mortalities were compared. A total of 1,069,730 PCIs and 273,715 CABGs were performed for ACS, of which 0.6% and 0.7%, respectively, were performed in patients with cirrhosis. In both the PCI cohort (odds ratio = 1.56; 95% confidence interval, 1.10-2.25; P = 0.01) and the CABG cohort (odds ratio = 2.34; 95% confidence interval, 1.19-4.62; P = 0.01), cirrhosis was associated with higher in-hospital mortality. In-hospital mortality was greatest in cardiac cirrhosis (8.4% and 7.1%), followed by noncardiac cirrhosis (5.5% and 5.0%) and no cirrhosis (2.6% and 2.3%) in PCI and CABG cohorts, respectively. Higher in-hospital mortality and periprocedural morbidities should be considered when performing coronary revascularization in patients with cirrhosis.

Disseminated Intravascular Coagulation in Sepsis and Associated Factors

Background: sepsis is a life-threatening organ dysfunction caused by an excessive host immunological response to infection. The incidence of sepsis is increasing every year, and sepsis is the primary cause of mortality in intensive care units (ICUs). DIC is a coagulopathy syndrome that causes microvascular and macrovascular thrombosis and increases the risk of bleeding due to consumptive coagulopathy. The pathophysiology of DIC in sepsis is complex, and further research is required to investigate the involved mechanisms and risk factors. Method: this study is a prognostic analysis of a retrospective cohort. Samples were patients diagnosed with sepsis and admitted to Cipto Mangunkusumo National General Hospital from January 2016 to October 2022. Research subjects were followed until occurrence of DIC during sepsis or recovery from sepsis. The research subjects were selected from medical records using a consecutive total sampling approach. The inclusion criteria were patients aged ≥18 years old and diagnosed with sepsis according to qSOFA criteria with a score of 2. The exclusion criterion was an incomplete medical record. Bivariate and multivariate logistic regression analyses were performed to determine which independent variables contributed to the incidence of DIC and obtain the odds ratios (ORs). p < 0.05 was considered to indicate a statistically significant difference. Results: a total of 248 patients were included after considering the inclusion and exclusion criteria. Of these, 50 (20.2%) septic patients developed DIC. In the multivariate analysis, albumin ≤2.5 g/dL (OR: 2.363; 95% CI: 1.201−4.649), respiratory infection (OR: 2.414; 95% CI: 1.046−5.571), and antibiotic treatment ≥1 h (OR: 2.181; 95% CI: 1.014−4.689) were associated with DIC development. On the basis of the ROC curve, the area under the curve (AUC) was determined to be 0.705 with 95% CI = (0.631−0.778). Conclusion: in our study, the prevalence of DIC in septic patients was 20.2%. Low albumin, respiratory infection, and antibiotic treatment ≥1 h were found to be risk factors for development of DIC in septic patients.

Adverse events, short- and long-term outcomes of extra corporeal liver therapy in the intensive care unit: 16 years experience with MARS® in a single center

Background

Molecular Adsorbent Recirculating System (MARS®) is a non-biological artificial liver device. The benefit risk ratio between uncertain clinical effects and potential adverse events remains difficult to assess. We sought to describe adverse events related to MARS® therapy as well as biological and clinical effects.

Methods

All intensive care unit (ICU) admissions to whom MARS® therapy was prescribed from March 2005 to August 2021 were consecutively and prospectively included. The main endpoint was the incidence of adverse events related to MARS® therapy. Secondary endpoints were the biological and clinical effects of MARS® therapy.

Results

We reported 180 admissions treated with MARS® therapy. Among the 180 admissions, 56 (31.1%) were for acute-on-chronic liver failure, 32 (17.8%) for acute liver failure, 28 (15.5%) for post-surgery liver failure, 52 (28.9%) for pruritus and 12 (6.7%) for drug intoxication. At least one adverse event occurred in 95 (52.8%) admissions. Thrombocytopenia was the most frequent adverse event which was recorded in 55 admissions (30.6%). Overall, platelets count was 131 (± 95) × 10⁹/L before and 106 (± 72) × 10⁹/L after MARS® therapy (p < .001). After MARS® therapy, total bilirubin was significantly decreased in all groups (p < 0.05). Hepatic encephalopathy significantly improved in both the acute-on-chronic and in the acute liver failure group (p = 0.01). In the pruritus group, pruritus intensity score was significantly decreased after MARS® therapy (p < 0.01).

Conclusion

In this large cohort of patients treated with MARS® therapy we report frequent adverse events. Thrombocytopenia was the most frequent adverse event. In all applications significant clinical and biological improvements were shown with MARS® therapy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-04165-z.

Short-term biological variation study of plasma hemophilia and thrombophilia parameters in a population of apparently healthy Caucasian adults

OBJECTIVES

Biological variation (BV) data obtained in a standardized way is valuable to assess the analytical requirements and the utility of a reference interval. Our study aimed to determine the short-term BV of thrombophilia (protein S, protein C, activated protein C resistance (APCR) and factor VIII) and hemophilia (factors VIII, IX and XI) parameters in plasma. Coagulation factors V and XII were also evaluated. Based on the obtained data, we assessed analytical performance specifications for the parameters. Finally, we intended to provide a robust tool for comparison of serial measurements of factors V, VIII, IX and XI.

METHODS

A blood draw was performed weekly in 19 apparently healthy Caucasian adults for five weeks at Saint-Luc University Hospital (Brussels, Belgium). Parameters were measured in duplicate. BV components were calculated with a nested analysis of variance after exclusion of outliers.

RESULTS

The analytical coefficient of variation (CV) varied from 1.5 to 4.6%, the within-subject CV from 1.6 to 8.9% and the between-subject CV from 3.8 to 24.1%. All parameters showed high individuality. For most parameters, the analytical goal was met with our assays. Reference change values (RCV) of -16.7% to +20.0%, -20.7% to +26.0%, -15.3% to +18.1% and -13.1% to +15.1% were obtained for factors V, VIII, IX and XI respectively.

CONCLUSIONS

All studied parameters were highly individualized. The assessment of BV data can guide setting analytical goal specifications. Comparison of serial measurements in the follow-up of patients suffering from hepatic failure or mild hemophilia is facilitated by evaluation of the RCV.

Consensus Statement on Hemostatic Management, Anticoagulation, and Antiplatelet Therapy in Liver Transplantation

Anticoagulation and antiplatelet therapies are increasingly used in liver transplant (LT) candidates and recipients due to cardiovascular comorbidities, portal vein thrombosis, or to manage posttransplant complications. The implementation of the new direct-acting oral anticoagulants and the recently developed antiplatelet drugs is a great challenge for transplant teams worldwide, as their activity must be monitored and their complications managed, in the absence of robust scientific evidence. In this changing and clinically heterogeneous scenario, the Spanish Society of Liver Transplantation and the Spanish Society of Thrombosis and Haemostasis aimed to achieve consensus regarding the indications, drugs, dosing, and timing of anticoagulation and antiplatelet therapies initiated from the inclusion of the patient on the waiting list to post-LT surveillance. A multidisciplinary group of experts composed by transplant hepatologists, surgeons, hematologists, transplant-specialized anesthesiologists, and intensivists performed a comprehensive review of the literature and identified 21 clinically relevant questions using the patient-intervention-comparison-outcome format. A preliminary list of recommendations was drafted and further validated using a modified Delphi approach by a panel of 24 transplant delegates, each representing a LT institution in Spain. The present consensus statement contains the key recommendations together with the core supporting scientific evidence, which will provide guidance for improved and more homogeneous clinical decision making.

The impact of nucleic acid testing as a blood donor screening method in transfusion-associated hepatitis C among children with bleeding disorders in Indonesia: a single-center experience

Background

Children with bleeding disorders, such as hemophilia and von Willebrand disease (VWD), have an increased risk of acquiring transfusion-transmitted infections (TTI). Screening methods to exclude blood donations that are at risk of transmitting infection from donors to recipients are critical to preventing disease transmission. Nucleic acid testing (NAT) is the latest blood donor-screening method. This study aimed to determine the incidence of hepatitis C virus (HCV) infection in children with hemophilia and VWD at Dr. Cipto Mangunkusumo Hospital with a history of blood transfusion before and after implementation of a NAT screening method.

Methods

A cohort retrospective study was conducted on children aged 0‒18 years with bleeding disorders and a history of blood transfusion. In our center, all blood transfusions before 2015 were screened using non-NAT methods, while all blood transfusions were screened using NAT starting in 2015. Eligible patient characteristics were collected from medical records. From July to December 2019, blood samples were obtained from eligible patients for anti-HCV examination. HCV RNA examinations were performed on subjects with reactive anti-HCV results, and the relative risk was calculated.

Results

In total, 108 eligible participants were included in this study. We observed that 91 (94.3%) patients had history of receiving non-NAT blood transfusions, while 17 (15.7%) patients received NAT-screened blood transfusions. The proportion of anti-HCV reactivity in the non-NAT group and that in the NAT group were 3.3% (3/91) and 0% (0/17), respectively.

Conclusion

None of the patients exhibited reactivity to anti-HCV after implementing the NAT screening method.

Perioperative coagulation profile in major liver resection for cancer: a prospective observational study

Hepatectomy induced coagulation disturbances have been well studied over the past decade. Cumulative evidence supports the superiority of global coagulation analysis compared to conventional coagulation tests (i.e. PT or aPTT) for clinical decision making. Cancer, however, represents an acquired prothrombotic state and liver resection for cancer deserves a more thorough investigation. This prospective observational study was conducted to assess the perioperative coagulation status of patients undergoing major hepatectomies for primary or metastatic hepatic malignancy. Patients were followed up to the 10th postoperative day by serial measurements of conventional coagulation tests, plasma levels of coagulation factors and thrombin generation assay parameters. An abnormal coagulation profile was detected at presentation and included elevated FVIII levels, decreased levels of antithrombin and lag time prolongation in thrombin generation. Serial hematological data demonstrated increased vWF, FVIII, D-dimer, fibrinogen and decreased levels of natural anticoagulant proteins in the early postoperative period predisposing to a hypercoagulable state. The ratio of the anticoagulant protein C to the procoagulant FVIII was low at baseline and further declined postoperatively, indicating a prothrombotic state. Though no bleeding complications were reported, one patient experienced pulmonary embolism while under thromboprophylaxis. Overall, patients with hepatic carcinoma presenting for elective major hepatectomy may have baseline malignancy associated coagulation disturbances, aggravating the hypercoagulable state documented in the early postoperative period.

Albumin-Bilirubin (ALBI) and Monocyte to Lymphocyte Ratio (MLR)-Based Nomogram Model to Predict Tumor Recurrence of AFP-Negative Hepatocellular Carcinoma

Purpose

In this study, we aimed to develop a novel liver function and inflammatory markers-based nomogram to predict recurrence-free survival (RFS) for AFP-negative (<20 ng/mL) HCC patients after curative resection.

Patients and Methods

A total of 166 pathologically confirmed AFP-negative HCC patients were included at the Ningbo Medical Center Lihuili Hospital. A LASSO regression analysis was used for data dimensionality reduction and element selection. Univariate and multivariate Cox regression analyses were performed to identify the independent risk factors relevant to RFS. Finally, clinical nomogram prediction model for RFS of HCC was established. Nomogram performance was assessed via internal validation and calibration curve statistics. Receiver operating characteristic (ROC) and decision curve analysis (DCA) curve were used to validate the performance and clinical utility of the nomogram.

Results

Multivariate Cox regression analysis indicated that ALBI grade (hazard ratio, [HR] = 2.624, 95% confidence interval [CI]: 1.391-4.949, P = 0.003), INR (HR = 2.605, 95% CI: 1.061-6.396, P = 0.037), MLR (HR = 1.769, 95% CI: 1.073-2.915, P = 0.025) and MVI (HR = 4.726, 95% CI: 2.365-9.444, P < 0.001) were independent prognostic factors of RFS. Nomogram with independent factors was established and achieved a better concordance index of 0.753 (95% CI: 0.672-0.834) for predicting RFS. The ROC found that the area under curve (AUC) was consistent with the C-index and the sensitivity was 85.4%. The risk score calculated by nomogram could divide AFP-negative HCC patients into high-, moderate- and low-risk groups (P < 0.05). DCA analysis revealed that the nomogram could augment net benefits and exhibited a wider range of threshold probabilities by the risk stratification than the AJCC T and BCLC stage in the prediction of AFP-negative HCC recurrence.

Conclusion

The ALBI grade- and MLR-based nomogram prognostic model for RFS showed high predictive accuracy in AFP-negative HCC patients after surgical resection.

The Role of Vitamin Deficiency in Liver Disease: To Supplement or Not Supplement?

Over the past few years, growing interest has been shown for the impact of dietary requirements and nutritional factors on chronic diseases. As a result, nutritional programs have been reinforced by public health policies. The precise role of micronutrients in chronic liver disease is currently receiving particular attention since abnormalities in vitamin levels are often detected. At present, treatment programs are focused on correcting vitamin deficiencies, which are frequently correlated to higher rates of comorbidities with poor outcomes. The literature reviewed here indicates that liver diseases are often related to vitamin disorders, due to both liver impairment and abnormal intake. More specific knowledge about the role of vitamins in liver disease is currently emerging from various results and recent evidence. The most significant benefits in this area may be observed when improved vitamin intake is combined with a pharmacological treatment that may also affect the progression of the liver disease, especially in the case of liver tumors. However, further studies are needed.

[Acute liver failure in a dog after mushroom intake, presumably of the genus Amanita]

A 4-year-old, neutered male Husky-mix dog weighing 29.4 kg that reportedly ingested a mushroom most likely of the genus Amanita one day prior to presentation exhibited signs of diarrhea, vomitus, inappetence and progressively worsening lethargy. Clinical chemistry revealed hypoglycemia, hyperbilirubinemia, decreased prothrombin and thromboplastin time, as well as increased liver enzyme activities. Despite hospitalization and supportive therapy over a period of 3 days the dog's general condition worsened leading to euthanasia. The pathomorphological findings were characterized by hemorrhage in several organs, hemorrhagic ingesta, icterus, and marked hepatic cellular necrosis.

The hemostatic and thrombotic complications of liver disease

Hepatic cirrhosis leads to numerous hematologic derangements resulting in a complex and tenuously rebalanced hemostatic milieu. The utility of common hematologic tests including the INR and aPTT in assessing hemostatic and thrombotic risk in patients with cirrhosis is limited, and consensus on transfusion thresholds and proper management of thrombotic complications continues to evolve. This review summarizes the pathophysiology of key derangements of hemostasis including those of platelets, von Willebrand factor, pro- and anticoagulation factors, and fibrin. Additionally, the pathogenesis, consequences, optimal management, and prevention of major thrombotic and bleeding complications in cirrhosis arte discussed.

Predictive utility of fibrinogen in acute kidney injury in living donor liver transplantation: A propensity score-matching analysis

Background

This study investigated the association between the fibrinogen level and the risk of acute kidney injury (AKI) in patients who have undergone living donor liver transplantation (LDLT).

Patients and methods

A total of 676 patients who underwent LDLT were analyzed retrospectively. Exclusion criteria included a history of severe kidney dysfunction, emergency operation, deceased donor, ABO-incompatible transplantation, and missing data. The study population was divided into low and normal fibrinogen groups. A 1:1 propensity score (PS) matching analysis was used to evaluate the association between a low fibrinogen level (< 160 mg/dL) and postoperative development of AKI.

Results

In total, 142 patients (23.1%) developed AKI after LDLT. The PS matching analysis showed that the probability of AKI was two-fold higher in the low fibrinogen group than in the normal fibrinogen group. In addition, patients with AKI had poorer postoperative outcomes such as longer hospitalization, longer ICU stay, and higher mortality than patients without AKI.

Conclusions

The preoperative fibrinogen level may be useful for risk stratification of patients undergoing LDLT in terms postoperative development of AKI.

Exploring the Complex Role of Coagulation Factor VIII in Chronic Liver Disease

Chronic liver disease is one of the leading causes of death in the United States. Coagulopathy is often a sequela of chronic liver disease, however, the role and regulation of coagulation components in chronic liver injury remain poorly understood. Clinical and experimental evidence indicate that misexpression of the procoagulant factor VIII (FVIII) is associated with chronic liver disease. Nevertheless, the molecular mechanism of FVIII-induced chronic liver injury progression remains unknown. This review provides evidence supporting a pathologic role for FVIII in the development of chronic liver disease using both experimental and clinical models.

Clinical Considerations of Coagulopathy in Acute Liver Failure

Acute liver failure (ALF) is the rapid onset of severe liver dysfunction, defined by the presence of hepatic encephalopathy and impaired synthetic function (international normalized ratio of ≥1.5) in the absence of underlying liver disease. The elevated international normalized ratio value in ALF is often misinterpreted as an increased hemorrhagic tendency, which can lead to inappropriate, prophylactic transfusions of blood products. However, global assessments of coagulopathy via viscoelastic tests or thrombin generation assay suggest a reestablished hemostatic, or even hypercoagulable, status in patients with ALF. Although the current versions of global assays are not perfect, they can provide more nuanced insights into the hemostatic system in ALF than the conventional measures of coagulopathy.

Translational insight into prothrombotic state and hypercoagulation in nonalcoholic fatty liver disease

Non-alcoholic fatty liver disease (NAFLD) is an emerging and threatening pathological condition, ranging from fatty liver (FL) to chronic steatohepatitis (NASH), liver cirrhosis, and eventually to hepatocellular carcinoma (HCC). Recent findings suggest that patients with NAFLD have a higher risk of cardiovascular events and thromboembolism and that this risk is independent of metabolic diseases that are frequently associated with NAFLD, such as diabetes, hyperlipidaemia, and obesity. The vascular involvement of NAFLD might be considered its systemic burden, conditioning higher mortality in patients affected by the disease. These clinical findings suggested the existence of a prothrombotic state in NAFLD, which is partially unexplored and whose underlying mechanisms are to date not completely understood. Here, we review the mechanisms involved in the pathogenesis of the prothrombotic state in NAFLD across the progression from the healthy liver through the different stages of the disease. We focused on the possible role of several metabolic features of NAFLD possibly leading to hypercoagulation other than endothelial and platelet activation, such as insulin-resistance, nitric oxide production regulation, and gut microbiota homeostasis. Also, we analysed the involvement of plasminogen activator inhibitor-1 (PAI-1) and thromboinflammation taking place in NAFLD. Finally, we described factors striking a prothrombotic imbalance in NASH cirrhosis, with a particular focus on the pathogenesis of portal vein thrombosis.

Timing and Type of Venous Thromboembolic Prophylaxis in Isolated Severe Liver Injury Managed Non-Operatively

BACKGROUND

The optimal timing and type of pharmacological venous thromboembolic prophylaxis (VTEp) after severe liver injury selected for nonoperative management (NOM) are controversial. The aim of this study was to assess the effect of timing and type of VTEp in severe liver injuries selected for NOM.

METHODS

ACS-TQIP database study (2013-17) including patients with blunt isolated severe liver injuries (AIS ≥ 3), selected for NOM, who received VTEp with either unfractionated heparin (UH) or low-molecular-weight heparin (LMWH). Patients who underwent laparotomy or angiointervention within 24 h or prior to the initiation of VTEp were excluded. The study population was stratified according to the timing of VTEp ≤ 48 h (EP) and > 48 h (LP) groups. Univariate and multivariate analyses were used to identify differences between the groups.

RESULTS

A total of 4074 patients was included in the study. 2004 (49.2%) received EP and 2070 (50.8%) LP. Patients with more severe injuries were more likely to receive LP than an EP [ISS 24 (19-29) vs 22 (17-27), p < 0.001]. On multivariate analysis (correcting for age, gender, comorbidities, blood pressure, GCS, ISS, type of VTEp), LP was identified as an independent risk factor for thromboembolic events (OR 1.52, p = 0.032) and mortality (OR 2.49, p = 0.031). LMWH was independently associated with lower mortality (OR 0.36, p = 0.007), compared to UH. EP did not increase the risk of laparotomy or angiointervention after starting VTEp, compared to LP (p = 0.992).

CONCLUSION

Early VTEp (≤ 48 h) is safe and independently associated with fewer thromboembolic events and a lower mortality after isolated severe liver injuries managed nonoperatively. LMWH was independently associated with improved outcomes when compared with UH.

Thromboelastography Better Reflects Hemostatic Abnormalities in Cirrhotics Compared With the International Normalized Ratio

GOAL

The goal of this study was to describe potential key differences in thromboelastography (TEG) variables in hospitalized cirrhotics compared with a healthy population, identify patterns of hematologic disturbance with disease progression, and assess the value of traditional tests such as international normalized ratio (INR) and platelet count to determine coagulopathy in cirrhotics.

BACKGROUND

TEG, a functional assay of coagulation, has emerged as a useful tool for predicting bleeding risk in cirrhosis.

STUDY

Hospitalized cirrhotics who received a TEG before any blood products between January 2017 and February 2018 at a liver transplant center were included. Reaction time (r-time), coagulation time (k-time), angle-rate of clot polymerization (α) and maximum clot strength (maximum amplitude) were measured with kaolin-activated citrated blood TEG assays.

RESULTS

A total of 106 cirrhotic patients (Child-Turcotte-Pugh A, B, C; n=25, 25, 56) were identified for comparison against data from 53 healthy controls. TEG parameters in cirrhotics were statistically different from controls. Mean INR and platelet count for all cirrhotics were largely outside the normal reference range, contrary to TEG parameters which demonstrated parameters mostly within the normal reference ranges. The r-time, k-time, and α values in the cirrhotics progressively increased and maximum amplitude values progressively decreased as the liver disease progressed. Regression analysis showed no significant correlations between INR and r-time across any Child-Turcotte-Pugh class (r=0.01, 0.18, 0.23; P=0.95, 0.39, 0.08, respectively).

CONCLUSIONS

Although cirrhotics had TEG parameters within normal ranges, there was a propensity for decreased clot formation as liver function worsened. Importantly, the INR did not correlate with TEG parameters in cirrhotic patients, and given the precarious hemostatic balance in these patients, a TEG may be a better predictor of bleeding risk.

Frequency of Venous Thromboembolism in Patients with Liver Cirrhosis

Introduction

The major hemostatic problem in cirrhotic patients is the increased risk of bleeding, but venous thromboembolism is also being reported as a noticeable feature of cirrhosis. Therefore, we conducted this study to determine the frequency of venous thromboembolism in patients with liver cirrhosis.

Materials and methods

This cross-sectional study took place at a major metropolitan hospital in Karachi for a period of six months. A total of 142 patients age 40 to 70 years, either gender and Child-Pugh class A to C liver cirrhosis for >3 months were enrolled in this study. The demographic features like age, gender, weight, height, body mass index (BMI), duration of symptoms, and Child-Pugh class were noted. The patients were examined for calf swelling, tenderness, and pitting edema. Venous thrombosis was diagnosed on ultrasound of the calf done by an experienced radiologist in patients having two or more than two of the above-stated findings. The mean and standard deviation were calculated for age, weight, height, body mass index (BMI), and duration of symptoms. The frequency and percentage were calculated for the range of age, gender, range of weight, range of height, range of BMI, range of duration of symptoms, Child-Pugh class, and venous thrombosis. Stratification was done of venous thrombosis with age, obesity, gender, Child-Pugh class, and duration of symptoms by applying the chi-square test and assuming p-value ≤0.05 as significant.

Results

The mean age of the study population was 60.73 ± 10.83 years and most patients, i.e., 95 (66.9%) were >60 years. There were 89 (62.7%) female and 53 (37.3%) male patients. The mean weight of the study population was 60.15 ± 5.11 kg and most patients, i.e., 81 (57%), weighed ≤60 kg. The mean height of the study population was 1.53 ± 0.59 m and most patients, i.e., 99 (69.7%) were ≤1.5 m. The mean BMI of the study population was 27.24 ± 5.02 kg/m² and most patients, i.e., 81 (57%) were ≤30 kg/m². The mean duration of symptoms of the patients was 5.63 ± 1.77 months and most patients, i.e., 86 (60.6%) had ≤6 months of duration of symptoms. Eighty-six (60.56%) patients had Child-Pugh class A, 39 (27.47%) patients had Child-Pugh class B, and 17 (11.97%) patients had Child-Pugh class C liver cirrhosis. Ten (7%) of the patients had venous thrombosis. Stratification of venous thrombosis with age, gender, obesity, Child-Pugh class, and duration of symptoms showed a significant linear relationship with gender (p-value= 0.040), obesity (p-value= 0.043), and Child-Pugh class (p-value= 0.001).

Conclusions

Venous thromboembolism is a frequent complication and a pathogenic factor in liver cirrhosis that should be given attention to in cirrhotic patients especially in male and obese patients of Child-Pugh class B and C. Low serum albumin and increased partial thromboplastin time (PTT) can have some role in its prediction and early prevention. But more studies are needed to establish this.

Approach to the liver transplant early postoperative period: an institutional standpoint

The liver transplant program in our center started in 1992, and post-liver transplant patients are still admitted to the intensive care unit. For the intensive care physician, a learning curve started then, skills were acquired, and a specific practice was established. Throughout this time, several concepts changed, improving the care of these patients. The practical approach varies between liver transplant centers, according to local specificities. Hence, we wanted to present our routine practice to stimulate the debate between dedicated teams, which can allow the introduction of new ideas and potentially improve each local standard of care.

Coagulopathy and Hospital Outcomes in Patients With Spontaneous Bacterial Peritonitis: A Call for Action to Improve Care of Inpatients

Objectives

To assess the risk of in-hospital mortality in spontaneous bacterial peritonitis (SBP) with coagulopathy, and to understand the impact of comorbid coagulopathy on length of stay (LOS) and total charges for SBP inpatients.

Methods

We included adult patients (age, 18-50 years) with a principal diagnosis of SBP using the Nationwide Inpatient Sample (NIS, 2012 to 2014). These patients were further subgrouped by comorbid coagulopathy. The independent sample t-test was used to measure the mean difference in LOS and total charges between subgroups. The logistic regression model was used to measure the odds ratio (OR) of association of coagulopathy and in-hospital mortality after adjusting for demographic confounders and other comorbid risk factors.

Results

SBP with comorbid coagulopathy was prevalent in males (68.7%) and white (58.1%). When compared with the non-coagulopathy cohort, males had 1.6 times (95% CI 1.46-1.84), and hispanics had 1.4 times (95% CI 1.19-1.58) high odds for coagulopathy. In-hospital mortality was statistically significant in SBP inpatients with coagulopathy (6.5% vs. 2.8% in non-coagulopathy), and with two times higher odds of association (95% CI 1.47-2.51) compared with non-coagulopathy cohort. SBP inpatients with comorbid coagulopathy had a statistically significantly higher LOS by 1.1 days and higher total charges by $14,123 per hospitalization compared with the non-coagulopathy cohort.

Conclusions

Coagulopathy is a significant risk factor that increases the risk of in-hospital mortality in SBP inpatients by 92%. Comorbid coagulopathy is also associated with extended LOS and higher hospitalization costs, thereby increasing the healthcare burden. Clinicians need to effectively manage coagulopathy in SBP patients to improve patient outcomes and reduce the healthcare burden with better health-related quality of life.

Comparison of Coagulation Conditions in Patients With Liver Cirrhosis Due to Primary Sclerosing Cholangitis and Nonbiliary Causes of Cirrhosis Before Orthotopic Liver Transplant

OBJECTIVES

Orthotopic liver transplant can be accompanied by an obscure bleeding pattern in patients with severe hepatic malfunction. In the present study, coagulation conditions of patients with cirrhosis of the liver due to primary sclerosing cholangitis and nonbiliary causes of cirrhosis were compared using rotational thromboelastometry assays obtained before orthotopic liver transplant.

MATERIALS AND METHODS

This case control study analyzed patients who were candidates for orthotopic liver transplant from 2010 to 2016. Eighty patients with cirrhosis of the liver (40 patients with primary sclerosing cholangitis and 40 with nonbiliary causes of cirrhosis) were randomly selected and enrolled into the study. Patients received rotational thromboelastometry assays under anesthesia just before the start of the operation, and results were compared between the 2 patient groups.

RESULTS

Of 80 patients, 52 were men and 28 were women. In the assays, we found that maximum amplitudes in 10 and in 20 minutes and maximum clot firmness parameters were higher in patients with primary sclerosing cholangitis. The alpha angle and clot formation time were different in the intrinsic and extrinsic assay panels. In the intrinsic assay, we found clotting time to be shorter (P < .05). The average of all parameters in all 3 assays (intrinsic, extrinsic, and fibrinogen contribution) was lower in patients with nonbiliary causes of cirrhosis than in those with primary sclerosing cholangitis.

CONCLUSIONS

In contrast with previous studies that found that patients with primary sclerosing cholangitis are hypercoagulable, our study observed that they have normal coagulable results. Furthermore, we found that, although mean coagulation indexes in patients with primary sclerosing cholangitis were within normal ranges, in patients with nonbiliary causes of cirrhosis, these indexes were generally lower.

Assessment and management of coagulopathy in critically-ill patients with liver failure

PURPOSE OF REVIEW

This review provides insight into our current understanding of the pathophysiology and treatment of coagulopathy associated with liver failure, and bleeding risk assessment.

RECENT FINDINGS

Patients with end-stage liver disease (ESLD) have a rebalanced coagulation profile and are at risk for both excessive clotting and bleeding. Hypercoagulability is associated with profound endothelial dysfunction and an increased concentration of liver-independent coagulation factors. Because of this rebalanced coagulation profile, standard laboratory tests have been demonstrated to be ineffective in either predicting and/or guiding the management of coagulopathy. Viscoelastic testing, however, is able to provide a dynamic assessment of clot formation in whole blood and has been demonstrated to be invaluable in both monitoring and management of coagulation problems associated with liver failure. More recently, there is increasing interest in thrombin generation tests to monitor coagulation in patients with ESLD.Multiple institutional protocols for prophylaxis and treatment of ESLD-related thromboses have been developed. High-quality studies evaluating these approaches are lacking.

SUMMARY

Patients with ESLD are at risk for excessive bleeding and clotting. Treatment of any significant coagulopathy should not be based solely on standard laboratory tests. Thrombosis prophylaxis has to be considered in susceptible populations.

Liver Diseases and the Hemostasis (Rewiew) Part 1. Non-Cholestatic Diseases of the Liver and Hemostasis

In liver diseases, most commonly in the terminal stage of liver failure, a variety of hemostatic defects affecting almost all parts of the blood coagulation system are developing. This leads to diminishing the capabilities of patients with liver diseases to correctly maintain the hemostatic balance.The severity of hemostatic disorders depends on the nosological form and degree of a liver damage. Depending on the imbalance of the hemostasis system and accumulated clinical/laboratory data, patients with liver diseases can be subdivided into three groups as exhibiting: 1. non-cholestatic liver damage; 2. cholestatic liver damage and 3. liver damage of vascular origin.The first part of the review discusses multiple alterations in the hemostasis system in patients with noncholestatic liver diseases, which are commonly accompanied by hypocoagulation.

A Review on Clinical, Pathophysiological, and Diagnostic Hematological Features in Children With Liver Cirrhosis

Appropriate diagnostic and therapeutic measures for liver cirrhosis is critical, particularly in children. In the present review, a comprehensive approach was provided toward hematological parameters in pediatric liver cirrhosis. The literature search included MeSH terms "liver cirrhosis" and "hepatic cirrhosis" and databases such as PubMed, Web of Science, Scopus, and Google Scholar were searched up until December 2017. Hematologic changes in the liver cirrhosis mainly encompassed anemia and coagulopathies. In addition, bleeding diathesis was considered as the most clinical complication in these patients. In addition to reduced coagulation factors, hyperfibrinolysis is a common feature in childhood cirrhosis and may be an important contributor to the risk of bleeding. Based on the results, children with liver cirrhosis also demonstrated a procoagulant state at laboratory and clinical levels. This may be partly due to a reduction in coagulation inhibitors such as anti-thrombin, C1 inhibitor, and α1-antitrypsin in children with cirrhosis. The portal vein thrombosis and portal hypertension are considered as the most clinical presentations of the hypercoagulable state. Further, children with liver cirrhosis complicated with portal hypertension usually show leukopenia, anemia, and thrombocytopenia due to hypersplenism. Although the etiology of childhood and adult cirrhosis may be different, their hematological compilations and clinicopathological features are somehow similar.

Stereological Comparison of Imbibed Fibrinogen Gauze versus Simple Gauze in External Packing of Grade IV Liver Injury in Rats

Objective

To evaluate the effect of imbibed fibrinogen gauze on survival, bleeding and healing in liver trauma.

Methods

This animal experimental study was conducted on 20 adult male Sprague-Dawley rats; with a mean weight of 300±50 gram; divided into two groups. Grade IV injury was induced to the subjects' liver. Then, the bleeding site was packed with simple gauze in the control group, and imbibed fibrinogen gauze in the experimental group. All animals were re-evaluated for liver hemostasis 48 hours after the initial injury. Bleeding in the intra peritoneal cavity was measured using Tuberculosis Syringe in the first and second operations. Subjects were followed-up for 14 days. Eventually, the rats were sacrificed and their livers were sent to a lab for stereological assessment. Statistical comparisons were performed via Mann-Whitney U-test using SPSS. P-Values less than 0.05 were considered to be statistically significant.

Results

Half of the rats in the control group died, while all the rats in the imbibed fibrinogen gauze group survived after two weeks (p= 0.032). Bleeding in the imbibed fibrinogen gauze was significantly less than control group, 48 hours' post-surgery (p<0.001). According to the stereological results, granulation tissue in the imbibed fibrinogen gauze group were more than the control group (P= 0.032). Also, fibrosis in the imbibed fibrinogen gauze group were more than the control group (P= 0.014).

Conclusion

Our study indicated that imbibed fibrinogen gauze can potentially control liver bleeding and improve survival through increasing granulation tissue and fibrosis in injured liver.

Hemostasis based on a novel 'two-path unifying theory' and classification of hemostatic disorders

: Hemostasis is the most important protective mechanism for human survival following harmful vascular damage caused by internal disease or external injury. Physiological mechanism of hemostasis is partially understood. Hemostasis can be initiated by either intravascular injury or external bodily injury involving two different levels of damage [i.e., limited to the endothelium or combined with extravascular tissue (EVT)]. In intravascular injury, traumatic damage limited to local endothelium typically is of no consequence, but disease-induced endothelial damage associated with systemic endothelial injury seen in sepsis and other critical illnesses could cause generalized 'endotheliopathy'. It triggers no bleeding but promotes serious endothelial molecular response. If intravascular local trauma extends beyond the endothelium and into EVT, it causes intravascular 'bleeding' and initiate 'clotting' via normal hemostasis. In external bodily injury, local traumatic damage always extends to the endothelium and EVT, and triggers 'bleeding' and 'clotting'. Systemic endotheliopathy activates only unusually large von Willebrand factor multimers (ULVWF) path and mediates 'microthrombogenesis', producing 'microthrombi' strings. This partial activation of hemostasis with ULVWF path leads to vascular microthrombotic disease. But localized traumatic injury extending to the endothelium and EVT activates both ULVWF and tissue factor paths. Combined activation of ULVWF and tissue factor paths provides normal hemostasis in external bodily injury, but causes 'macrothrombus' formation in intravascular injury. This 'two-path unifying theory' concept succinctly elucidates simplified nature of hemostasis in intravascular and external bodily injuries. It also clarifies different pathogenesis of every hemorrhagic disease and thrombotic disorder related to internal vascular disease and external vascular injury.

Thrombogenesis and thrombotic disorders based on 'two-path unifying theory of hemostasis': philosophical, physiological, and phenotypical interpretation

: 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.

Effect of Liver Disease Etiology on ROTEM Profiles in Patients Undergoing Liver Transplantation

BACKGROUND

Coagulation abnormalities in liver transplant patients are complex and may be related to the underlying liver disease. We evaluated the effects of disease etiology on whole-blood rotational thromboelastometry (ROTEM; Pentapharm GmbH, Munich, Germany) profile and association with thrombotic complications following liver transplantation.

METHODS

Analysis of perioperative data from patients undergoing liver transplantation between January 1, 2012 and December 31, 2016. Patients were grouped based on the biology of their underlying liver disease: hepatocellular carcinoma (HCC), biliary etiology, and non-biliary etiology. The primary outcome was the EXTEM A10 value of the pre-incision ROTEM. Secondary outcomes included associations between EXTEM A10 value and incidence of postoperative thrombotic complications.

RESULTS

Three hundred fifty patients met the eligibility criteria: 60 had biliary etiologies, 203 had non-biliary etiologies, and 87 had HCC. EXTEM A10 values were significantly higher in patients with biliary etiologies than those with non-biliary etiologies (mean difference, 13.8; 95% CI: 10.1 to 17.5; P = .001) and those with HCC (mean difference, 10.4; 95% CI: 6.2 to 14.7; P = .001). Patients with non-biliary etiologies had slightly higher values than those with HCC (mean difference, -3.3; 95% CI: -6.6 to -0.1; P = .04). Higher values for biliary etiologies remained after adjusting for liver disease severity, platelet count, and fibrinogen level. There was no significant difference in EXTEM A10 values between patients who suffered thrombotic complications and those who did not (mean difference: 4.3, 95% CI: -1.3 to 9.9, P = .13).

CONCLUSION

Patients with biliary diseases demonstrated higher EXTEM A10 values compared to those with non-biliary diseases or HCC. This was not fully explained by differences in disease severity, platelet count, or fibrinogen level. Pre-incision EXTEM A10 values do not predict incidence of postoperative thrombotic complications.

Taiwan consensus statement on the management of chronic hepatitis B

The experts of Taiwan Association for the Study of Liver (TASL) have actively participated and led the guidelines on hepatitis B virus (HBV) management by Asian Pacific Association for the Study of Liver (APASL) which is the first international association for the study of liver to publish the statement on HBV management before. However, there are more and more new data on the natural history and treatment of HBV infection in the past decade. These include new application of an old biomarker (quantitative HBsAg), clinical significance of HBV genotype and naturally occurring mutations, the role of non-invasive examination in evaluating severity of hepatic fibrosis, clinical significance of outcome calculators, new drug or new combination strategies towards more effective therapy and organ transplantation including liver and non-liver transplantation. It is time to publish the guidelines on HBV management of Taiwan. Hence, TASL have conducted an expert meeting to review, to discuss and to debate the relevant literatures, followed by draft the manuscript of HBV management guidelines and recommendations. The guidelines include general management, indications for fibrosis assessment, time to start or stop drug therapy, choice of drug to initiate therapy, when and how to monitor the patients during and after stopping drug therapy. Recommendations on the therapy of patients in special circumstances, including women in childbearing age, patients with antiviral drug resistance, concurrent viral infection, hepatic decompensation, patient receiving immune suppression or chemotherapy and patients in the setting of liver transplantation and hepatocellular carcinoma, are also included.

The System of Blood Coagulation in Normal and in Liver Transplantation (Review)

The review dwells on the problem of hemostatic disorders in patients undergoing liver transplantation and their correction in the perioperative period. The physiology of the hemostatic system, disorders of the blood coagulation system in patients at various stages of liver transplantation, correction of hemostatic disorders during and after orthotopic liver transplantation are discussed. Liver transplantation is performed in patients with liver diseases in the terminal stage of liver failure. At the same time, changes in the hemostatic system of these patients pose a significant risk of developing bleeding and/or thrombosis during and after liver transplantation. The hypothesis is suggested that the personalized correction of hemostasis disorder in liver transplantation should be based on considerating the nosological forms of the liver damage, mechanisms of development of recipient’s hemostatic disorders, and the stage of the surgery.

Hypercoagulability in End-stage Liver Disease: Review of Epidemiology, Etiology, and Management

In this review, we analyze the epidemiology of thromboses related to end-stage liver disease (ESLD), discuss causes of hypercoagulability, describe susceptible populations, and critically evaluate proposed prophylaxis and treatment of thromboses. Classically, ESLD has been regarded as a model for coagulopathy, and patients were deemed to be at high risk for bleeding complications. Patients with ESLD are not auto-anticoagulated, and they do not have a lower risk of portal vein thrombosis, intracardiac thrombus formation, pulmonary embolism or hepatic artery thrombosis. Though the cause of hypercoagulability is multifactorial, endothelial dysfunction likely plays a central role for all patients with ESLD. Some subpopulations, such as patients with nonalcoholic steatohepatitis and autoimmune conditions, are at increased risk of thrombotic events as are patients of Hispanic ethnicity. The science behind prophylaxis of different types of clotting and treatment of thromboses is developing rapidly. A number of medications, including low molecular weight heparin, unfractionated heparin, aspirin, vitamin K antagonists, and direct oral anticoagulants can be used, but clear guidelines are lacking. Acute intraoperative clotting can be associated with high mortality. Routine use of transesophageal echocardiography can be helpful in early recognition and treatment of intraoperative thrombosis. Heparin should be reserved for cases of intracardiac thrombus/pulmonary embolism without hemodynamic instability. In unstable patients, low dose of recombinant tissue plasminogen activator can be used. In this new era of heightened awareness of thrombotic events in ESLD patients, prospective randomized trials are urgently needed to best guide clinical practice.

Use of Rotational Thromboelastometry in Liver Transplantation Is Associated With Reduced Transfusion Requirements

OBJECTIVES

Increased transfusion requirements in liver transplantation have been reported to be associated with worsened outcomes, more frequent reinterventions, and higher expenses. Anesthesiologists might counteract this through improved coagulation management. We evaluated the effects of rotational thromboelastometry on transfusion and coagulation product requirements and on outcome measurements.

MATERIALS AND METHODS

Patients who were 14 years or older and who were undergoing liver transplant at Hannover Medical School between January 2005 and December 2009 were included in this retrospective analysis. Demographic, clinical, and laboratory data, use of rotational thromboelastometry, intraoperative need for blood or coagulation products and antifibrinolytic substances, and clinical course were recorded. Correlations were examined using appropriate statistical tests.

RESULTS

Our study included 413 patients. Use of rotational thromboelastometry was associated with less frequent intraoperative administration of red blood cell concentrates, fresh frozen plasma, platelet concentrates, prothrombin complex concentrates, and antithrombin concentrates (all P < .05). In addition, univariate and multivariate tests showed that rotational thromboelastometry was correlated with decreased need for red blood cell concentrates and fresh frozen plasma (all P < .05). Intraoperative administration rates of antifibrinolytic substances and fibrinogen concentrate were significantly increased in patients who received rotational thromboelastometry monitoring (both P < .05). However, use of rotational thromboelastometry was not associated with massive transfusion rates (> 10 units vs less), clinical outcome, or length of stay in the intensive care unit (all P > .05).

CONCLUSIONS

Use of rotational thromboelastometry during liver transplant may reduce the need for intraoperative transfusion and coagulation products. Relevant effects of rotational thromboelastometry on patient outcomes or lengths of stay in the intensive care unit could not be ascertained. However, readjustment of therapeutic thresholds may improve the clinical impact.

Disseminated intravascular coagulation: is it fact or fancy?

: 'Disseminated intravascular coagulation (DIC)' occurs commonly in critical illnesses such as sepsis, trauma, cancer, and complications of surgery and pregnancy. Mortality is very high. The pathogenesis has been ascribed to tissue factor-initiated coagulation disorder, resulting in disseminated microblood clots that are made of platelets, plasma factors, fibrins, and blood cells. True DIC depletes coagulation factors and consumes platelets, and activates fibrinolysis. 'DIC' is assumed to orchestrate thrombocytopenia, microangiopathic hemolytic anemia and hypoxic multiorgan dysfunction syndrome, and causes hemorrhagic disorder due to depleted coagulation factors. In contrast, disseminated intravascular microthrombosis (DIT) occurs in thrombotic thrombocytopenic purpura (TTP) and TTP-like syndrome due to ADAMTS13 deficiency or insufficiency. The pathogenesis is due to formation of intravascular 'microthrombi' composed of complexes of platelets and unusually large von Willebrand factor multimers. Interestingly, DIT also occurs in the same critically ill patients as 'DIC' does. Following activation of complement system, the terminal complex C5b-9 causes endotheliopathy via channel formation to the endothelial cell membrane. Endotheliopathy activates microthrombotic pathway and initiates microthrombogenesis, leading to endotheliopathy-associated DIT. DIT results in TTP-like syndrome with hematologic phenotype of consumptive thrombocytopenia, microangiopathic hemolytic anemia, and multiorgan dysfunction syndrome. In reinterpretation of 'DIC', the true lesion is 'microthrombi' but not microblood clots. Thus, 'DIC' is endotheliopathy-associated DIT. This concept reconciles all the clinical features of 'DIC', and dramatically changes our understanding of pathophysiological mechanism in hemostasis and thrombosis. This new paradigm should assist the physician with correct diagnostic evaluation and treatment intervention.

The Misunderstood Coagulopathy of Liver Disease: A Review for the Acute Setting

The international normalized ratio (INR) represents a clinical tool to assess the effectiveness of vitamin-K antagonist therapy. However, it is often used in the acute setting to assess the degree of coagulopathy in patients with hepatic cirrhosis or acute liver failure. This often influences therapeutic decisions about invasive procedures or the need for potentially harmful and unnecessary transfusions of blood product. This may not represent a best-practice or evidence-based approach to patient care. The author performed a review of the literature related to the utility of INR in cirrhotic patients using several scientific search engines. Despite the commonly accepted dogma that an elevated INR in a cirrhotic patient corresponds with an increased hemorrhagic risk during the performance of invasive procedures, the literature does not support this belief. Furthermore, the need for blood-product transfusion prior to an invasive intervention is not supported by the literature, as this practice increases the risk of complications associated with a patient's hospital course. Many publications ranging from case studies to meta-analyses refute this evidence and provide examples of thrombotic events despite elevated INR values. Alternative methods, such as thromboelastogram, represent alternate means of assessing in vivo risk of hemorrhage in patients with acute or chronic liver disease in real-time in the acute setting.

TTP-like syndrome: novel concept and molecular pathogenesis of endotheliopathy-associated vascular microthrombotic disease

TTP is characterized by microangiopathic hemolytic anemia and thrombocytopenia associated with brain and kidney dysfunction. It occurs due to ADAMTS13 deficiency. TTP-like syndrome occurs in critically ill patients with the similar hematologic changes and additional organ dysfunction syndromes. Vascular microthrombotic disease (VMTD) includes both TTP and TTP-like syndrome because their underlying pathology is the same disseminated intravascular microthrombosis (DIT). Microthrombi are composed of platelet-unusually large von Willebrand factor multimers (ULVWF) complexes. TTP occurs as a result of accumulation of circulating ULVWF secondary to ADAMTS13 deficiency. This protease deficiency triggers microthrombogenesis, leading to "microthrombi" formation in microcirculation. Unlike TTP, TTP-like syndrome occurs in critical illnesses due to complement activation. Terminal C5b-9 complex causes channel formation to endothelial membrane, leading to endotheliopathy, which activates two different molecular pathways (i.e., inflammatory and microthrombotic). Activation of inflammatory pathway triggers inflammation. Activation of microthrombotic pathway promotes platelet activation and excessive endothelial exocytosis of ULVWF from endothelial cells (ECs). Overexpressed and uncleaved ULVWF become anchored to ECs as long elongated strings to recruit activated platelets, and assemble "microthrombi". In TTP, circulating microthrombi typically be lodged in microvasculature of the brain and kidney, but in TTP-like syndrome, microthrombi anchored to ECs of organs such as the lungs and liver as well as the brain and kidneys, leading to multiorgan dysfunction syndrome. TTP occurs as hereditary or autoimmune disease and is the phenotype of ADAMTS13 deficiency-associated VMTD. But TTP-like syndrome is hemostatic disorder occurring in critical illnesses and is the phenotype of endotheliopathy-associated VMTD. Thus, this author's contention is TTP and TTP-like syndrome are two distinctly different disorders with dissimilar underlying pathology and pathogenesis.

Thrombosis of the Portal Venous System in Cirrhotic vs. Non-Cirrhotic Patients

INTRODUCTION AND AIM

Thrombosis is a vascular disorder of the liver often associated with significant morbidity and mortality. Cirrhosis is a predisposing factor for portal venous system thrombosis. The aim of this study is to determine differences between cirrhotics and non-cirrhotics that develop thrombosis in portal venous system and to evaluate if cirrhosis severity is related to the development of portal venous system thrombosis.

MATERIAL AND METHODS

We studied patients diagnosed with portal venous system thrombosis using contrast-enhanced computed tomography scan and doppler ultrasound at Medica Sur Hospital from 2012 to 2017. They were categorized into two groups; cirrhotics and non-cirrhotics. We assessed the hepatic function by Child-Pugh score and model for end-stage liver disease.

RESULTS

67 patients with portal venous system thrombosis (25 with non-cirrhotic liver and 42 with cirrhosis) were included. The mean age (± SD) was 65 ± 9.5 years in cirrhotic group and 57 ± 13.2 years (p = 0.009) in non-cirrhotic group. Comparing non-cirrhotics and cirrhotics, 8 non-cirrhotic patients showed evidence of extra-hepatic inflammatory conditions, while in the cirrhotic group no inflammatory conditions were found (p &lt; 0.001). 27 (64.29%) cirrhotic patients had thrombosis in the portal vein, while only 9 cases (36%) were found in non-cirrhotics (p = 0.02).

CONCLUSIONS

In cirrhotic patients, hepatocellular carcinoma and cirrhosis were the strongest risk factors to develop portal venous system thrombosis. In contrast, extrahepatic inflammatory conditions were main risk factors associated in non-cirrhotics. Moreover, the portal vein was the most frequent site of thrombosis in both groups.

Decreased protein C function predicts mortality in patients with cirrhosis

INTRODUCTION

Protein C (PrC), a physiological anticoagulant, regulates inflammation and cell death and has known predictive/therapeutic roles in sepsis. Accumulating evidences suggest plasma hypercoagulability results in progression of fibrosis and formation of microclots causing end-organ dysfunction. We investigated a possible association between natural anticoagulants-PrC, protein S (PrS) and antithrombin III (AT)-and clinical outcomes in cirrhotics.

METHODS

Functional PrC, PrS and AT were analysed in 515 cirrhotic patients and compared with 229 noncirrhotics. Among those with cirrhosis, we conducted multivariable predictive model on 3-month survival to assess the prognostic ability of anticoagulants.

RESULTS

Protein C (P < .001), PrS (P < .001) and AT (P < .001) levels were lower in cirrhotics compared with noncirrhotics. In addition, patients with Child-Pugh (CP)-C had significantly lower (P < .05) functional PrC, PrS and AT levels than CP-B, CP-A and noncirrhotic patients. Low PrC function correlated with markers of liver dysfunction and inflammation: INR(r = -.72, P < .001), bilirubin (r = -.620, P < .001), albumin (r = .539, P < .001), creatinine (r = -.417, P < .001), ferritin (r = -.68, P = .035), procalcitonin (r = -.79, P = .01), raised ESR (r = .56, P < .001) and liver fibrosis (r = -.840, P < .001). Patients who died (n = 160) had significantly lower median PrC function (23.8%, 16.3-33.0]) compared with those who remained alive (74.9%, [59.7-92.5]); P < .001. In a multivariable predictive model using PrC, and MELD score, we found a significant impact of low PrC levels on survival (P < .001, IRR = 0.97, 95% CI = 0.96-0.98). Receiver operating characteristic (ROC) curve analysis revealed that functional PrC levels <52% were associated with increased mortality (P < .001).

CONCLUSION

Low functional protein C level correlated with markers of liver dysfunction, inflammation and sepsis and independently predicted mortality at 3 months in cirrhotics, especially if functional levels were <52%.

Significance of measured intraoperative portal vein flows after thrombendvenectomy in deceased donor liver transplantations with portal vein thrombosis

Adequate portal vein (PV) flow in liver transplantation is essential for a good outcome, and it may be compromised in patients with portal vein thrombosis (PVT). This study evaluated the impact of intraoperatively measured PV flow after PV thrombendvenectomy on outcomes after deceased donor liver transplantation (DDLT). The study included 77 patients over a 16-year period who underwent PV thrombendvenectomy with complete flow data. Patients were classified into 2 groups: high PV flow (>1300 mL/minute; n = 55) and low PV flow (≤1300 mL/minute; n = 22). Postoperative complications and graft survival were analyzed according to the PV flow. The 2 groups were similar in demographic characteristics. Low PV flow was associated with higher cumulative rates of biliary strictures (P = 0.02) and lower 1-, 2-, and 5-year graft survival (89%, 85%, and 68% versus 64%, 55%, and 38%, respectively; P = 0.002). There was no difference in the incidence of postoperative PVT between the groups (1.8% versus 9.1%; P = 0.19). No biliary leaks or hepatic artery thromboses were reported in either group. By multivariate analyses, age >60 years (hazard ratio [HR], 3.04, 95% confidence interval [CI], 1.36-6.82; P = 0.007) and low portal flow (HR, 2.31; 95% CI, 1.15-4.65; P = 0.02) were associated with worse survival. In conclusion, PV flow <1300 mL/minute after PV thrombendvenectomy for PVT during DDLT was associated with higher rates of biliary strictures and worse graft survival. Consideration should be given to identifying reasons for low flow and performing maneuvers to increase PV flow when intraoperative PV flows are <1300 mL/minute. Liver Transplantation 23 1032-1039 2017 AASLD.

Thrombin activatable fibrinolysis inhibitor as a bleeding predictor in liver transplantation: a pilot observational study

OBJECTIVE

To correlate the levels of thrombin activatable fibrinolysis inhibitor in the immediate postoperative period and at 24 hours postoperatively with the volume of intraoperative bleeding.

METHODS

Twenty-one patients allocated immediately before (elective or emergency) liver transplantation were analyzed. Blood samples were collected for thrombin activatable fibrinolysis inhibitor analysis at three different time points: immediately before liver transplantation (preoperative thrombin activatable fibrinolysis inhibitor), immediately after the surgical procedure (immediate postoperative thrombin activatable fibrinolysis inhibitor), and 24 hours after surgery (thrombin activatable fibrinolysis inhibitor 24 hours after surgery). The primary outcome of the study was to correlate the preoperative and immediate postoperative levels of thrombin activatable fibrinolysis inhibitor with intraoperative blood loss.

RESULTS

There was a correlation between the preoperative thrombin activatable fibrinolysis inhibitor levels and bleeding volume (ρ = -0.469; p = 0.05) but no correlation between the immediate postoperative thrombin activatable fibrinolysis inhibitor and bleeding volume (ρ = -0.062; p = 0.79). No variable included in the linear regression analysis (prehemoglobin, prefibrinogen and preoperative thrombin activatable fibrinolysis inhibitor) was a bleeding predictor. There was a similar trend in the variation between the levels of thrombin activatable fibrinolysis inhibitor at the three different time points and fibrinogen levels. Patients who died within 6 months (14.3%) showed decreased preoperative and immediate postoperative levels of thrombin activatable fibrinolysis compared with survivors (preoperative: 1.3 ± 0.15 versus 2.55 ± 0.53, p = 0.06; immediate postoperative: 1.2 ± 0.15 versus 2.5 ± 0.42, p = 0.007).

CONCLUSION

There was a moderate correlation between preoperative thrombin activatable fibrinolysis inhibitor and intraoperative bleeding in liver transplantation patients, although the predictive role of this variable independent of other variables remains uncertain. Preoperative and immediate postoperative thrombin activatable fibrinolysis inhibitor levels may have a role in the survival prognosis of this population; however, this possibility requires confirmation in further studies with larger sample sizes.

Bleeding Risk and Management in Interventional Procedures in Chronic Liver Disease

The coagulopathy of liver disease is distinctly different from therapeutic anticoagulation in a patient. Despite stable elevated standard clot-based coagulation assays, nearly all patients with stable chronic liver disease (CLD) have normal or increased clotting. Common unfamiliarity with the limitations of these assays in CLD may lead to inappropriate and sometimes harmful interventions, including blood product transfusions before a procedure. Knowledge of the distinct hemostatic alterations in CLD can allow identification of the small subset of patients with clinically significant coagulopathy who can benefit from hematologic optimization before invasive procedures.

Protein C Deficiency in Chronic Hepatitis C

There is accumulating evidence that the coagulation system is involved in the process of fibrogenesis in chronic liver disease. Recent studies postulated a possible connection between plasmatic hypercoagulability and progression of fibrosis. The aim of the study was to investigate disorders of the coagulation system in patients with chronic hepatitis C having different extent of hepatic fibrosis well defined by liver histology. A total of 62 patients with chronic hepatitis C were recruited and categorized into 2 groups according to their histological fibrosis stage : mild/moderate fibrosis group (F0-F3 group, n = 30) and extensive fibrosis/cirrhosis group (F4-F6 group, n = 32). The control group consisted of 31 healthy individuals. The following hemostatic assays were evaluated: antithrombin III (AT), protein C (PC) activity, activated partial thromboplastin time, prothrombin time, plasma fibrinogen as well as conventional liver function test. The PC level exhibited a significant reduction in both patient groups when compared to the normal control group (89.25% ± 10.05% and 48.33% ± 15.86% vs 111.86 ± 10.90; P < .001 and P < .001). The PC was found to be the strongest associated factor to histological fibrosis stage ( r = –.834; P < .0001). Univariate and multivariate analysis showed that AT ( P = .003) and PC ( P = .0001) were the most important factors associated with advanced fibrosis. The PC ( P = .001) was found to be the only predictor of mild fibrosis. In conclusion, PC deficiency occurs in an early stage of liver fibrosis. The severity of deficiency is proportional to extent of fibrosis. The PC may have a key role in linking hypercoagulability with hepatic fibrogenesis in chronic liver disease.