Transfusion practices in cirrhotic patients at a tertiary liver care center from Northern India

Kakkar, Brinda; Maiwall, Rakhi; Bajpai, Meenu

doi:10.1016/j.htct.2020.05.010

Cited by 7 publications

(9 citation statements)

References 15 publications

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“…Prophylactic blood product transfusions are thus frequently prescribed in patients with chronic liver disease, with rates of 11.7% in a nationwide UK study, 48 to up to 33.6% in patients at a tertiary liver care centre in India. 49 Data on the efficacy of FFP transfusions in correcting haemostatic abnormalities are contradictory: in one study, FFP transfusion led to a minimal increase in thrombin formation (5% increase in ETP), 50 whereas in a recent study by our group this increase was more profound (20% increase in ETP). 51 Of note, in the latter study, baseline ETP in patients with chronic liver disease was similar to that in healthy controls, raising the question of whether transfusion of FFP was actually indicated.…”

Section: Clinical Evidence Of Haemostatic Rebalancementioning

confidence: 86%

“…The frequent abnormalities in INR and platelet levels in patients with chronic liver disease continue to lead to a perceived high risk of bleeding in these patients, whereas substantial evidence against a relation between abnormal conventional coagulation tests and the risk of bleeding in these patients exists. Prophylactic blood product transfusions are thus frequently prescribed in patients with chronic liver disease, with rates of 11.7% in a nationwide UK study, 48 to up to 33.6% in patients at a tertiary liver care centre in India 49 . Data on the efficacy of FFP transfusions in correcting haemostatic abnormalities are contradictory: in one study, FFP transfusion led to a minimal increase in thrombin formation (5% increase in ETP), 50 whereas in a recent study by our group this increase was more profound (20% increase in ETP) 51 .…”

Section: Haemostatic Complications In Liver Diseasementioning

confidence: 99%

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Pathophysiology and management of bleeding and thrombosis in patients with liver disease

Boom

Lisman

2022

Int J Lab Hematology

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Patients with liver disease often develop complex changes in their haemostatic system. Frequently observed changes include thrombocytopaenia and altered plasma levels of most of the proteins involved in haemostasis. Although liver disease was historically classified as a haemostasis-related bleeding disorder, it has now been well established that the antihaemostatic changes that promote bleeding are compensated for by prohaemostatic changes. Conventional coagulation tests however do not accurately reflect these prohaemostatic changes, resulting in an underestimation of haemostatic potential. Novel coagulation tests, such as viscoelastic tests (VETs) and thrombin generation assays (TGAs) better reflect the net result of the haemostatic changes in patients with liver disease, and demonstrate a new, "rebalanced" haemostatic status. Although rebalanced, this haemostatic status is more fragile than in patients without liver disease. Patients with liver disease are therefore not only at risk of bleeding but also at risk of thrombosis. Notably, however, many haemostatic complications in liver disease are not related to the haemostatic failure. It is, therefore, crucial to identify the cause of the bleed or thrombotic complication in order to provide adequate treatment. In this paper, we will elaborate on the haemostatic changes that occur in liver disease, reflect on laboratory and clinical studies over the last few years, and explore the pathophysiologies of bleeding and thrombosis in this specific patient group.

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Section: Clinical Evidence Of Haemostatic Rebalancementioning

confidence: 86%

Section: Haemostatic Complications In Liver Diseasementioning

confidence: 99%

Pathophysiology and management of bleeding and thrombosis in patients with liver disease

Boom

Lisman

2022

Int J Lab Hematology

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“…There is a significant discrepancy between recommendations of major societies and actual clinical practice regarding transfusions in cirrhotics. A recent study from a tertiary healthcare center in India revealed that 40.5% of cirrhotics admitted over a 6 mo period for various indications received transfusions, 82.8% of which were prophylactic[ 13 ]. The American Gastroenterology Association (AGA, 2019), European Association for the Study of the Liver (EASL, 2018, 2022) and the American Association for the Study of Liver Diseases (AASLD, 2016) recommend against the use of FFP for prophylactic correction of deranged PT/INR levels during AVB[ 24 - 28 ].…”

Section: Discussionmentioning

confidence: 99%

“…Transfusion practices regarding the use of FFP are clearer, with a recent retrospective cohort study demonstrating the potential harm of FFP transfusion in patients with AVB[ 11 ]. Prophylactic blood product transfusion is common in clinical practice, as reported in various studies[ 12 , 13 ]. The current study aimed to determine how platelet counts, platelets transfusions, and FFP transfusions affect the outcomes of AVB in cirrhosis patients in terms of bleeding control, rebleeding, and mortality.…”

Section: Introductionmentioning

confidence: 99%

Effect of thrombocytopenia and platelet transfusion on outcomes of acute variceal bleeding in patients with chronic liver disease

Biswas¹,

Vaishnav²,

Pathak³

et al. 2022

WJH

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BACKGROUND Platelet transfusion in acute variceal bleeding (AVB) is recommended by few guidelines and is common in routine clinical practice, even though the effect of thrombocytopenia and platelet transfusion on the outcomes of AVB is unclear. AIM To determine how platelet counts, platelets transfusions, and fresh frozen plasma transfusions affect the outcomes of AVB in cirrhosis patients in terms of bleeding control, rebleeding, and mortality. METHODS Prospectively maintained database was used to analyze the outcomes of cirrhosis patients who presented with AVB. The outcomes were assessed as the risk of rebleeding at days 5 and 42, and risk of death at day 42, considering the platelet counts and platelet transfusion. Propensity score matching (PSM) was used to compare the outcomes in those who received platelet transfusion. Statistical comparisons were done using Kaplan-Meier curves with log-rank tests and Cox-proportional hazard model for rebleeding and for 42-d mortality. RESULTS The study included 913 patients, with 83.5% men, median age 45 years, and Model for End-stage Liver Disease score 14.7. Platelet count < 20 × 10 9 /L, 20-50 × 10 9 /L, and > 50 × 10 9 /L were found in 23 (2.5%), 168 (18.4%), and 722 (79.1%) patients, respectively. Rebleeding rates were similar between the three platelet groups on days 5 and 42 (13%, 6.5%, and 4.7%, respectively, on days 5, P = 0.150; and 21.7%, 17.3%, and 14.4%, respectively, on days 42, P = 0.433). At day 42, the mortality rates for the three platelet groups were also similar (13.0%, 23.2%, and 17.2%, respectively, P = 0.153). On PSM analysis patients receiving platelets transfusions ( n = 89) had significantly higher rebleeding rates on day 5 (14.6% vs 4.5%; P = 0.039) and day 42 (32.6% vs 15.7%; P = 0.014), compared to those who didn't. The mortality rates were also higher among patients receiving platelets (25.8% vs 23.6%; P = 0.862), although the difference was not significant. On multivariate analysis, platelet transfusion and not platelet count, was independently associated with 42-d rebleeding. Hepatic encephalopathy was independently associated with 42-d mortality. CONCLUSION Thrombocytopenia had no effect on rebleeding rates or mortality in cirrhosis patients with AVB; however, platelet transfusion increased rebleeding on days 5 and 42, with a higher but non-significant effect on mortality.

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“…Currently, factor concentrates are used in some centres in patients with liver disease, 11 , 12 , 13 , 14 , 15 but without a clear evidence‐base. Use of concentrates is in part driven by studies showing an increased bleeding risk in those patients with factor deficiencies (including fibrinogen 15 , 16 and factor XIII 17 ), or a further decrease in factor levels with specific external triggers (such as acute kidney injury which has been linked to a specific exaggeration of FXIII deficiency in cirrhosis 18 , 19 ).…”

Section: Introductionmentioning

confidence: 99%

Fibrin clot quality in acutely ill cirrhosis patients: Relation with outcome and improvement with coagulation factor concentrates

Blasi

Patel

Spanke

et al. 2021

Liver International

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Background & Aims Patients with liver disease may acquire substantial changes in their hemostatic system, which are most pronounced in patients who are critically ill. Changes in the quality of the fibrin clot in critically ill patients have not been studied in detail. Here we assessed markers of fibrin clot quality and effects of coagulation factor concentrates in patients with acutely decompensated (AD) cirrhosis and acute on chronic liver failure (ACLF). Methods We measured plasma levels of fibrinogen, factor XIII, prothrombin and performed thrombin generation assays in 52 AD patients, 58 ACLF patients and 40 controls. In addition, we examined the effects of coagulation factor concentrates on functional assays of fibrin quality. Results We found increased thrombin generating capacity in both AD and ACLF in comparison with healthy controls. Plasma levels of prothrombin, fibrinogen, and factor XIII were lower in patients compared to controls, appeared lower in ACLF compared to AD patients, and were related to clinical outcomes. Fibrinogen concentrate, but not factor XIII or prothrombin complex concentrate, improved clot quality in vitro. Prothrombin complex concentrate increased the resistance of the clot to break down. Conclusions We have demonstrated elevated thrombin generation but decreased plasma levels of prothrombin, fibrinogen and FXIII in acutely ill patients with cirrhosis. In addition, we showed that fibrinogen concentrate and PCCs, but not factor XIII concentrate, improve clot properties in patient plasma. Whether there is true clinical benefit from coagulation factor concentrates in prevention or treatment of bleeding requires further study. Lay summary Patients with liver diseases are at risk of bleeding, but mechanisms involved in this bleeding risk are incompletely understood. We studied components that determine the stability of the blood clot and found that concentrations of certain proteins involved in clot stability are present in low levels in acutely ill patients with liver disease. We furthermore demonstrated that some clinically available drugs improve the stability of blood clots from these patients in a test tube.

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Transfusion practices in cirrhotic patients at a tertiary liver care center from Northern India

Cited by 7 publications

References 15 publications

Pathophysiology and management of bleeding and thrombosis in patients with liver disease

Pathophysiology and management of bleeding and thrombosis in patients with liver disease

Effect of thrombocytopenia and platelet transfusion on outcomes of acute variceal bleeding in patients with chronic liver disease

Fibrin clot quality in acutely ill cirrhosis patients: Relation with outcome and improvement with coagulation factor concentrates

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