Association of thromboelastography profile with severity of liver cirrhosis and portal venous system thrombosis

Abstract

Background and aim Hemostasis profile is often complicated in liver cirrhosis. Thromboelastography is a global viscoelastic test recommended by the current practice guideline and consensus. This cross-sectional study aimed to evaluate the association of thromboelastography profile with severity of liver cirrhosis and presence of portal venous system thrombosis (PVST). Methods Overall, 116 and 50 cirrhotic patients were included in the Shenyang and Xi’an cohorts, respectively. Thromboelastography parameters were compared between cirrhotic patients with Child–Pugh class A and B/C, those with and without decompensated events, and those with and without PVST. Hypercoagulability would be considered if at least two of the following thromboelastography parameters were met: shortened reactive time (R), shortened coagulation time (K), increased angle, and increased maximum amplitude (MA). Results In the Shenyang cohort, 16 patients had shortened R, of whom seven (43.75%) had prolonged K and 11 (68.75%) decreased MA. In the Xi’an cohort, 24 patients had shortened R, of whom seven (29.17%) had prolonged K and 15 (62.50%) decreased MA. In the Shenyang cohort, the prevalence of hypercoagulability was not significantly different between cirrhotic patients with Child–Pugh class A and B/C (3.85% vs. 6.25%, P = 0.873), those with and without decompensated events (5.49% vs. 4.00%, P = 1.000), and those with and without PVST (4.17% vs. 5.88%, P = 1.000), which were similar to the results obtained in the Xi’an cohort. Conclusion There is a high rate of discordance between R and other thromboelastography parameters. In addition, hypercoagulability may not be related to more advanced stage of liver cirrhosis or presence of PVST.

Review article: thromboelastography in liver diseases

“…Evidence suggests that an imbalance of pro‐ and anti‐coagulants, such as an increased ratio of factor VIII and protein C, causes a hypercoagulable state, 43 but may not be associated with the presence of PVST in cirrhosis 44,45 . Similarly, most published studies, 14,46,47 except the one by Huang et al, 48 did not find any hypercoagulable state indicated by R alone in cirrhosis with PVST. In addition, nearly all published studies did not show any hypercoagulable state indicated by MA alone in cirrhosis with PVST, 14,46–48 although clot strength could discriminate non‐cirrhotic PVST (AUROC = 0.824 ± 0.112, p = 0.006) 47 and was sensitive for predicting venous thromboembolism in patients with critically ill coagulopathy, defined as thrombocytopenia and/or elevated INR or prolonged activated partial thromboplastin time 49 .…”

“…There is a correlation between TEG parameters and CCTs, 12,13 but haemostatic status indicated by CCTs and TEG is often inconsistent in patients with liver disease. Normal haemostatic status indicated by R and MA in cirrhotic patients is more common than that indicated by PT and PLT 12,14 . In a proportion of cirrhotic patients with increased INR, TEG profile is within the normal range 15 .…”

“…In addition, nearly all published studies did not show any hypercoagulable state indicated by MA alone in cirrhosis with PVST, 14,46–48 although clot strength could discriminate non‐cirrhotic PVST (AUROC = 0.824 ± 0.112, p = 0.006) 47 and was sensitive for predicting venous thromboembolism in patients with critically ill coagulopathy, defined as thrombocytopenia and/or elevated INR or prolonged activated partial thromboplastin time 49 . Furthermore, hypercoagulable state indicated by two or more TEG parameters remained not significantly associated with PVST in cirrhotic patients 14 . Taken together, such a poor association between PVST and TEG profile suggests that hypercoagulable state should not be crucial for PVST in cirrhosis 44,50 …”

“…49 Furthermore, hypercoagulable state indicated by two or more TEG parameters remained not significantly associated with PVST in cirrhotic patients. 14 Taken together, such a poor association between PVST and TEG profile suggests that hypercoagulable state should not be crucial for PVST in cirrhosis. 44,50…”

“…Normal haemostatic status indicated by R and MA in cirrhotic patients is more common than that indicated by PT and PLT. 12,14 In a proportion of cirrhotic patients with increased INR, TEG profile is within the normal range. 15 In most patients with acute on chronic liver failure (ACLF) and acute liver failure, who are manifested as INR >1.5 or prothrombin activity ≤40%, 16,17 TEG profile is also within the normal range.…”