Clinical Validation of Global Coagulation Tests to Guide Blood Component Transfusions in Cirrhosis and ACLF

Abstract

Background and Aims Patients with cirrhosis and acute-on-chronic liver failure (ACLF) may have bleeding complications and need for invasive procedures. Point-of-care (POC) coagulation tests like thromboelastography (TEG) and Sonoclot may be better for guiding patient management than the standard coagulation tests (SCTs), like prothrombin time, platelet count and international normalized ratio. Methods We prospectively compared and validated the POC tests and SCTs in 70 persons with ACLF and 72 persons with decompensated cirrhosis who had clinical bleeding and checked for episodes of re-bleeding and transfusion requirements. We assessed pre-procedure requirement of blood components when correction was done based on an SCT or POC strategy. Results Episodes of bleeding were seen in 45% and 28% of ACLF and cirrhosis patient, respectively ( p =0.036), with the major site of bleeding being gastrointestinal (31% and 16%, respectively). Platelet counts correlated with TEG-maximum amplitude in cirrhosis ( p =0.045) and prothrombin time correlated positively with TEG-reaction (R) time ( p =0.032), TEG-Clot kinetics (K) time ( p =0.042), Son-activated clotting time ( p =0.038) and negatively with clot rate ( p =0.043) in ACLF, making these correctable target variables in POC transfusion algorithms. Of 223 procedures, transfusion of fresh frozen plasma and platelet concentrate was reduced by 25% ( p =0.035) and 20.8% ( p =0.045) by using a POC strategy in 76 patients. Correction of deranged Son-activated clotting time and TEG-reaction time was noted in 68% and 72% after 24 h of fresh frozen plasma transfusion in ACLF and 85% and 80% in cirrhosis, respectively. Conclusions Our study clinically validates that POC tests can better detect coagulation defects and transfusion thresholds in ACLF and cirrhosis, whereas use of conventional tests appear to be less suitable in patients with clinical bleeding. Trial Registration NCT04332484.

Thromboelastography-Guided Therapy Enhances Patient Blood Management in Cirrhotic Patients: A Meta-analysis Based on Randomized Controlled Trials

“…However, despite this, it is encouraging that the data presented herein are corroborated by other meta-analyses of RCTs and/or nonrandomized observational studies that included the limited data on rotational thromboelastometry, suggesting these findings may be applicable across comparable VET platforms. 39,40,43,[61][62][63][64] With the publication of RCTs using a wider range of devices, the evidence landscape will evolve and warrant further analyses on this topic.…”

COVID-19-related dynamic coagulation disturbances and anticoagulation strategies using conventional D-dimer and point-of-care Sonoclot tests: a prospective cohort study

“…Moreover, a significant proportion of severely ill COVID-19 patients had evidence of major bleeding that can be attributed to sepsis induced coagulopathy and anticoagulation regimen guided by SCTs. Considering the complex interplay between prothrombotic and anti-haemostatic pathways, their influence on outcome in terms of thrombosis or bleeding cannot be measured on SCTs 26 27…”

Coagulation and Endothelial Dysfunction Associated with NAFLD: Current Status and Therapeutic Implications

“…49 The use of thromboelastography (TEG), viscoelastic testing (VET), and rotational thromboelastometry (ROTEM) for comprehensive analysis of coagulation status is being extensively studied in clinical settings. [50][51][52] TEG may be usefull in NAFLD patients, because increased cardiovascular risk may be partially at- tributed to altered clot kinetics resulting in lysis-resistant clots. Further studies are needed to substantiate those findings.…”