Coagulation parameters and major bleeding in critically ill patients with cirrhosis

Abstract

Disturbances of coagulation and hemostasis are common in patients with liver cirrhosis. The typical laboratory pattern mimics disseminated intravascular coagulation (DIC). The aim of this study was to assess the impact of routine coagulation parameters in critically ill cirrhosis patients with regard to new onset of major bleeding and outcome. A total of 1,493 critically ill patients were studied prospectively. Routine coagulation parameters were assessed, and the DIC score was calculated based on platelets, fibrinogen, d-dimer, and prothrombin index. New onset of major bleeding during the stay at the intensive care unit and mortality were assessed. Patients were followed for 1 year. Two hundred eleven patients of the cohort had liver cirrhosis. Platelets, fibrinogen, prothrombin index, activated partial thromboplastin time, and d-dimer as well as the DIC score differed significantly between patients with and without cirrhosis (P < 0.001 for all). Moreover, fibrinogen, platelets, and activated partial thromboplastin time (but not prothrombin index) differed significantly between cirrhosis patients with and without major bleeding (P < 0.01 for all). Bleeding on admission, platelet count <30 < 10 9 /L, fibrinogen level <60 mg/dL, and activated partial thromboplastin time values >100 seconds were the strongest independent predictors for new onset of major bleeding in multivariate regression analysis. One-year mortality in cirrhosis patients with and without major bleeding was 89% and 68%, respectively (P < 0.05 between groups). Conclusion: Abnormal coagulation parameters and high DIC scores (primarily due to fibrinogen and platelets) correspond to increased bleeding risk in patients with liver cirrhosis in the intensive care unit, and fibrinogen and platelet count were identified as the best routine coagulation parameters for prediction of new onset of major bleeding; however, further studies are required to evaluate the potential therapeutic implications of these findings. (HEPATOLOGY 2016;64:556-568)

Study of coagulation profile in hepatic disorders in a Tertiary Care Centre

“…Platelet count was found to be altered in 52.2% cases while it was normal in 47.8% cases. These findings were similar to that observed by Varnika Rai et al [4] , Kyung-Hwa Shin et al [7] and Andreas Drolz et al [6] .…”

“…Alcohol was the most common cause of cirrhosis in the present study. This finding is similar to Andreas Drolz et al [6] while hepatitis virus infection was the most common cause of cirrhosis in the study conducted by Jaeyoung Cho et al [5] , Varnika Rai et al [4] and Sohail Ahmed Siddiqui et al [3] . This difference may be due to the difference in the socioeconomic practices of the study population.…”

“…This male preponderance was similar to the observation made by Varnika Rai et al [4] and Jaeyoung Cho et al [5] . Female preponderance was seen in the study conducted by Andreas Drolz et al [6] . This may be due to the socioeconomic reasons.…”

How I treat disseminated intravascular coagulation

“…54 Helpful clues may be that in contrast to patients with DIC in severe liver disease the (low) platelet count is usually stable and fibrin degradation products (such as D-dimer) are only mildly elevated, due to the simultaneous presence of fibrinolytic activation and impairment in this condition. [55][56][57] In addition, clinical signs, such as the presence of splenomegaly and ascites, may indicate that liver disease rather than DIC is the cause of the coagulopathy. In the case presented the DIC score was 4 (suggestive of no DIC) and in combination with the clinical signs and symptoms a diagnosis of coagulopathy due to severe liver failure was made.…”

Management of Coagulopathy during Bleeding and Invasive Procedures in Patients with Liver Failure

“…Accordingly, global coagulation tests, such as international normalized ratio (INR), are insufficient to assess the coagulation system and bleeding risk in these patients [4,6,7]. …”