Hemostasis testing in patients with liver dysfunction: Advantages and caveats

Abstract

Due to concomitant changes in pro- and anti-coagulant mechanisms, patients with liver dysfunction have a “rebalanced hemostasis”, which can easily be tipped toward either a hypo- or a hypercoagulable phenotype. Clinicians are often faced with the question whether patients with chronic liver disease undergoing invasive procedures or surgery and those having active bleeding require correction of the hemostasis abnormalities. Conventional coagulation screening tests, such as the prothrombin time/international normalized ratio and the activated partial thromboplastin time have been demonstrated to have numerous limitations in these patients and do not predict the risk of bleeding prior to high-risk procedures. The introduction of global coagulation assays, such as viscoelastic testing (VET), has been an important step forward in the assessment of the overall hemostasis profile. A growing body of evidence now suggests that the use of VET might be of significant clinical utility to prevent unnecessary infusion of blood products and to improve outcomes in numerous settings. The present review discusses the advantages and caveats of both conventional and global coagulation assays to assess the risk of bleeding in patients with chronic liver disease as well as the current role of transfusion and hemostatic agents to prevent or manage bleeding.

Clinical Guideline on Perioperative Management of Patients with Advanced Chronic Liver Disease

“…Thrombopoietin receptor (TPO-R) agonists, lusutrombopag or avatrombopag, are approved for regulatory agencies in ACLD patients undergoing invasive procedures with severe thrombocytopenia (platelet count < 50,000/uL). Again, they are not routinely recommended, and their administration can be regarded in elective high-risk surgeries (as patients need to complete a 5- to 7-day course of treatment before the procedure) [ 46 , 48 ]. Moreover, general considerations have been described as beneficial for periprocedural management of hemostasis in ACLD patients as (1) optimize anemia by treating iron, folic acid, and vitamin B6 and B12 deficiencies; (2) treat infections; (3) improve renal function; and (4) avoid acidosis.…”

“…In ACLD patients with active bleeding, a fibrinogen level >120 mg/dL is mandatory [ 48 ]. Prothrombin concentrates complexes (Coagulation Factors II, VII, IX, X) involve less volume than the FFP.…”

Management of Decompensated Cirrhosis in the Surgical ICU: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document

“…Several studies of VET-guided algorithms for both periprocedural as well as variceal bleeding transfusion algorithms suggest that VET-guided platelet transfusion is associated with similar or reduced blood product transfusion without increased risk of bleeding. 66…”

Platelets as a Gauge of Liver Disease Kinetics?

“…Aggregability testing is thus insufficient to fully delineate the interplay between multimers of vWF, platelets, and blood vessel walls under in vivo high-flow conditions. To enhance platelet function monitoring in validity and reliability in platelet-assisted CLD monitoring, advances in the utility of specialized analyzers, electron microscopy, flow cytometry, mass spectrometry and ‘omics’ studies, and various molecular biological techniques are therefore warranted [ 50 ].…”