Hemostatic balance in patients with liver cirrhosis: Report of a consensus conference

Abstract

a b s t r a c tPatients with cirrhosis present with hemostatic alterations secondary to reduced availability of procoagulant and anti-coagulant factors. The net effect of these changes is a rebalanced hemostatic system. The Italian Association of the Study of the Liver (AISF) and the Italian Society of Internal Medicine (SIMI) promoted a consensus conference on the hemostatic balance in patients with cirrhosis. The consensus process started with the review of the literature by a scientific board of experts and ended with a formal consensus meeting in Rome in December 2014. The statements were graded according to quality of evidence and strength of recommendations, and approved by an independent jury. The statements presented here highlight strengths and weaknesses of current laboratory tests to assess bleeding and thrombotic risk in cirrhotic patients, the pathophysiology of hemostatic perturbations in this condition, and outline the optimal management of bleeding and thrombosis in patients with liver cirrhosis.

Low molecular weight heparin does not increase bleeding and mortality post‐endoscopic variceal band ligation in cirrhotic patients

“…Among the six bleeders, two (one no‐LMWH and one on‐LMWH) had kidney failure at the moment of bleeding. This indicates very careful evaluation of both indication and possible correction of underlying coagulopathy in patients with such a comorbidity …”

“…We demonstrate the safety of LMWH also in patients otherwise considered at high risk of bleeding for both the endoscopic procedure (ie, EVL) and the underlying disease (ie cirrhosis further complicated by PVT). Although PVT increases the risk of variceal bleeding in cirrhotic patients and anticoagulation is indicated as its first line treatment, no clear‐cut indication has been provided on the opportunity of performing prophylactic EVL as a concomitant treatment to avoid variceal bleeding . A recent study has shown prophylactic treatment with TIPS as more effective than EVL plus non‐selective betablockers and warfarin for the prevention of rebleeding in patients with non‐cavernomatosus PVT .…”

“…It has been demonstrated that anticoagulants do not increase the risk of death associated with acute upper‐gastrointestinal bleeding in patients with cirrhosis . However, management of anticoagulation therapy in patients scheduled to endoscopic variceal ligation (EVL) for primary or secondary prophylaxis of variceal bleeding is still a matter of debate owing to the lack of dedicated studies . Anticoagulants are frequently stopped or the endoscopic procedure is delayed/contraindicated fearing causal haemorrhagic complications.…”

Coagulation Failure in Patients With Acute‐on‐Chronic Liver Failure and Decompensated Cirrhosis: Beyond the International Normalized Ratio

“…Patients with both acute and chronic liver disease are considered to have a higher risk of bleeding on the basis of abnormal standard coagulation tests (SCTs) such as the prothrombin time, activated partial thromboplastin time (aPTT), or platelet count . However, spontaneous hemorrhage not related to portal hypertension or bleeding events after invasive procedures is infrequent in these patients . The abnormal coagulation profile in cirrhosis is mainly due to the diminished synthesis of coagulation factors and to the spleen sequestration of platelets.…”

“…in these patients. (2) The abnormal coagulation profile in cirrhosis is mainly due to the diminished synthesis of coagulation factors and to the spleen sequestration of platelets. However, the synthesis of anticoagulant proteins is also reduced, and thrombin generation is normal when measured with thrombomodulin.…”