Incidence of Bleeding and Thrombosis in Patients with Liver Disease

Abstract

Historically, liver disease has been associated with a bleeding tendency. Global hemostatic assays have demonstrated that hemostasis is overall rebalanced, in both acute liver failure and chronic liver disease. It is now recognized that many bleeding events in chronic liver disease are mediated by portal hypertension rather than an underlying hemostatic defect. This is acknowledged in recent guidelines, which recommend against coagulation testing prior to low risk procedures in this patient group, with avoidance also of attempts at correction of prolonged coagulation times. Over time, the incidence of bleeding events has decreased in both chronic liver disease and acute liver failure, with improved supportive care, targeted treatments for underlying cause of liver disease, and the advent of liver transplantation. Concurrently, there has been increased recognition of the risk of thrombosis in chronic liver disease, with a predilection for the splanchnic vasculature. This review describes the incidence of bleeding and thrombosis in chronic liver disease and acute liver failure, including the periprocedural and liver transplantation setting.

Intensive care management of acute-on-chronic liver failure

“…83 Bleeding in critically ill patients with ESCLD mostly results from portal hypertension and spontaneous haemorrhage is uncommon. 84 There is a very limited role for prophylactic use of blood products; procedure-related bleeding is very uncommon, and risk is principally determined by the nature of the procedure and operator experience. 84 Despite SLTs not being reliable predictors of bleeding risk, their use in coagulation monitoring remains common.…”

“…84 There is a very limited role for prophylactic use of blood products; procedure-related bleeding is very uncommon, and risk is principally determined by the nature of the procedure and operator experience. 84 Despite SLTs not being reliable predictors of bleeding risk, their use in coagulation monitoring remains common. 85,86 Plasma-based SLTs are poor predictors of risk of both spontaneous and procedure-related bleeding.…”

Treatment of bleeding in patients with liver disease

“…Whilst global hemostasis assays demonstrate rebalanced hemostasis with hypercoagulable features in patients with acute decompensation, in ACLF there is broad individual variation with evidence of both hypo‐ and hypercoagulable characteristics and variable fibrinolytic activity 56,57 . Sepsis, acute kidney injury and procedural intervention predispose to bleeding and are common in patients with cirrhosis 58‐60 . Importantly, over a third of admissions to critical care units are precipitated by sepsis 37 .…”

Heparins have adequate ex vivo anticoagulant effects in hospitalized patients with cirrhosis

“…3 Although published data are scarce, VTE likely occur more often in sicker patients with systemic complications of their liver disease, as seen in acute decompensation of cirrhosis and acute-onchronic liver failure (ACLF). 4 However, it is yet unclear which individual cirrhotic patient is at particular risk for VTE, and thus which patients might benefit from thromboprophylaxis.…”

“…Even though liver disease has historically been classified as a bleeding disorder, large meta‐analyses have shown that patients with cirrhosis have a more than 2‐fold increased risk of venous thromboembolism (VTE) compared with patients without underlying liver disease 3 . Although published data are scarce, VTE likely occur more often in sicker patients with systemic complications of their liver disease, as seen in acute decompensation of cirrhosis and acute‐on‐chronic liver failure (ACLF) 4 . However, it is yet unclear which individual cirrhotic patient is at particular risk for VTE, and thus which patients might benefit from thromboprophylaxis.…”