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

Drolz, Andreas; Ferlitsch, Arnulf; Fuhrmann, Valentin

doi:10.1159/000491106

Cited by 25 publications

(25 citation statements)

References 34 publications

(53 reference statements)

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“…Haemostasis in chronic stable liver disease is often referred to as 'rebalanced' with a net effect of normal haemostasis or even a procoagulant state and this is reflected in more 'global' assays of coagulation in patients with chronic liver disease, such as thrombin generation and viscoelastic haemostatic assays. [147][148][149][150][151][152][153][154] There appears to be a similar rebalancing in acute liver disease. 155 The INR is only sensitive for fibrinogen, factor II, factor V, factor VII and factor X and does not test the haemostatic balance in a patient with liver disease.…”

Section: Coagulation Testingmentioning

confidence: 87%

Guidelines on the use of liver biopsy in clinical practice from the British Society of Gastroenterology, the Royal College of Radiologists and the Royal College of Pathology

Neuberger

Patel

Caldwell

et al. 2020

Gut

233

201

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Liver biopsy is required when clinically important information about the diagnosis, prognosis or management of a patient cannot be obtained by safer means, or for research purposes. There are several approaches to liver biopsy but predominantly percutaneous or transvenous approaches are used. A wide choice of needles is available and the approach and type of needle used will depend on the clinical state of the patient and local expertise but, for non-lesional biopsies, a 16-gauge needle is recommended. Many patients with liver disease will have abnormal laboratory coagulation tests or receive anticoagulation or antiplatelet medication. A greater understanding of the changes in haemostasis in liver disease allows for a more rational, evidence-based approach to peri-biopsy management. Overall, liver biopsy is safe but there is a small morbidity and a very small mortality so patients must be fully counselled. The specimen must be of sufficient size for histopathological interpretation. Communication with the histopathologist, with access to relevant clinical information and the results of other investigations, is essential for the generation of a clinically useful report.

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Section: Coagulation Testingmentioning

confidence: 87%

Guidelines on the use of liver biopsy in clinical practice from the British Society of Gastroenterology, the Royal College of Radiologists and the Royal College of Pathology

Neuberger

Patel

Caldwell

et al. 2020

Gut

233

201

View full text Add to dashboard Cite

show abstract

“…However, clinicians should always be aware of the fact that (despite decreased antithrombin III concentrations) its anticoagulation effect in vivo remains practically unaffected [24]. More aspects of 'hemostasis dysregulation' are shown by Drolz et al [25] in this focus issue of Visceral Medicine.…”

Section: Hemostasis Dysfunctionmentioning

confidence: 95%

Intensive Care Therapy for Patients with Advanced Liver Diseases

Katsounas

Canbay

2018

Visc Med

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Decompensated cirrhosis is characterized by high hospitalization rates and costs, frequent readmissions, and poor short-term survival. Patients admitted to the hospital with acute variceal bleeding and/or hepatic encephalopathy and/or renal dysfunction are at serious risk for developing infection and/or sepsis; in turn, this renders them highly susceptible to the development of multi-system organ failure. The lack of standardized intensive care unit management protocols in patients with cirrhosis along with only few data reports from longitudinal clinical trials makes it difficult for hepatologists and critical care specialists to provide uniform evidence for clinical practice that could safely consolidate favorable outcomes such as lower hospitalization rates and/or mortality. Based on a rigorous online search of the scientific literature as well as a longtime clinical experience of the authors in the field of hepatology and critical care medicine, this work represents a focused effort to elucidate the specific bio-morbidity of advanced liver diseases in relation to the aforementioned challenges in clinical management. Further meta-analyses and/or systematic reviews are needed to enable clinicians to develop more effective strategies to bridge patients with decompensated liver disease to recompensation or liver transplantation.

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“…Drolz et al studied 211 patients in the intensive care unit with decompensated cirrhosis (CTP C) and ACLF. 57 While reported bleeding complications included both bleed events attributed to portal hypertension bleeds from other causes, 6.7% of patients developed bleeding (ISTH definition of bleeding) unrelated to portal hypertension, with the majority of these (10/14) related to procedures or surgical interventions.…”

Section: Hemostasis With Procedures In Patients With Cirrhosismentioning

confidence: 99%

The Spectrum of Disease Severity in Cirrhosis and Its Implications for Hemostasis

Stotts

Lisman

Intagliata

2020

Semin Thromb Hemost

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Bleeding and thrombosis are both common complications that patients with advanced liver disease experience. While hemostatic pathways remain largely intact with cirrhosis, this balance can quickly shift in the direction of bleeding or clotting in an unpredictable manner. A growing body of literature is attempting to shed light on difficult scenarios that clinicians often face, ranging from predicting and mitigating bleeding risk in those who need invasive procedures to determining the best strategies to manage both bleeding and thrombotic complications when they occur. Studies examining hemostasis in those with advanced liver disease, however, often include heterogeneous cohorts with varied methodology. While these studies often select a cohort of all types and degrees of cirrhosis, emerging evidence suggests significant differences in underlying systemic inflammation and hemostatic abnormalities among specific phenotypes of liver disease, ranging from compensated cirrhosis to decompensated cirrhosis and acute-on-chronic liver failure. It is paramount that future studies account for these differing disease severities if we hope to address the many critical knowledge gaps in this field.

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

Cited by 25 publications

References 34 publications

Guidelines on the use of liver biopsy in clinical practice from the British Society of Gastroenterology, the Royal College of Radiologists and the Royal College of Pathology

Guidelines on the use of liver biopsy in clinical practice from the British Society of Gastroenterology, the Royal College of Radiologists and the Royal College of Pathology

Intensive Care Therapy for Patients with Advanced Liver Diseases

The Spectrum of Disease Severity in Cirrhosis and Its Implications for Hemostasis

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