Rebalanced hemostasis in patients with liver disease: evidence and clinical consequences

Abstract

Patients with liver disease frequently acquire a complex disorder of hemostasis secondary to their disease. Routine laboratory tests such as the prothrombin time and the platelet count are frequently abnormal and point to a hypocoagulable state. With more sophisticated laboratory tests it has been shown that patients with liver disease may be in hemostatic balance as a result of concomitant changes in both pro-and antihemostatic pathways. Clinically, this rebalanced hemostatic system is reflected by the large proportion of patients with liver disease who can undergo major surgery without any requirement for blood product transfusion. However, the hemostatic balance in the patient with liver disease is relatively unstable as evidenced by the occurrence of both bleeding and thrombotic complications in a significant proportion of patients. Although it is still common practice to prophylactically correct hemostatic abnormalities in patients with liver disease before invasive procedures by administration of blood products guided by the prothrombin time and platelet count, we believe that this policy is not evidence-based. In this article, we will provide arguments against the traditional concept that patients with liver failure have a hemostasis-related bleeding tendency. Consequences of these new insights for hemostatic management will be discussed. (Blood. 2010;116(6):878-885)

Critical Care Management after Adult Liver Transplantation

“…Bazı araştırmacılara göre karaciğer yetersizliğindeki koagülopati, pro-ve antikoagülan faktörlerin aynı oranda azaldığı bir dengeli koagülopatidir ve komplikasyonların (böbrek yetersizliği, enfeksiyon vb.) seyrine göre kanama, tromboz veya her ikisi de görülebilir (2,59,60). Bu yüzden KT'nin perioperatif döneminde koagülasyon sisteminin hızlı ve sensitif monitörizasyonu gereklidir.…”

Bleeding and Clotting Disorders in Pediatric Liver Disease

“…24,28,29 Platelet procoagulant activity as assessed in thrombin-generation assays in plateletrich plasma is fully preserved in patients with cirrhosis. 12 Clinical data on the most relevant bleeding problem in adult patients with cirrhosis, bleeding from esophageal varices, show that it is a consequence of local vascular abnormalities and increased splanchnic blood pressure, and the role of abnormal hemostasis is questionable.…”

“…26 Lisman postulates that in the "average" patient with liver disease, overall hemostasis is rebalanced due to the alterations in both the pro-and antihemostatic processes, but that this is probably less stable than in the healthy individual due to the reduced plasma levels of most of these proteins, making the individual hepatic coagulopathy patient able to flip into a hypo-or hypercoagulable state, depending on complications such as infections and renal failure. 24 Prophylactic treatment with antibiotics in cirrhosis patients has been shown to decrease bleeding risk, presumably by helping to maintain the balance between the decreased levels of pro-and anticoagulation factors, but also possibly by improvement of hemodynamics. 27 …”

“…However, elevated venous pressure may contribute to bleeding problems that appear initially to be related to hemostatic problems, and FFP infusions may instigate or exaggerate this problem. 24 Bacterial infections are common in patients with cirrhosis and are associated with increased bleeding risk. 31 Renal failure complicates hepatic failure and uremia is associated with disturbed platelet-vessel wall interaction.…”

“…10,[23][24][25] Defects in platelet number and function, procoagulant function, and regulation of fibrinolysis appear to be balanced by substantially elevated levels of FVIII and VW and reduced levels of ADAMTS13 in cirrhosis, which may result in enhanced thrombus formation by decreased proteolysis of VWF, and deficiencies of the natural anticoagulants protein C, protein S, and antithrombin in liver failure. Decreased levels of antifibrinolytics (eg, antiplasmin and thrombin-activatable fibrinolysis inhibitors) may also change the balance of coagulation and anticoagulation in patients with hepatic coagulopathy and reduce the risk of bleeding.…”