The Coagulopathy of Chronic Liver Disease

Tripodi, Armando; Mannucci, Pier Mannuccio

doi:10.1056/nejmra1011170

Cited by 1,175 publications

(1,018 citation statements)

References 67 publications

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“…In these patients, the rate of spontaneous recanalization of portal veins was exceptionally high (70%), compared with only 1/41 in the prospective study by Luca et al [202]. Retrospective studies [43,181,203,205] yielded discordant data but overall indicated poorer survival in patients with stable or progressive PVT, if left untreated [2,4,5]. In addition, PVT in liver transplant candidates correlated with increased mortality after liver transplantation [206].…”

Section: Impact Of Portal Vein Thrombosis On the Natural History Of Cmentioning

confidence: 95%

“…However, increasing evidence suggests that PT (and other congener tests) poorly reflects the hemostatic balance in cirrhosis. In these patients, reduced levels of pro-coagulants are counteracted by a parallel reduction of their anti-coagulant counterparts [4]. The paradoxical prolongation of the PT, in spite of normal thrombin generation, stands to the fact that the PT is more sensitive to the reduction of procoagulants than to the reduction of anti-coagulants, especially of protein C. Protein C, which is reduced in cirrhosis, must be activated to express its full anti-coagulant activity.…”

Section: Prothrombin Timementioning

confidence: 99%

“…Because of their design, TGA approximate the in vivo coagulation balance better than conventional coagulation tests (PT/activated partial thromboplastin time [APTT]). When evaluated by TGA, patients with cirrhosis have the potential to generate as much thrombin as healthy subjects after thrombomodulin addition [1,4]. Patients with cirrhosis and relatively high levels of thrombin generation present with a hypercoagulable state in vitro [29] and may be at risk of thrombotic events.…”

Section: Thrombin Generation Assaysmentioning

confidence: 99%

“…The net effect of these changes is a rebalanced hemostasis. However, this hemostatic profile is unstable, and patients can be tipped toward both bleeding and thrombosis under certain conditions [1][2][3][4][5]. Thus, there is growing evidence that proper understanding of the hemostatic pathways in liver disease requires a global perspective which account for the complexity of hemostasis, with dynamic interactions between pro-coagulant and anti-coagulant factors.…”

Section: Introductionmentioning

confidence: 99%

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

Andriulli

Tripodi

Angeli

et al. 2016

Digestive and Liver Disease

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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.

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Section: Impact Of Portal Vein Thrombosis On the Natural History Of Cmentioning

confidence: 95%

Section: Prothrombin Timementioning

confidence: 99%

Section: Thrombin Generation Assaysmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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

Andriulli

Tripodi

Angeli

et al. 2016

Digestive and Liver Disease

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“…The INR is the most commonly used measure of coagulation in cirrhosis; however, the INR does not truly reflect coagulation in cirrhotic patients [7]. In fact, the INR was devised and validated for patients on a vitamin K antagonist [8].…”

Section: Discussionmentioning

confidence: 99%

Coagulation in chronic liver disease and the use of prothrombin complex concentrate for an emergent procedure: a case report and review of literature

Laubham

Kallwitz

2018

Journal of Community Hospital Internal Medicine Perspectives

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Synthetic dysfunction observed in cirrhosis results in altered production of procoagulants and anticoagulants that can lead to both bleeding and thrombotic events, respectively. In patients with decompensated cirrhosis, frequent hospital visits often require bedside procedures such as diagnostic paracenteses, thoracenteses and endoscopy. It can be difficult to determine at what coagulation threshold procedures can safely be performed. Currently, the most common therapies given pre-procedurally include fresh frozen plasma (FFP) and vitamin K. The effectiveness of these treatments is estimated by international normalized ratio (INR), an imprecise measure of coagulation in the setting of cirrhosis. Transfusion with FFP may lead to detrimental side effects, including worsening volume overload and increased portal hypertension. We present a case of a 60-year-old patient intubated for acute hypoxic respiratory failure secondary to volume overload who subsequently developed bilateral pneumothoraces, requiring immediate chest tube placement. In this case, the patient had ongoing hepatic decompensation with volume overload and acute worsening of coagulopathy with an INR of 4.2. In this setting, 4-Factor Prothrombin Complex Concentrate (4F-PCC) was chosen to correct coagulation parameters with a low infusion volume. One hour following administration, INR was 1.5. Chest tubes were placed bilaterally and oxygenation improved without bleeding complications. While the data is still lacking, 4F-PCC may be considered for urgent and emergency situations in cirrhotic patients.

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Balanced Coagulopathy in Cirrhosis—Clinical Implications

Roberts

Bambha²

2014

JAMA Intern Med

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The Coagulopathy of Chronic Liver Disease

Cited by 1,175 publications

References 67 publications

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

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

Coagulation in chronic liver disease and the use of prothrombin complex concentrate for an emergent procedure: a case report and review of literature

Balanced Coagulopathy in Cirrhosis—Clinical Implications

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