Thromboelastographic Evaluation of Coagulation in Patients With Liver Disease

Shin, Kyung‐Hwa; Kim, In Suk; Lee, Hyunji; Kim, Hyung Hoi; Chang, Chulhun L.; Hong, Young Mi; Yoon, Ki Tae; Cho, Mong

doi:10.3343/alm.2017.37.3.204

Cited by 41 publications

(25 citation statements)

References 34 publications

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“…There have been only two previous studies examining the association between R-time and INR. 13,14 These investigators did not find a significant association between these variables, which is congruent with our results. The INR was originally introduced to monitor the effect of warfarin on the vitamin K-dependent clotting factor.s 3,6 Over the years, this test has evolved to be used as an assessment of the synthetic function of the liver, and it has been assumed that this also correlates with the coagulation status.…”

Section: Discussionsupporting

confidence: 92%

“…12 Another recent study using the TEG showed hypocoagulability in patients with cirrhotic liver disease. 13 This contrasts with previous studies and highlights the complexity of liver disease, and the fact that different liver pathologies may have a significant impact on the coagulation profile. The majority of our patients had drug/toxin and Hepatitis B-induced liver injury, which may have resulted in a differing coagulation profile from those with alcoholic liver cirrhosis or biliary cirrhosis, which have been more extensively researched internationally.…”

Section: Discussionmentioning

confidence: 57%

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Thromboelastography in mild, chronic liver disease: challenging conventional coagulation tests preceding liver biopsy

Veronese

Miller

Spearman

2018

Southern African Journal of Anaesthesia and Analgesia

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Patients presenting for liver biopsy may have a deficiency of the synthetic function of the liver. They commonly undergo testing of their INR, which is used to decide if there may be a bleeding risk and if that needs to be mitigated by the administration of clotting factors. This study aimed to observe the coagulation profile of these patients via a thromboelastogram (TEG), and to search for a relationship between the traditionally used INR and the R-time of the TEG. A prospective observational pilot study was conducted over a seven-month period. An FBC, INR and kaolin activated thromboelastogram were performed on each patient. Spearman's correlation coefficient was used to determine the relationship between the INR and the R-time of the TEG. The TEG was performed on 28 participants. Two were excluded from analysis as they had received Vitamin K. Twenty-three patients (88%) had abnormal liver function tests. Drug or toxins were responsible for liver injury in 15 (58%) participants. Twenty-two (85%) had normal platelet counts. Three (12%) were found to be hypocoagulable, four (15%) were hypercoagulable, and the remaining 19 (73%) had normal thromboelastography. The three (12%) participants who were hypocoagulable had a normal platelet count. No association was found between INR and the R-time of TEG (Spearman's rho −0.20, p = 0.34). In the two participants (8%) with a raised INR (1.26 and 1.7 respectively), the TEG suggested a normal or hypercoagulable status. This study revealed that most patients with mild, chronic liver disease presenting for liver biopsy have a normal TEG. There was no association between INR and the R-time of the TEG. This suggests that INR may not be a reliable test of coagulation status in these patients with mild chronic liver disease, which is contrary to the traditional practice of using INR to infer coagulation status. Further larger studies looking specifically at patients with drug and toxin induced liver injury are warranted.

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Section: Discussionsupporting

confidence: 92%

Section: Discussionmentioning

confidence: 57%

Thromboelastography in mild, chronic liver disease: challenging conventional coagulation tests preceding liver biopsy

Veronese

Miller

Spearman

2018

Southern African Journal of Anaesthesia and Analgesia

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“…Platelet count was found to be altered in 52.2% cases while it was normal in 47.8% cases. These findings were similar to that observed by Varnika Rai et al [4] , Kyung-Hwa Shin et al [7] and Andreas Drolz et al [6] .…”

Section: Discussionsupporting

confidence: 82%

“…PT was found to be altered in 71.3% cases of cirrhosis while it was normal in 28.7% cases which is similar to that observed by Jaeyoung Cho et al [5] , Sohail Ahmed Siddiqui et al [3] and KyungHwa Shin et al [7] . APTT was found to be altered in 81.7% cases while it was normal in 18.3% cases.…”

Section: Discussionsupporting

confidence: 79%

Study of coagulation profile in hepatic disorders in a Tertiary Care Centre

Ozukum¹

2018

jmscr

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“…Ben-Ari et al [31] found that 28% of patients with PBC and 43% of patients with PSC were hypercoagulable compared with only 5% of noncholestatic cirrhosis patients and none in the healthy controls. In this study, two of 17 patients with PBC were in a hypocoagulable state, and none of the patients with PBC was in a hypercoagulable state.…”

Section: Discussionmentioning

confidence: 99%

Thromboelastographic Evaluation of Coagulation in Patients with Liver Disease

Shin

Kim

2015

Blood

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Background: Patients with acute and chronic liver disease have long been assumed to have a bleeding tendency on the basis of abnormal results for standard tests of hemostasis. The concept that patients with liver disease are at an increased risk of bleeding, based solely on abnormalities of conventional coagulation tests such as prothrombin time (PT) and international normalized ratio (INR), is now recognized to be an overly simplistic interpretation of an extremely complex situation. Thromboelastography (TEG) is a commercially available, rapid, point-of-care whole blood viscoelastic assay that assesses the kinetics of coagulation from initial clot formation to final clot strength in whole blood, including plasmatic and cellular components. The aim of this study was to compare TEG citrated whole blood coagulation parameters and conventional coagulation parameters in liver disease patients and in healthy controls. Methods: Between January and July 2015, we investigated citrated blood samples from 35 healthy controls and 171 adult patients with liver disease who were divided into two groups of hepatitis group (including patients with acute and chronic hepatitis) and liver cirrhosis group (including patients with liver cirrhosis with or without hepatocellular carcinoma). The parameters of clot formation, which were R (reaction time, a measure of initial fibrin formation), K (constant, indicative of clot formation time), a (angle, indicative of the rapidity of fibrin cross-linking), MA (maximal amplitude, indicative of overall clot firmness) were measured with activator, kaolin, by using TEG 5000 system (Haemonetics Corporation, USA) and CI (Coagulation Index) was derived from the R, K, α and MA. Hemoglobin, platelet count, creatinine, total bilirubin and PT INR was simultaneously measured. MELD (The Model for End-Stage Liver Disease) score for assessing the severity of liver disease was calculated by creatinine, bilirubin and PT INR. Results: A total 206 cases, 53 patients with hepatitis group, 118 patients with liver cirrhosis group, and 35 patients with control group, was enrolled. In the liver cirrhosis group, all of parameters of TEG and hemoglobin showed significant difference with those of control group. In the hepatitis group, only R time and platelet count were significant different from that of the control group. There were significant differences of all parameter, except R time, between hepatitis group and liver cirrhosis group. According to etiology, PT-INR, MELD score, platelet count, K, angle, MA, CI of autoimmune liver disease were different form liver disease of viral and other cause. All parameter of TEG were statistically significantly correlated with the number of platelets and PT INR and MELD score (Table 1). Table 1. Correlation coefficients and P value among the parameters of thromboelastography, PT INR, platelets, and MELD scoreTable 1.PT INRPlateletsMELD scoreReaction Time (R)0.247(<0.001)-0.286(<0.001)0.157(<0.01)Constant (K)0.296(<0.001)-0.567(<0.001)0.219(<0.001)Angle (α)-0.293(<0.001)0.613(<0.001)-0.206(<0.001)Maximal Amplitude (MA)-0.348(<0.001)0.719(<0.001)-0.287(<0.001)Coagulation Index (CI)-0.364(<0.001)0.672(<0.001)-0.275(<0.001) Conclusion: The patients with liver disease with high MELD score, elevated PT INR, and thrombocytopenia demonstrated the trend to hypocoagulability and hyperfibrinolysis using TEG. TEG is considered as an additional test for investigating liver disease and predicting the prognosis in this category of patients. Disclosures No relevant conflicts of interest to declare.

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Thromboelastographic Evaluation of Coagulation in Patients With Liver Disease

Cited by 41 publications

References 34 publications

Thromboelastography in mild, chronic liver disease: challenging conventional coagulation tests preceding liver biopsy

Thromboelastography in mild, chronic liver disease: challenging conventional coagulation tests preceding liver biopsy

Study of coagulation profile in hepatic disorders in a Tertiary Care Centre

Thromboelastographic Evaluation of Coagulation in Patients with Liver Disease

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