Assessment of Bleeding Risk in Patients with Cirrhosis

Zanetto, Alberto; Senzolo, Marco; Ferrarese, Alberto; Simioni, Paolo; Burra, Patrizia; Rodríguez–Castro, Kryssia Isabel

doi:10.1007/s11901-015-0250-1

Cited by 5 publications

(4 citation statements)

References 118 publications

(113 reference statements)

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“…Reduced platelet number or function due to bone marrow suppression, the hypersplenism of portal hypertension or uraemia is counteracted by enhanced platelet-endothelial adhesion mediated by von Willebrand factor (vWF). vWF concentrations are increased and breakdown reduced in the context of impaired production of liver derived ADAMTS-13, a vWF-cleaving protease [38] . Thrombin generation is well preserved [39] and may even be enhanced in patients with liver disease compared with healthy controls [40] .…”

Section: Underlying Coagulation Incompetencementioning

confidence: 99%

Reducing transfusion requirements in liver transplantation

Donohue

Mallett

2015

WJT

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Liver transplantation (LT) was historically associated with massive blood loss and transfusion. Over the past two decades transfusion requirements have reduced dramatically and increasingly transfusionfree transplantation is a reality. Both bleeding and transfusion are associated with adverse outcomes in LT. Minimising bleeding and reducing unnecessary transfusions are therefore key goals in the perioperative period. As the understanding of the causes of bleeding has evolved so too have techniques to minimize or reduce the impact of blood loss. Surgical "piggyback" techniques, anaesthetic low central venous pressure and haemodilution strategies and the use of autologous cell salvage, point of care monitoring and targeted correction of coagulopathy, particularly through use of factor concentrates, have all contributed to declining reliance on allogenic blood products. Pre-emptive management of preoperative anaemia and adoption of more restrictive transfusion thresholds is increasingly common as patient blood management (PBM) gains momentum. Despite progress, increasing use of marginal grafts and transplantation of sicker recipients will continue to present new challenges in bleeding and transfusion management. Variation in practice across different centres and within the literature demonstrates the current lack of clear transfusion guidance. In this article we summarise the causes and predictors of bleeding and present the evidence for a variety of PBM strategies in LT. Core tip: Liver transplantation (LT) was historically associated with massive blood loss. Many factors have contributed to the decline in bleeding and transfusion in the past two decades including refinement of surgical techniques, anaesthetic management and the use of point of care guided goal-directed haemostatic therapies. Increasing awareness of the adverse associations of allogenic transfusion has driven the quest for transfusion-free transplantation. Increasing use of marginal grafts and transplantation of sicker recipients will continue to challenge perioperative care and transfusion practice. Inter-institutional variability suggests a current lack of clear guidance and limited application of the principles of patient blood management to LT.

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Section: Underlying Coagulation Incompetencementioning

confidence: 99%

Reducing transfusion requirements in liver transplantation

Donohue

Mallett

2015

WJT

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“…(17,18) As knowledge on coagulation alterations that occur in patients with cirrhosis has increased, there has been an increased interest in functional hemostatic assays such as thromboelastography (TEG). (19) By measuring the viscoelastic changes of thrombus formation that occur during the hemostatic process, TEG allows for a more global evaluation of hemostasis and realtime quantification of clot formation and stability. (20) In patients with cirrhosis who undergo invasive procedures, the use of TEG has been recently associated with a significant reduction of blood product requirements (21)(22)(23)(24)(25) ; however, the utility of TEG to estimate the risk of procedure-related bleeding remains unclear.…”

Section: Reduced Clot Stability By Thromboelastography As a Potentialmentioning

confidence: 99%

“…As knowledge on coagulation alterations that occur in patients with cirrhosis has increased, there has been an increased interest in functional hemostatic assays such as thromboelastography (TEG). ( 19 ) By measuring the viscoelastic changes of thrombus formation that occur during the hemostatic process, TEG allows for a more global evaluation of hemostasis and real‐time quantification of clot formation and stability. ( 20 )…”

mentioning

confidence: 99%

Reduced Clot Stability by Thromboelastography as a Potential Indicator of Procedure-Related Bleeding in Decompensated Cirrhosis

Zanetto

Rinder

Senzolo

et al. 2021

Hepatology Communications

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In patients with decompensated cirrhosis, procedure-related bleeding is a potentially lethal complication. Routine coagulation tests such as international normalized ratio and platelet count do not predict bleeding risk. We investigated whether thromboelastography (TEG) can identify patients with cirrhosis who are at risk of procedure-related bleeding. As a part of a prospective study on hemostasis in decompensated cirrhosis, patients had TEG performed on admission and were followed prospectively during hospitalization for the development of procedure-related bleeding. Eighty patients with cirrhosis were included. Among the 72 who had procedures performed, 7 had procedure-related bleeding, which was major in three cases (two following paracentesis and one following thoracentesis). Conventional coagulation tests were comparable between bleeding and nonbleeding patients, whereas TEG parameters of k-time (4.5 minutes vs. 2.2 minutes; P = 0.02), α-angle (34° vs. 59°; P = 0.003), and maximum amplitude (37 mm vs. 50 mm; P = 0.004) were significantly different (all indicative of hypocoagulability). TEG maximum amplitude (MA), a marker of overall clot stability, accurately discriminated between patients who had major, life-threatening bleeding (all with MA < 30 mm) and those who had mild or no bleeding (all with MA > 30 mm), whereas a platelet count < 50 × 109/L could not discriminate between bleeding (minor or major) and nonbleeding patients. Conclusion: In a prospective cohort of hospitalized patients with decompensated cirrhosis, TEG parameters associated with hypocoagulability appeared to predict procedure-related bleeding, particularly a TEG MA < 30 mm. If results are validated in a larger cohort, this could be a threshold to identify patients with decompensated cirrhosis at higher risk for procedure-related bleeding, in whom to consider preprocedural prophylaxis.

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“…What’s more, platelet quality tests include platelet aggregation rate, platelet factor 3 validity tests and blood clot retraction test (Table 2.2 ) [ 146 ].…”

Section: Laboratory Testsmentioning

confidence: 99%

Main Complications of AECHB and Severe Hepatitis B (Liver Failure)

Song

Zhu

et al. 2019

Acute Exacerbation of Chronic Hepatitis B

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This chapter describes the clinical features, and diagnosis of complications in AECHB including secondary bacterial infections, coagulation disorder, water electrolyte disorder, hepatorenal syndrome, hepatic encephalopathy, hepatopulmonary syndrome and endotoxemia Patients with severe hepatitis have impaired immunity and are therefore vulnerable to all kinds of infections. After infection, these patients may experience shock, DIC and multiple organ failure, all of which seriously affect their prognosis and are major causes of death. Concurrent infections consist primarily of infections of the lungs, intestines, biliary tract, and urinary tract, as well as spontaneous bacterial peritonitis and sepsis. Severe hepatitis may reduce the synthesis of coagulation factors and enhance their dysfunction and increase anticoagulants and platelet abnormalities, leading to coagulopathy. Infection, hepatorenal syndrome and complications can further aggravate coagulopathy, resulting in DIC and seriously affecting patient prognosis. Hepatorenal syndrome, which is characterized by renal failure, hemodynamic changes in arterial circulation and abnormalities in the endogenous vascular system, is a common clinical complication of end-stage liver disease, and one of the important indicators for the prognosis of patients with severe hepatitis. Water electrolyte disorder (water retention, hyponatremia, hypokalemia, hyperkalaemia) and acid-base imbalance are common in patients with severe hepatitis. These internal environment disorders can lead to exacerbation and complication of the illness. Hepatic encephalopathy is a neurological and psychiatric anomaly syndrome based on metabolic disorder, and an important prognostic indicator for patients with severe hepatitis. The hepatopulmonary syndrome is an important vascular complication in lungs due to systemic hypoxemia in patients with cirrhosis and portal hypertension. The majority of patients with HPS are asymptomatic. Long-term oxygen therapy remains the most frequently recommended therapy for symptoms in patients with severe hypoxemia. Endotoxemia, an important complication of severe hepatitis, is not only a second hit to the liver, but also leads to other complications including SIRS and MODS.

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Assessment of Bleeding Risk in Patients with Cirrhosis

Cited by 5 publications

References 118 publications

Reducing transfusion requirements in liver transplantation

Reducing transfusion requirements in liver transplantation

Reduced Clot Stability by Thromboelastography as a Potential Indicator of Procedure-Related Bleeding in Decompensated Cirrhosis

Main Complications of AECHB and Severe Hepatitis B (Liver Failure)

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