Bleeding after invasive procedures is rare and unpredicted by platelet counts in cirrhotic patients with thrombocytopenia

Napolitano, G.; Iacobellis, A.; Merla, Antonio; Niro, Grazia; Valvano, Maria Rosa; Terracciano, Fulvia; Siena, D.; Caruso, Mariangela; Ippolito, A.; Mannuccio, Pier; Andriulli, Angelo

doi:10.1016/j.ejim.2016.11.007

Cited by 100 publications

(95 citation statements)

References 20 publications

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“…Elevation of the platelet count was associated with an increased risk of thrombosis, which may be attributable to the high VWF levels, although alternative explanations for the thrombotic risk of thrombopoietin receptor agonists in these patients cannot be excluded. On the other hand, it has been suggested that thrombocytopenia (and not prolonged routine coagulation tests) increase the risk for procedure‐associated bleeding, although not all studies agree …”

Section: Rebalanced Hemostasis In Liver Diseasesmentioning

confidence: 99%

“…Although some investigators argue that a correction of the platelet count may be helpful in preventing bleeding in high risk procedures, clinical data substantiating this are lacking. It is even debated whether a low preprocedural platelet count increases procedural bleeding risk . Nevertheless, preprocedural administration of platelet concentrates are still common, and thrombopoietin receptor agonists have been tested in clinical trials and are considered as potential alternatives for platelet transfusions, although they may be associated with an risk for thrombotic events .…”

Section: Prevention and Management Of Bleeding In Liver Diseasesmentioning

confidence: 99%

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Pathogenesis, prevention, and management of bleeding and thrombosis in patients with liver diseases

Lisman

Porte

2017

Research and Practice in Thrombosis and Haemostasis

111

129

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Essentials Patients with liver diseases may acquire substantial changes in all components of hemostasis.Hemostasis is in unstable balance due to simultaneous changes in pro‐ and antihemostatic systems.Intrahepatic activation of hemostasis may contribute to disease progression.Optimal strategies for prevention and treatment of bleeding and thrombosis are currently unknown. Patients with liver diseases may develop alterations in all components of the hemostatic system. Thrombocytopenia, low levels of coagulation factors and inhibitors, low levels of fibrinolytic proteins, and increased levels of endothelial‐derived proteins such as von Willebrand factor are all part of the coagulopathy of liver disease. Due to concomitant changes in pro‐ and antihemostatic drivers, the net effects of these complex hemostatic changes have long been unclear. According to current concepts, the hemostatic system of patients with liver disease is in an unstable balance, which explains the occurrence of both bleeding and thrombotic complications. This review will discuss etiology and management of bleeding and thrombosis in liver disease and will outline unsolved clinical questions. In addition, we will discuss the role of intrahepatic activation of coagulation for progression of liver disease, a novel paradigm with potential consequences for the general management of patients with liver disease.

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Section: Rebalanced Hemostasis In Liver Diseasesmentioning

confidence: 99%

Section: Prevention and Management Of Bleeding In Liver Diseasesmentioning

confidence: 99%

Pathogenesis, prevention, and management of bleeding and thrombosis in patients with liver diseases

Lisman

Porte

2017

Research and Practice in Thrombosis and Haemostasis

111

129

View full text Add to dashboard Cite

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“…[2][3][4] The overall risk of clinically significant bleeding after invasive procedures is 0.70% in patients with liver cirrhosis, 5 reaching up to 2.75% in some series. 6 In patients with cirrhosis submitted to CVC, minor bleeding varies from 11.8% to 13% for oozing and 10.3% to 31.5% for local hematoma. 7,8 However, major bleeding is rare.…”

Section: Introductionmentioning

confidence: 99%

Comparison of three transfusion protocols prior to central venous catheterization in patients with cirrhosis: A randomized controlled trial

Rocha

Neto

Pessoa

et al. 2020

Journal of Thrombosis and Haemostasis

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Background Transfusion of blood components prior to invasive procedures in cirrhosis patients is high and associated with adverse events. Objectives We compared three transfusion strategies prior to central venous catheterization in cirrhosis patients. Patients/Methods Single center randomized trial that included critically ill cirrhosis patients with indication for central venous line in a tertiary private hospital in Brazil. Interventions: Restrictive protocol, thromboelastometry‐guided protocol, or usual care (based on coagulogram). The primary endpoint was the proportion of patients transfused with any blood component (ie, fresh frozen plasma, platelets, or cryoprecipitate). The secondary endpoints included incidence of bleeding and transfusion‐related adverse events. Results A total of 57 patients (19 per group; 64.9% male; mean age, 53.4 ± 11.3 years) were enrolled. Prior to catheterization, 3/19 (15.8%) in the restrictive arm, 13/19 (68.4%) in the thromboelastometry‐guided arm, and 14/19 (73.7%) in the coagulogram‐guided arm received blood transfusion (odds ratio [OR], 0.07; 95% confidence interval [CI], 0.01‐0.45; P = .002 for restrictive versus coagulogram‐guided arm; OR, 0.09; 95% CI, 0.01‐0.56; P = .006 for restrictive versus thromboelastometry‐guided arm; and OR, 0.77; 95% CI, 0.14‐4.15; P = .931 for thromboelastometry‐guided versus coagulogram‐guided arm). The restrictive protocol was cost saving. No difference in bleeding, length of stay, mortality, and transfusion‐related adverse events was found. Conclusions The use of a restrictive strategy is associated with a reduction in transfusion prior to central venous catheterization and costs in critically ill cirrhosis patients. No effect on bleeding was found among the groups.

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“…This supports the clinical observation that post‐transfusion platelet counts are generally not increased, and patients can receive numerous transfusions due to the inability to achieve a certain platelet threshold. A recent observational study reported a series of 862 invasive procedures in 363 patients with cirrhosis . Decisions on platelet or fresh‐frozen plasma transfusions were made by the attending physician, and marginal improvements in platelet count and prothrombin time were observed with transfusions.…”

mentioning

confidence: 99%

Editorial: platelet transfusions in cirrhosis—do the risks outweigh the unclear benefits?

Patel

Muir

2018

Aliment Pharmacol Ther

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Bleeding after invasive procedures is rare and unpredicted by platelet counts in cirrhotic patients with thrombocytopenia

Cited by 100 publications

References 20 publications

Pathogenesis, prevention, and management of bleeding and thrombosis in patients with liver diseases

Pathogenesis, prevention, and management of bleeding and thrombosis in patients with liver diseases

Comparison of three transfusion protocols prior to central venous catheterization in patients with cirrhosis: A randomized controlled trial

Editorial: platelet transfusions in cirrhosis—do the risks outweigh the unclear benefits?

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