Bleeding Risk and Management in Interventional Procedures in Chronic Liver Disease

Abstract

The coagulopathy of liver disease is distinctly different from therapeutic anticoagulation in a patient. Despite stable elevated standard clot-based coagulation assays, nearly all patients with stable chronic liver disease (CLD) have normal or increased clotting. Common unfamiliarity with the limitations of these assays in CLD may lead to inappropriate and sometimes harmful interventions, including blood product transfusions before a procedure. Knowledge of the distinct hemostatic alterations in CLD can allow identification of the small subset of patients with clinically significant coagulopathy who can benefit from hematologic optimization before invasive procedures.

British Society of Haematology Guidelines on the spectrum of fresh frozen plasma and cryoprecipitate products: their handling and use in various patient groups in the absence of major bleeding

“…A fibrinogen level <0Á6 g/l and a platelet count of <30 9 10 9 /l were the most important predictors of bleeding (Drolz et al, 2016). The rates of spontaneous bleeding and bleeding secondary to minimally invasive procedures in patients with liver disease are both low (DeAngelis et al, 2016). However, there is variable clinical practice in the use of FFP and cryoprecipitate for prophylaxis in patients with liver disease (Desborough et al, 2016).…”

Thrombocytopenia and Procedural Prophylaxis in the Era of Thrombopoietin Receptor Agonists

“…This threshold is also supported by 2013 American Society of Hematology guidelines that suggest targets ≥50,000/μL for any patient undergoing an invasive procedure within the next 4 hours . These guidelines have recently been critiqued …”

ACVIM consensus statement on the diagnosis and treatment of chronic hepatitis in dogs

“…Assessment of bleeding risk in CH is challenging because of the liver's complex and antagonistic role in the synthesis and degradation of pro‐ and anti‐thrombotic proteins and its role in fibrinolysis . Assessment by evaluation of prothrombin time (PT), activated partial thromboplastin time (aPTT), plasma fibrinogen concentration, platelet count, or buccal mucosal bleeding time (BMBT) does not consistently predict risk of bleeding after liver biopsy in humans . In humans, there is consensus that moderate to severe prolongations in PT and aPTT (>1.5 × upper limit of normal), platelet count <50 000/μL, anemia (PCV < 30%), and low plasma fibrinogen concentration (<100 mg/dL) have some predictive ability in assessing bleeding risk and thus these variables have been incorporated into pre‐procedural standard of care guidelines …”

“…214,[230][231][232][233] Assessment by evaluation of prothrombin time (PT), activated partial thromboplastin time (aPTT), plasma fibrinogen concentration, platelet count, or buccal mucosal bleeding time (BMBT) does not consistently predict risk of bleeding after liver biopsy in humans. [234][235][236][237] In humans, there is consensus that moderate to severe prolongations in PT and aPTT (>1.5 × upper limit of normal), platelet count <50 000/μL, anemia (PCV < 30%), and low plasma fibrinogen concentration (<100 mg/dL) have some predictive ability in assessing bleeding risk and thus these variables have been incorporated into pre-procedural standard of care guidelines. [237][238][239][240] Coagulation and hematological abnormalities may exist in dogs with CH.…”

“…[234][235][236][237] In humans, there is consensus that moderate to severe prolongations in PT and aPTT (>1.5 × upper limit of normal), platelet count <50 000/μL, anemia (PCV < 30%), and low plasma fibrinogen concentration (<100 mg/dL) have some predictive ability in assessing bleeding risk and thus these variables have been incorporated into pre-procedural standard of care guidelines. [237][238][239][240] Coagulation and hematological abnormalities may exist in dogs with CH. Mild anemia develops in approximately one-third of affected dogs (Table 13) where it may reflect gastrointestinal bleeding from mucosal ulceration, coagulopathies, or anemia of chronic disease.…”