Cirrhosis patients have a coagulopathy that is associated with decreased clot formation capacity

Kleinegris, Marie-Claire; Bos, Mettine H.A.; Roest, Mark; Henskens, Yvonne; Cate‐Hoek, Arina J. ten; Deursen, C. van; Spronk, Henri M. H.; Reitsma, P. H.; Groot, Philip G. de; Cate, Hugo Ten; Koek, Ger H.

doi:10.1111/jth.12706

Cited by 70 publications

(69 citation statements)

References 25 publications

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“…25 However, increased severity of cirrhosis was associated with ROTEM evidence of decreased velocity of clot formation, delayed clot formation time, and reduced maximum clot strength. 26 TEG may have clinical utility for evaluating the severity of coagulopathy and risk of bleeding in chronic liver disease. Cirrhotic patients with active variceal bleeding who experienced early re-bleeding had significantly more hypocoagulable TEG parameters than those who did not.…”

Section: Global Tests Of Hemostasismentioning

confidence: 99%

Coagulopathy in liver disease: a balancing act

Kujovich

2015

Hematology

114

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Liver disease results in complex alterations of all 3 phases of hemostasis. It is now recognized that hemostasis is rebalanced in chronic liver disease. The fall in clotting factor levels is accompanied by a parallel fall in anticoagulant proteins. High von Willebrand factor levels counteract defects in primary hemostasis. Conventional coagulation tests do not fully reflect the derangement in hemostasis and do not accurately predict the risk of bleeding. Global coagulation assays (thrombin generation, thromboelastography) reflect the interaction between procoagulant factors, anticoagulant factors, platelets, and the fibrinolytic system and show promise for assessing bleeding risk and guiding therapy. These assays are not yet commercially approved or validated. Prevention of bleeding should not be aimed at correcting conventional coagulation tests. Thrombopoietin receptor agonists were shown to increase the platelet count in cirrhotic patients undergoing invasive procedures

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Section: Global Tests Of Hemostasismentioning

confidence: 99%

Coagulopathy in liver disease: a balancing act

Kujovich

2015

Hematology

114

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Section: Coagulopathymentioning

confidence: 99%

“…Thrombocytopenia due to poor nutritional status, hypersplenism and/or bleeding from varices may exacerbate bleeding problems [27,28] . Myelosuppression due to hepatitis C, folate deficiency, and ethanol toxicity can also aggravate thrombopoietin deficiency [27] . However, primary homeostasis may not be defective in LC, and a low platelet count, if not severe, should not be automatically considered as an index of an increased risk of bleeding [29] .…”

Section: Coagulopathymentioning

confidence: 99%

Outcomes of abdominal surgery in patients with liver cirrhosis

López-Delgado

Ballús

Esteve

et al. 2016

WJG

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Patients suffering from liver cirrhosis (LC) frequently require non-hepatic abdominal surgery, even before liver transplantation. LC is an important risk factor itself for surgery, due to the higher than average associated morbidity and mortality. This high surgical risk occurs because of the pathophysiology of liver disease itself and to the presence of contributing factors, such as coagulopathy, poor nutritional status, adaptive immune dysfunction, cirrhotic cardiomyopathy, and renal and pulmonary dysfunction, which all lead to poor outcomes. Careful evaluation of these factors and the degree of liver disease can help to reduce the development of complications both during and after abdominal surgery. In the emergency setting, with the presence of decompensated LC, alcoholic hepatitis, severe/advanced LC, and significant extrahepatic organ dysfunction conservative management is preferred. A multidisciplinary, individualized, and s p e c i a l i z e d a p p r o a c h c a n i m p r o v e o u t c o m e s ; preoperative optimization after risk stratification and careful management are mandatory before surgery. Laparoscopic techniques can also improve outcomes. We review the impact of LC on surgical outcome in non-hepatic abdominal surgeries required in this cirrhotic population before, during, and after surgery.Key words: Liver cirrhosis; Outcomes; Coagulopathy; Nutritional status; Abdominal surgery; Adaptive levels of expertise of the surgeons, anesthetists, and intensive care unit (ICU) staff. Liver function is usually assessed by the Child-Turcott-Pugh (CTP) and Model for End-Stage Liver Disease (MELD) scores [11] . Early studies found 30 d mortality rates after surgery were 10% in CTP-A, 30% in CTP-B, and 76%-82% in CTP-C, figures that have not significantly changed in more recent assessments [12,13] . Despite the poor results, advances in the medical management of LC and life expectancy have increased the eligibility of these patients for abdominal surgery [14] . To be able to give definitive recommendations and indications for non-hepatic abdominal surgery in the cirrhotic population, it is important to identify the patients most likely to benefit from it. There is also a need to assess contemporary surgical techniques and the various scoring systems currently in use.This review summarizes the outcomes of patients with LC undergoing non-hepatic abdominal surgery. Indexed articles in Medline of series of patients with LC who underwent non-hepatic abdominal surgery between 1950 and March 2014 were reviewed using the OVID interface. We aimed to select manuscripts addressing outcome based on the degree of LC assessed with MELD and/or CTP scores. Articles addressing the pathophysiology of cirrhotic patients and the clinical implications in non-hepatic abdominal surgery were selected based on their importance, their date of publication, and the citations of the manuscripts. As for articles describing the different types of surgery in LC patients, the most recent publications were selected in order to preser...

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“…An improvement in anaemia to at least 30% of haematocrit [54] improves platelet adhesion because more red blood cells push platelets and leucocytes from the axial centre toward the periphery, thereby enhancing cell contact with the vessel wall and formation of the primary haemostatic clot lysis [38] . A good correlation has been found in these patients between platelet count and MCF (r = 0.691) and a reasonably good correlation between Clauss fibrinogen and MCF (r = 0.590) [39] .…”

Section: Coexisting Factors/conditionsmentioning

confidence: 99%

Coagulopathy in liver disease: Lack of an assessment tool

Blasi

2015

WJG

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There is a discrepancy between the information from clotting tests which have routinely been used in clinical practice and evidence regarding thrombotic and bleeding events in patients with liver disease. This discrepancy leads us to rely on other variables which have been shown to be involved in haemostasis in these patients and/or to extrapolate the behaviour of these patients to other settings in order to decide the best clinical approach. The aims of the present review are as follows: (1) to present the information provided by clotting tests in cirrhotic patients; (2) to present the factors that may influence clotting in these patients; (3) to review the clinical evidence; and (4) to put forward a clinical approach based on the first 3 points.

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Cirrhosis patients have a coagulopathy that is associated with decreased clot formation capacity

Cited by 70 publications

References 25 publications

Coagulopathy in liver disease: a balancing act

Coagulopathy in liver disease: a balancing act

Outcomes of abdominal surgery in patients with liver cirrhosis

Coagulopathy in liver disease: Lack of an assessment tool

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