How do we transfuse blood components in cirrhotic patients undergoing gastrointestinal procedures?

Abstract

The liver plays a pivotal role in hemostasis. Consequently, patients with cirrhosis frequently demonstrate abnormal coagulation profiles on routine laboratory tests. These tests mainly reflect decreased procoagulant proteins. However, in cirrhosis, complex changes also occur in anticoagulant and fibrinolytic pathways. Recent evidence demonstrates that patients with cirrhosis exist in a state of hemostatic rebalance. Accordingly, routine tests inadequately represent hemostatic alterations in these patients. Unfortunately, these tests are regularly used to guide the transfusion of blood components with the assumption that they will correct laboratory abnormalities and improve hemostasis in a bleeding patient or prevent excessive bleeding following a procedure. With an absence of both accurate laboratory testing to assess hemostasis and evidence-based guidelines to direct the transfusion of blood components, management of patients with cirrhosis poses a significant challenge to clinicians. Therefore, we developed multidisciplinary guidelines for the periprocedural transfusion of blood components in patients with cirrhosis based on concurrent evidence and personal experience at our medical center.

The Risk of Endoscopy-Related Bleeding in Patients with Liver Cirrhosis: A Retrospective Study

“…The liver is an important hematologic organ that synthesizes or eliminates several factors related to hemostasis and thrombosis. Patients with liver cirrhosis are prone to coagulopathy due to increased portal pressure and dysfunction of coagulation factors [ 27 , 28 , 29 ]. This makes liver specialists and endoscopists cautious when performing invasive procedures in patients with cirrhosis.…”

“…Therefore, it is challenging to accurately predict the clotting status of patients with cirrhosis simply using the prothrombin time and platelet count [ 27 , 28 , 29 ]. Our study showed no difference in bleeding risk according to commonly used laboratory results, including platelet count and prothrombin time.…”

Management of Hepatic Coagulopathy in Bleeding and Nonbleeding Patients: An Evidence-Based Review

“…An additional concern with administering plasma is the increased risk for rebleeding due to the increased intravascular pressure caused by the volume transfused, particularly among patients with advanced portal hypertension and esophageal varices. 44,81 –85 During the perioperative period in liver transplant recipients, transfusion of any plasma or >4 U packed red bold cells (PRBCs) 86 or platelets 87 is associated with decreased short-term transplant survival.…”

“…43 Blood product transfusions are associated with transfusion-transmitted infections, febrile and allergic reactions, transfusion-associated circulatory overload, transfusion-related acute lung injury, and elevated portal pressures in patients with cirrhosis. 44,81 –85…”

Adverse transfusion reactions in patients with liver disease

“…Patients with severe liver disease have a greater risk of bleeding. In cases involving gastrointestinal bleeding, coagulopathies (Tripodi & Mannucci, 2011), gastrointestinal procedures (Yates et al, 2016) or liver transplantation (Choi et al, 2016), transfusions are often needed, and adverse transfusion reactions (AR) may occur in these recipients.…”