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

Abstract

Patients with varying degrees of hepatic dysfunction often present with presumed bleeding diathesis based on interpretation of routine measures of coagulation (prothrombin time [PT], international normalized ratio [INR], and activated partial thromboplastin time). However, standard markers of coagulation do not reflect the actual bleeding risk in this population and may lead to inappropriate administration of hemostatic agents and blood products. The concept of “rebalanced hemostasis” explains both the risk of bleeding and clotting seen in patients with liver dysfunction. The role of pharmacologic agents and blood products for prevention of bleeding during high-risk procedures and treatment of clinically significant bleeding remains unclear. Viscoelastic measurements of the clotting cascade provide information about platelets, fibrinogen/fibrin polymerization, coagulation factors, and fibrinolysis that might better represent hemostasis in vivo and may better inform management strategies. Due to the paucity of available data, firm recommendations for the use of blood products and pharmacologic agents in patients with hepatic coagulopathies are lacking, and thus, these products should not be routinely administered. Traditional laboratory tests such as PT/INR should not be the sole determinant of potential interventions. Rather, clinicians should assess factors such as the severity of bleed or bleeding risk of the procedure, the patient’s risk of thromboembolism, and the strength of available evidence for specific agents and blood products to guide decision-making.

Recombinant human thrombopoietin treatment in patients with chronic liver disease-related thrombocytopenia undergoing invasive procedures: A retrospective study

“…PLT transfusion carries the risk of PLT antibody production, which results in resistance to subsequent PLT transfusion[ 13 ]. Moreover, PLT transfusion still has potential risks[ 14 ], such as infectious diseases caused by blood transfusion, fever, allergic reactions, and hemolytic reactions. Besides, PLT transfusion has a limited effect on CLD, with PLT counts increasing by approximately 10 × 10 9 /L after transfusion[ 15 , 16 ], while PLT transfusion can increase PLT count by 30 × 10 9 /L in healthy patients[ 17 ].…”

Individualized Management of Coagulopathy in Patients with End-Stage Liver Disease

“…Summing up, it can be stated that taking the studies published so far into consideration, a restrictive coagulation management in ESLD patients is warranted as long as patients are not actively bleeding [ 79 ].…”

Thrombocytopenia in Chronic Liver Disease: Challenges and Treatment Strategies

“…While studies have shown that a progressive decline in liver function does directly correlate to a lower platelet count, there are no formal guidelines for indicators of disease severity [6]. However, since individuals with cirrhosis or chronic liver disease often require frequent interventions or medications, those with severe thrombocytopenia are often associated with poorer prognosis due to delay to treatment [4,7,8].…”

“…While it is common practice to monitor platelet levels and intervene prior to planned treatments or procedures, these are not formally indicated but rather more clinician-based [2,8]. Harrison explored further the concept of reliable monitoring, finding no strong evidence towards the predictability of monitoring coagulation tests and bleeding risk; monitoring is often associated with increased prophylactic management in unnecessary cases [7].…”

“…The gold standard for management of thrombocytopenia has been widely accepted as platelet transfusions. However, with this treatment comes many disadvantages and unclear beneficial effects that are steering clinicians away from its frequent use [8]. Currently, no clear guidelines exist for cutoffs regarding prophylactic transfusions.…”