Mixed Fibrinolytic Phenotypes in Decompensated Cirrhosis and Acute‐on‐Chronic Liver Failure with Hypofibrinolysis in Those With Complications and Poor Survival

Abstract

Background and Aims Patients with liver disease acquire complex changes in their hemostatic system, which results in a fragile rebalanced status. The status of the fibrinolytic system is controversial, as is the role of fibrinolytic dysfunction in bleeding and thrombosis in patients with cirrhosis. Here, we aimed to determine fibrinolytic status and its relationship with outcome in acutely ill patients with cirrhosis. Approach and Results We assessed plasma fibrinolytic potential in a large cohort of patients with acutely decompensated cirrhosis (AD, n = 52) or acute‐on‐chronic liver failure (ACLF, n = 57). Compared with 40 healthy volunteers, median clot lysis times (CLTs) were shorter in patients with AD but comparable to controls in patients with ACLF. However, the variability in CLTs in patients was much larger than in healthy controls, and in both patient groups, a proportion of patients had clearly prolonged or shortened CLTs. The variability in CLTs in patients was not readily explained by variations in plasma levels of key fibrinolytic proteins. However, CLTs were clearly related to clinical characteristics, with longer CLTs in patients with sepsis and patients with any organ failure (as defined by the European Foundation for the Study of Chronic Liver Disease organ failure scores). CLTs were not different between patients that did or did not experience bleeding or a thrombotic event during follow‐up. Baseline CLTs were substantially longer in patients that died within 30 days of admission. Conclusions Our study demonstrates a mixed fibrinolytic phenotype in acutely ill patients with cirrhosis with baseline hypofibrinolysis associated with sepsis, organ failure, and short‐term mortality. These associations may be explained by defective clearance of intraorgan microthrombi that have been proposed to drive organ failure.

In vitro hypercoagulability and ongoing in vivo activation of coagulation and fibrinolysis in COVID‐19 patients on anticoagulation

“…Five patients had substantially elevated CLT (>100 minutes). Two of these had underlying liver disease and may have been hypofibrinolytic related to decompensating liver disease as we have described previously 20 ; the other three were all admitted to the ICU, and hypofibrinolysis is a common feature of patients that are critically ill. Viscoelastic tests have shown evidence of fibrinolytic shutdown in one‐quarter of COVID‐19 patients and fibrinolytic shutdown was associated with thrombosis 21 . However, the definition of hypofibrinolysis using viscoelastic tests is not straightforward because “no lysis” is in fact part of the reference range 22 .…”

Global hemostatic status in patients with acute‐on‐chronic liver failure and septics without underlying liver disease

“…41 In addition, a prothrombotic state (notably hypofibrinolysis) is related to organ failure and poor outcome in ACLF. 10 Therefore, interventions that improve outcome in sepsis-associated DIC may also be beneficial for patients with ACLF.…”

Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial

“…Recent research shows that acutely ill patients with cirrhosis have a mixed fibrinolytic phenotype. 17 Some have increased fibrinolysis, but others have profound hypo fibrinolysis. The prevalence of hypofibrinolysis appears to be greatest in the most critically ill patients.…”