Periprocedural management of abnormal coagulation parameters and thrombocytopenia in patients with cirrhosis: Guidance from the SSC of the ISTH

Abstract

Prolonged prothrombin time and thrombocytopenia are common in patients with cirrhosis. These parameters do not reflect the overall hemostatic rebalance or bleeding risk in the periprocedural setting; however, attempts to correct these parameters remain frequent. We review the literature on periprocedural bleeding risk, bleeding risk factors, and the risk and benefits of hemostatic interventions in patients with cirrhosis. We provide guidance recommendations on evaluating bleeding risk in this patient group and management of hemostatic abnormalities in the periprocedural setting.

Global hemostatic profiling in patients with decompensated cirrhosis and bacterial infections

“…Although patients with cirrhosis and bacterial infections may be at increased risk of procedure-related bleeding, [5] , [6] , [7] the hemostatic factors eventually responsible for this bleeding tendency have not yet been thoroughly investigated.…”

“…As alterations of platelet aggregation may result in increased bleeding, our results lend support to a possible association between bacterial infections and bleeding complications in hospitalized patients with cirrhosis. [5] , [6] , [7] …”

“…increased von Willebrand factor, reduced levels of anticoagulants). [5] , [6] , [7] However, this rebalanced equilibrium is particularly susceptible to destabilizing factors and easily tilts towards either hypo-coagulability (increased risk of bleeding) or hyper-coagulability (increased risk of thrombosis). [5] , [6] , [7] For instance, recent studies have demonstrated that the development of acute kidney injury (AKI) in hospitalized patients with decompensated cirrhosis is associated with platelet dysfunction 8 and low levels of fibrin-stabilizing factor XIII, 8 , 9 which may explain the bleeding tendency in patients who undergo paracentesis in the presence of AKI.…”

“…Recent international guidelines recommend screening and treatment of bacterial infections in patients with cirrhosis undergoing procedures. [5] , [6] , [7] Unlike AKI-related bleeding, [8] , [9] , [10] however, the hemostatic factors potentially involved in the purported increased risk of procedure-related bleeding in patients with decompensated cirrhosis and infections have not yet been investigated. 17 Indeed, it is currently unclear whether alterations of hemostasis are truly responsible for the bleeding tendency of these patients.…”

The international normalized ratio – Great for prediction of bleeding in patients taking vitamin K antagonists, useless for prediction of bleeding in patients with chronic liver disease

“…2,3 Indeed, recent guidelines of the main international gastroenterological, hepatological, and hemostasis scientific societies strongly discouraged the correction of INR before invasive procedures due to the absence of a correlation between INR values and the risk of post-procedural bleeding. [4][5][6][7][8] However, these guidelines are not necessarily adopted in day-to-day clinical practice. Recent surveys showed that many clinicians in fact do use the INR to predict bleeding risk and that correction of the INR with the aim of reducing bleeding risk is still common.…”