Relevance of clotting tests in liver disease

Abstract

Liver disease is associated with impairment of the haemostatic function due to the abnormal and decreased synthesis of the clotting factors. It is thus only logical to have considered assessment of the clotting profile (to include prothrombin time (PT) and activated partial thromboplastin time (aPTT)) to be an integral part of the comprehensive assessment of a patient who presents with liver impairment. Laboratory abnormalities of coagulation are considered to be a predictive risk factor for bleeding, but patients with liver disease do not have bleeding pattern as those who have coagulation factor deficiencies. Recent experiments have cast doubts over the use of PT and aPTT as a marker of bleeding in liver disease and the use of such tests to decide the need for plasma replacement before interventions like liver biopsy. This article reviews the relevance of the clotting profile in liver disease, the other factors involved in the haemostatic failure associated with it, and the technical problems in the interpretation of these results. Most importantly, it stresses the need for more trials to help us guide the management of bleeding in patients with liver impairment.

Non‐alcoholic fatty liver disease is associated with cardiovascular disease risk markers

“…Many coagulation factors are synthesized by HCs (56,57). The limited data on the association between obesityindependent markers of NAFLD, among others coagulation factors, has recently been reviewed by Kotronen and Yki-Jarvinen (45).…”

“…This may suggest that initially increased factors will decrease while NAS progresses to advanced NASH. In advanced liver disease, bleeding problems are well known to occur (56,57).…”

Dispelling myths about coagulation abnormalities in internal medicine

“…It has always been taught in medical schools that these patients are 'auto-anticoagulated' because their PT and APTT are often prolonged. 22 It is no surprise that these tests are abnormal because the liver is the main organ for the synthesis of coagulation factors. However, in the same way, the liver also synthesizes all the endogenous coagulation inhibitors that exist in the circulation to regulate the clotting process.…”

Bleeding and Clotting Disorders in Pediatric Liver Disease

“…24,28,29 Platelet procoagulant activity as assessed in thrombin-generation assays in plateletrich plasma is fully preserved in patients with cirrhosis. 12 Clinical data on the most relevant bleeding problem in adult patients with cirrhosis, bleeding from esophageal varices, show that it is a consequence of local vascular abnormalities and increased splanchnic blood pressure, and the role of abnormal hemostasis is questionable.…”

“…There are no current tests that will allow the practitioner to confidently predict that a patient is not likely to have serious bleeding despite an abnormal bleeding test. 29 Thromboelastography (TEG) is a global test of hemostasis that measures the torque exerted on a pin immersed in whole blood in the middle of a rotating cylindrical vessel. This allows measurement of platelet interaction with fibrin and subsequent weakening of these interactions as fibrinolysis occurs.…”