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Coagulopathy in Liver Disease

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Coagulopathy in Liver Disease Gulara&Hajiyeva,&MD 1ThrombinDActivatable'Fibrinolysis'Inhibitor'Deficiency'in'Cirrhosis'Is'Not'Associated'With'Increased'Plasma'Fibrinolysis'Lisman et'al,'Gastroenterology'2001 2Intact'thrombin'generation'and'decreased'fibrinolytic'capacity'in'patients'with'acute'liver'injury'or'acute'liver'failure,'Lisman et'al,'Journal'of' Thrombosis'and'Haemostasis 2012'10;'1312D9 Rebalanced)Coagulation)in)Chronic)Liver)Disease • Basic&laboratory&tests&PT/PTT&correlate&poorly&with&bleeding&from&various& invasive&procedures&or&gastrointestinal&hemorrhage • Fresh&frozen&plasma&administration&does&not&prevent&or&minimize& procedural&bleeding • Elevated&PT/INR&in&patients&with&liver&cirrhosis&does&not&mean&&“autoBanticoagulation” A. Start'the'patient'on'furosemide'and'spironolactone B. Transfuse'2'units'of'FFPs,'then'perform'paracentesis C. Perform'diagnostic'and'therapeutic'paracentesis D. Transfuse'one'unit'of'platelets,'then'perform'paracentesis Bleeding(After(Liver(Biopsy Bleeding(After(Liver(Biopsy(Does(not(Correlate(with(Indices(of(Peripheral(Coagulation.((Ewe(K.((May(1981( Large&Volume&Paracentesis&in&Coagulopathy Grabau&M&et&al&Hepatology&2004;&40:&484@488 Central(Venous(Catheterization(in(Patients(With(Coagulopathy(Foster(et(al(JAMA(Surgery(March(1992 Central(Venous(Cannulation(in(Patients(with(Liver(Disease(and(Coagulopathy(– A(Prospective(Audit,(Fisher(et(al,(Intensive(Care(Medicine(May(1999 Bleeding(After(Invasive(Procedures(is(Rare(and(Unpredicted(by(Platelet(Counts(in(Cirrhotic(Patients(with(Thrombocytopenia(Napolitano(et(al,(European(Journal(of( Internal(Medicine,(December(2016( What'Do'the'Guidelines'Say? • Because'bleeding'is'sufficiently'uncommon,'the'routine'prophylactic'use'of'fresh'frozen'plasma'or' platelets'before'paracentesis'is'not'recommended by'AASLD • Uptodate recommends'against'transfusion'based'on'INR,'rather'use'the'value'as'prognostic'marker.'Also' recommends'PLT'>50H55'for'active,'severe'or'central'nervous'system'bleeding • Platelet'transfusion'should'be'considered'when'levels'are'less'than'50,000H60,000/mL'for'transcutaneous' or'transvenous liver'biopsy. The'use'of'prophylactic'or'rescue'strategies'such'as'plasma,'fibrinolysis' inhibitors,'or'recombinant'factors'should'be'considered'in'specific'situations,'although'their'effectiveness' remains'to'be'established'H AASLD • More'and'more'centers'report'transfusionHfree'liver'transplantation'in'a'substantial'proportion'of' patients'* *Transfusion'Rate'for'500'Consecutive'Liver'Transplantations:'Experience'of'One'Liver'Transplantation'Center,'Massicotte et'al,' Transplantation'June'2012 A. Knee&high&sequential&compression&device B. Subcutaneous&heparin&5000&Units&twice&daily C. Subcutaneous&enoxaparin&40&mg&daily D. Graduated&compression&stockings Risk%of%%Venous%Thromboembolism%in%Patients%with%Liver%Disease:%A%Nationwide%Population%Based%Case%Control%Study%Sogaard et%al%%The%AmeriCan%Journal%of Gastroenterology%Jan%2009 The$Risk$of$Venous$Thromboembolism$in$Patients$with$Cirrhosis,$Ambrosino et$al,$Thrombosis$and$Hemostasis$Issue$1$2017$ Effects'of'Anticoagulants'in'Patients'With'Cirrhosis'and'Portal'Vein'Thrombosis:'A'Systematic'Review'and'MetaAanalysis'L.'Loffredo et'al''Gastroenterology'August'2017 *Transfusion+related0Acute0Lung0Injury0in0ICU0Patients0Admitted0with0Gastrointestinal0Bleeding,0Benson0et0al00Intensive0Care0Medicine, July02010 • Aminocaproic acid+or+tranexamic+acid+in+ hyperfibrinolysis • Desmopressin+in+uremia • Prothrombin+complex+concentrate • Fibrinogen+concentrate .
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