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Surgical Procedures on the Cirrhotic Patient pp 19–28Cite as

Coagulopathy in Cirrhosis

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Abstract

The liver plays an integral role in hemostasis and is responsible for the synthesis of the majority of procoagulant, anticoagulant, and fibrinolytic proteins. Liver dysfunction disrupts this process, altering the normal hemostatic balance. Historically, liver disease was felt to represent a bleeding diathesis. More recently, evidence supports a model of rebalanced hemostasis where concomitant prohemostatic and antihemostatic changes lead to a rebalancing of the hemostatic system; however, this balance is far more unstable compared to healthy individuals and is easily shifted in either direction. Unfortunately, no one test can accurately predict the risk of bleeding or thrombosis in liver disease. The prothrombin and activation partial thromboplastin times, platelet count, and fibrinogen are commonly used tests, but they assess only a single aspect of the hemostatic system, which is not ideal in chronic liver disease. Global tests of hemostasis, such as thromboelastography, represent a method of measuring whole-blood coagulation. A variety of options are available for the treatment and prevention of bleeding and thrombosis in chronic liver disease. Bleeding is often treated with red blood cells, platelets, fresh frozen plasma, and cryoprecipitate. Recombinant factor VIIa and prothrombin complex concentrates should be reserved for refractory, or life-threatening bleeding. Portal venous thrombosis is the most common thrombotic event in liver disease, and whether or not treatment is necessary is often unclear. Furthermore, deciding which anticoagulant to use can be difficult. Interpreting normal measures of anticoagulation, such as INR and anti-Xa levels, is often problematic in chronic liver disease. Last, accumulating evidence supports thromboprophylaxis in hospitalized patients with chronic liver disease due to an increased risk of thrombosis.

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References

  1. Gale AJ. Current understanding of hemostasis. Toxicol Pathol. 2011;39:273–80.

    Article  PubMed  Google Scholar 

  2. Versteef HH, Heemskerk JWM, Levi M, et al. New fundamentals in hemostasis. Physiol Rev. 2013;3:1327–58.

    Google Scholar 

  3. Esmon CT. The protein C pathway. Chest. 2003;124:26S–32S.

    Article  CAS  PubMed  Google Scholar 

  4. Bajaj MS, Birktoft JJ, Steer SA, et al. Structure and biology of tissue factor pathway inhibitor. Thromb Haemost. 2001;86:959–72.

    CAS  PubMed  Google Scholar 

  5. Chapin JC, Hajjar KA. Fibrinolysis and the control of blood coagulation. Blood Rev. 2015;29:17–24.

    Article  CAS  PubMed  Google Scholar 

  6. Lisman T, Porte RJ. Rebalanced hemostasis in patients with liver disease: evidence and clinical consequences. Blood. 2009;116:878–85.

    Article  Google Scholar 

  7. Lisman T, Caldwell SH, Burroughs AK, et al. Hemostasis and thrombosis in patients with liver disease: the ups and downs. J Hepatol. 2010;53:362–7. x

    Article  PubMed  Google Scholar 

  8. Tripodi A, Mannucci PM. The coagulopathy of chronic liver disease. N Engl J Med. 2011;365:147–56.

    Article  CAS  PubMed  Google Scholar 

  9. Mannucci PM, Canciani MT, Forza I, et al. Changes in health and diseases of the metalloprotease that cleaves von Willebrand factor. Blood. 2001;98:2730–5.

    Article  CAS  PubMed  Google Scholar 

  10. Tripodi A, Primignani M, Chantarangkul V, et al. An imbalance of pro- vs anti-coagulation factors in plasma from patients with cirrhosis. Gastroenterology. 2009;137:2105–11.

    Article  CAS  PubMed  Google Scholar 

  11. Dell’era A, Bosch J. The relevance of portal pressure and other risk factors in acute gastro-esophageal variceal bleeding. Aliment Pharmacol Ther. 2004;20:8–15.

    Article  PubMed  Google Scholar 

  12. Aggarwal A, Puri K, Lianpunsakul S. Deep vein thrombosis and pulmonary embolism in cirrhotic patients: systematic review. World J Gastroenterol. 2014;20:5737–45.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Wanless IR, Wong F, Blendis LM, et al. Hepatic and portal vein thrombosis in cirrhosis: a possible role in development of parenchymal extinction and portal hypertension. Hepatology. 1995;21:1238–47.

    CAS  PubMed  Google Scholar 

  14. Amitrano L, Guardascione MA, Ames PR. Coagulation abnormalities in cirrhotic patients with portal vein thrombosis. Clin Lab. 2007;53:583–9.

    PubMed  Google Scholar 

  15. Tripodi A, Caldwell SH, Hoffman M, et al. Review article: the prothrombin time test as a measure of bleeding risk and prognosis in liver disease. Aliment Pharmacol Ther. 2007;26:141–8.

    Article  CAS  PubMed  Google Scholar 

  16. Northup PG, Caldwell SH. Coagulation in liver disease: a guide for the clinician. Clin Gastroenterol Hepatol. 2013;11:1064–74.

    Article  PubMed  Google Scholar 

  17. Tripodi A, Primignani M, Chantarangkul V, et al. The coagulopathy of cirrhosis assessed by thromboelastometry and its correlation with conventional coagulation parameters. Thromb Res. 2009;124:132–6.

    Article  CAS  PubMed  Google Scholar 

  18. Tripodi A, Salerno F, Chantarangkul V, et al. Evidence of normal thrombin generation in cirrhosis despite abnormal conventional coagulation tests. Hepatology. 2005;41:553–8.

    Article  CAS  PubMed  Google Scholar 

  19. Villanueva C, Colomo A, Bosch A, et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med. 2013;368:11–21.

    Article  CAS  PubMed  Google Scholar 

  20. Segal JB, Dzik WH. Paucity of studies to support that abnormal coagulation test results predict bleeding in the setting of invasive procedures: an evidence-based review. Transfusion. 2005;45:1413–25.

    Article  PubMed  Google Scholar 

  21. Holland LL, Brooks JP. Toward rational fresh frozen plasma transfusion: the effect of plasma transfusion on coagulation test results. Am J Clin Pathol. 2006;126:133–9.

    Article  PubMed  Google Scholar 

  22. Youssef WI, Salazar F, Dasarathy S, et al. Role of fresh frozen plasma infusion in correction of coagulopathy of chronic liver disease: a dual phase study. Am J Gastroenterol. 2003;98:1391–4.

    Article  PubMed  Google Scholar 

  23. Tripodi A, Primignani M, Chantarangkul V, et al. Thrombin generation in patients with cirrhosis: the role of platelets. Hepatology. 2006;44:440–5.

    Article  CAS  PubMed  Google Scholar 

  24. Violo F, Basili S, Raparelli V, et al. Patients with liver cirrhosis suffer from primary hemostatic defects? Factor or fiction? J Hepatol. 2011;55:1415–27.

    Article  Google Scholar 

  25. Rockey DC, Caldwell SH, Goodman ZD, et al. Liver biopsy. Hepatology. 2009;49:1017–44.

    Article  PubMed  Google Scholar 

  26. Amarapurkar PD, Amarapurkar DN. Management of coagulopathy in patients with decompensated liver cirrhosis. Int J Hepatol. 2011;11:1–5.

    Google Scholar 

  27. Lodge JP, Jonas S, Jones RM, et al. Efficacy and safety of perioperative dose of recombinant factor VIIa in liver transplantation. Liver Transpl. 2005;11:973–9.

    Article  PubMed  Google Scholar 

  28. Trotter JF, Olson J, Lefkowitz J, et al. Changes in international normalized ratio (INR) and model for end stage liver disease (MELD) based on selection of clinical laboratory. Am J Transplant. 2007;7:1624–8.

    Article  CAS  PubMed  Google Scholar 

  29. Bechmann LP, Sichau M, Wichert M, et al. Low-molecular-weight-heparin in patients with advanced cirrhosis. Liver Int. 2011;31:75–82.

    Article  CAS  PubMed  Google Scholar 

  30. Vall DC, Rautou PE. The coagulation system in patients with end stage liver disease. Liver Int. 2015;35:139–44.

    Article  Google Scholar 

  31. Huard G, Bissonnette J, Bilodeau M. Optimal management of portal vein thrombosis in patients with liver cirrhosis: a review. Curr Hepatol Rep. 2015;14:203–11.

    Article  Google Scholar 

  32. Senzolo M, Sartori TM, Rossetto V, et al. Prospective evaluation of anticoagulation and transjugular intrahepatic portosystemic shunt for the management of portal vein thrombosis in cirrhosis. Liver Int. 2012;32:919–27.

    Article  CAS  PubMed  Google Scholar 

  33. Garcia-Tsao G, Sanyal AJ, Grace ND, et al. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007;46:922–38.

    Article  CAS  PubMed  Google Scholar 

  34. Amitrano L, Guardascione MA, Menchise A, et al. Safety and efficacy of anticoagulation therapy with low molecular weight heparin for portal vein thrombosis in patients with liver cirrhosis. J Clin Gastroenterol. 2010;44:448–51.

    CAS  PubMed  Google Scholar 

  35. Qi X, Han G, Fan D. Management of portal vein thrombosis in liver cirrhosis. Nature. 2014;11:435–46.

    CAS  Google Scholar 

  36. Gulley D, Teal E, Suvannasankha A, et al. Deep vein thrombosis and pulmonary embolism in cirrhosis patients. Dig Dis Sci. 2008;53:3012–7.

    Article  PubMed  Google Scholar 

  37. Sogaard KK, Horvath-Puho E, Gronbaek H, et al. Risk of venous thromboembolism in patients with liver disease: a nationwide population-based case-control study. Am J Gastroenterol. 2009;104:96–101.

    Article  PubMed  Google Scholar 

  38. Ali M, Ananthakrishnan AN, McGibley EL, et al. Deep vein thrombosis and pulmonary embolism in hospitalized patients with cirrhosis: a nationwide analysis. Dig Dis Sci. 2011;56:2152–9.

    Article  PubMed  Google Scholar 

  39. Northup PG, McMahon MM, Ruhl AP, et al. Coagulopathy does not fully protect hospitalized cirrhosis patients from peripheral venous thromboembolism. Am J Gastroenterol. 2006;101:1524–8.

    Article  PubMed  Google Scholar 

  40. Runyon BA. Introduction to the revised American Association for the Study of Liver Diseases Practice Guideline management of adult patients with ascites due to cirrhosis. Hepatology. 2013;57:1651–3.

    Article  PubMed  Google Scholar 

  41. Kahn SR, Lim W, Dunn AS, et al. Prevention of VTE in nonsurgical patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American college of chest physicians evidence-based clinical practice guidelines. Chest. 2012;141:195–226.

    Article  Google Scholar 

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Authors and Affiliations

  1. Department of Medicine, University of Pittsburgh, Hemophilia Center of Western Pennsylvania, 3636 Blvd of the Allies, Pittsburgh, PA, 15213, USA

    Craig D. Seaman MD, MS & Margaret V. Ragni MD, MPH

Authors
  1. Craig D. Seaman MD, MS
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  2. Margaret V. Ragni MD, MPH
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Corresponding author

Correspondence to Margaret V. Ragni MD, MPH .

Editor information

Editors and Affiliations

  1. Transplantation Center, Department of General Surgery, Cleveland Clinic, Cleveland, Ohio, USA

    Bijan Eghtesad

  2. Department of Surgery, University of Chicago, Chicago, Illinois, USA

    John Fung

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Seaman, C.D., Ragni, M.V. (2017). Coagulopathy in Cirrhosis. In: Eghtesad, B., Fung, J. (eds) Surgical Procedures on the Cirrhotic Patient. Springer, Cham. https://doi.org/10.1007/978-3-319-52396-5_2

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  • DOI: https://doi.org/10.1007/978-3-319-52396-5_2

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-52394-1

  • Online ISBN: 978-3-319-52396-5

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