Management of coagulation abnormalities in liver disease

Abstract

Liver disease is characterized by changes in all phases of hemostasis. These hemostatic alterations were long considered to predispose patients with liver disease towards a bleeding tendency, as they are associated with prolonged conventional coagulation tests. However, these patients may also suffer from thrombotic complications, and we now know that the hemostatic system in patient with liver disease is, in fact, in a rebalanced state. In this review we discuss the concept of rebalanced hemostasis and its implications for clinical management of patients with liver disease. For instance, there is no evidence that the use of prophylactic blood product transfusion prior to invasive procedures reduces bleeding risk. Clinicians should also be aware of the possibility of thrombosis occurring in patients with a liver disease, and regular thrombosis prophylaxis should not be withheld in these patients.

Keywords:

• anticoagulants
• bleeding
• bleeding management
• coagulation
• coagulation tests
• hemostasis
• liver disease
• thrombin generation
• thrombosis
• thrombosis management

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Liver disease is characterized by a rebalanced hemostatic system.

• The balance of hemostasis is more precarious in patients with liver disease, with the risk of both bleeding and thrombotic complications.

• Conventional coagulation tests, such as the prothrombin time and the activated partial thromboplastin time, are poor predictors of bleeding or thrombotic risk.

• Research is necessary to assess the clinical value of new global hemostasis assays, such as thromboelastography and thrombin generation, to guide hemostatic management in patients with liver disease.

• There is no evidence that prophylactic transfusion of blood products helps to prevent procedural related bleeding in patients with liver diseases.

• In the prevention of (re)bleeding, the presence of independent risk factors, such as renal failure or infections, should also be addressed.

• Thrombosis prophylaxis should not be withheld from patients with liver disease, and clinicians should be aware of the possibility of thrombosis occurring in these patients.

• Future clinical research is necessary to identify the dose and choice of anticoagulant drug for the prevention and treatment of thrombosis in patients with liver disease.

• Antihemostatic drugs may slow down progression of liver disease.

Notes