The Hemostatic System in Patients with Cirrhosis, Monitoring of Coagulation and Management of Bleeding

Abstract

Acute on chronic liver failure (ACLF) has both a direct and an indirect impact on the entire hemostatic system. According to current understanding, cirrhosis and liver failure both evoke several changes in pro- and anti-coagulant as well as pro- and anti-fibrinolyticPro- and antifibrinolytic proteinsmechanisms, resulting in a fragile rebalanced state of hemostasis. However, standard laboratory coagulation assays frequently suggest hypocoagulability and are commonly understood as indicating a state of auto-anticoagulation and a risk of spontaneous bleeding. Nevertheless, patients suffering from ACLF are more frequently subject to thromboembolic events than to spontaneous coagulopathic bleeding episodes, suggesting implications for thromboprophylaxis. Comprehensive coagulation testing is required to characterize the changes counterbalancing deficiencies in certain coagulation factors, hypofibrinogenemia, and thrombocytopenia. A clear understanding of these rebalanced, highly specific alterations is essential to providing adequate perioperative care for the patients thus affected. In the perioperative setting, viscoelastic testing is increasingly being used to guide hemostatic interventions in order to provide individualized therapy. Furthermore, highly purified coagulation factor concentrates are increasingly being used in rendering such therapy and with the aim of reducing allogeneic blood transfusions, which have been found to be associated with adverse outcomes in patients undergoing liver transplantation.