Hemostasis testing in patients with liver dysfunction: Advantages and caveats

Abstract

Due to concomitant changes in pro- and anti-coagulant mechanisms, patients with liver dysfunction have a "rebalanced hemostasis", which can easily be tipped toward either a hypo- or a hypercoagulable phenotype. Clinicians are often faced with the question whether patients with chronic liver disease undergoing invasive procedures or surgery and those having active bleeding require correction of the hemostasis abnormalities. Conventional coagulation screening tests, such as the prothrombin time/international normalized ratio and the activated partial thromboplastin time have been demonstrated to have numerous limitations in these patients and do not predict the risk of bleeding prior to high-risk procedures. The introduction of global coagulation assays, such as viscoelastic testing (VET), has been an important step forward in the assessment of the overall hemostasis profile. A growing body of evidence now suggests that the use of VET might be of significant clinical utility to prevent unnecessary infusion of blood products and to improve outcomes in numerous settings. The present review discusses the advantages and caveats of both conventional and global coagulation assays to assess the risk of bleeding in patients with chronic liver disease as well as the current role of transfusion and hemostatic agents to prevent or manage bleeding.

Keywords: Bleeding risk; Conventional tests; Hemostasis; Hemostatic agents; Thrombin generation; Viscoelastic tests.

Figure 1

“Rebalanced” Hemostasis in patients with liver dysfunction. AT: Antithrombin; ADAMTS13: a disintegrin and metalloprotease with thrombospondin type I repeats-13; α2AP: α2-antiplasmin; PAI-1: Plasminogen activator inhibitor-1; PDFs: Fibrin degradation products; PC: Protein C; PS: Protein S; TAFI: Thrombin-activatable fibrinolysis inhibitor; t-PA: Tissue plasminogen activator; VWF: Von Willebrand factor.