Unravelling the coagulation paradox in liver cirrhosis: challenges and insights
- PMID: 39981790
- DOI: 10.1080/17843286.2025.2469906
Unravelling the coagulation paradox in liver cirrhosis: challenges and insights
Abstract
Patients with liver disease experience complex haemostatic changes leading to a state of 'rebalanced haemostasis' that may shift towards bleeding or thrombosis due to complications like kidney dysfunction, bacterial infection, or acute-on-chronic liver failure. Traditional coagulation tests inadequately capture haemostasis in cirrhosis, whereas advanced assays like thrombin generation assay and viscoelastic testing offer better insights but remain limited in clinical outcome prediction or guiding pre-procedural prophylaxis.Contrary to the traditional view of cirrhosis as a bleeding disorder, recent evidence highlights a paradox of higher venous thromboembolism incidence in hospitalised cirrhotic patients. Misconceptions about 'auto-anticoagulation' and concerns about anticoagulation safety hinder consistent thromboprophylaxis. Emerging data suggest that low molecular weight heparin is safe and effective in cirrhotic patients, supporting more evidence-based thromboprophylaxis. For thrombotic events or conditions like atrial fibrillation, therapeutic anticoagulation is recommended, and may offer additional benefits, such as attenuating liver fibrosis and portal hypertension. However, anticoagulation is not established as a core therapy in cirrhosis, given safety concerns in advanced disease.Bleeding remains a significant challenge in cirrhosis, with management focusing on specific aetiologies, including portal hypertension or procedural injuries. In pre-procedural planning, there is a trend of unnecessary blood product use, often based on an assumed bleeding risk. Rational pre-procedural planning should minimize unnecessary transfusions, optimise modifiable risks, and include a plan for managing potential bleeding.This review aims to clarify the 'coagulation paradox' in cirrhosis, promoting a nuanced, individualized approach to managing bleeding and thrombosis in chronic liver disease.
Keywords: Coagulation; bleeding; cirrhosis; dynamic haemostatic status; thrombosis.
Plain language summary
1) Dynamic haemostasis in cirrhosisHaemostatic balance in cirrhotic patients can fluctuate, influenced by factors such as renal impairment, bacterial infections, and the progression of liver disease. Haemostatic management must therefore be highly personalised.2) Limitations of traditional coagulation tests and role of global haemostatic assaysConventional coagulation tests poorly reflect the haemostatic capacity in cirrhosis. Advanced tools like rotational thromboelastometry (ROTEM) and thrombin generation assays (TGAs) offer a more accurate, global assessment, despite certain limitations.3) Prothrombotic risks in cirrhosisContrary to earlier beliefs, cirrhotic patients are not ‘auto-anticoagulated’, and thromboprophylaxis should be carefully considered for those hospitalised.4) Complexities of anticoagulation in cirrhosisDespite promising evidence suggesting a role in disease progression, anticoagulation has not yet become standard in cirrhosis management, mainly due to uncertainties around pharmacokinetics and pharmacodynamics in this population.5) Pre-procedural planning to minimise bleeding riskTailored pre-procedural planning is crucial for cirrhotic patients, focusing on minimising unnecessary transfusions, optimising modifiable risk factors, and having a clear strategy for managing potential bleeding complications.6) Tailored bleeding management in cirrhosisEffective bleeding management in cirrhosis requires a personalised approach, prioritising the underlying cause, whether portal hypertension, procedural injury, or spontaneous mucosal bleeding, with targeted strategies such as prompt intervention in procedural injury or individualised transfusion protocols in cases of spontaneous mucosal bleeding or marked coagulopathy contributing to ongoing bleeding.
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