Anticoagulation in the cirrhotic patient

Laura Turco, Emmanuelle de Raucourt, Dominique-Charles Valla, Erica Villa, Laura Turco, Emmanuelle de Raucourt, Dominique-Charles Valla, Erica Villa

Abstract

In the past, patients with liver cirrhosis were thought to be prone to increased bleeding risk. However, those with compensated liver cirrhosis actually have normal coagulative balance, which can become altered when liver function worsens, or infection, bleeding, or acute kidney insufficiency occur. When this happens, it is now recognized that patients with liver cirrhosis are at higher risk of thrombotic rather than haemorrhagic complications. Anticoagulation plays a favourable role both when used therapeutically or prophylactically. Successful anticoagulation is associated with a lower rate of decompensation and with improved survival. To date, treatment has involved the use of low molecular weight heparins and vitamin K antagonists. Preliminary data suggest that novel non-vitamin K antagonist oral anticoagulants can be used safely in patients with liver cirrhosis.

Keywords: Chronic liver disease; Coagulopathy; Decompensation; Portal Hypertension; Thrombophilia.

© 2019 The Author(s).

Figures

Fig. 1
Fig. 1
Haemostatic balance in cirrhotic patients in different Child-Pugh classes. Modifications of pro- and anti-coagulants factors during progression of chronic liver disease.
Fig. 2
Fig. 2
Changes in TEG® and ROTEM® tests in normal conditions, cirrhosis and anticoagulation. A: Whole blood viscoelastic tests can be detected using ROTEM (optical method, bottom line) or TEG (electromechanical method; upper line). ROTEM measures similar parameters on the graphic compared to TEG: R time is clotting time (CT) represent the period of initial fibrin formation. K time is clot formation time (CFT), which measures the rate of clot formation and reflects fibrin rate build up and cross linking, MA is maximum clot firmness (MCF) represents the ultimate strength of the clot (platelet and fibrin) and LY30 is (CL30) measures the rate of amplitude reduction from MA at 30 minutes detects fibrinolysis. B: TEG (left) ROTEM (right) showing prolonged clotting time and R in a patient treated with Heparin. C: TEG (left) ROTEM (right). Hypercoagulable state with short CT, CFT, R and K. increased MCF and MA. D: ROTEM (upper) and TEG (bottom) in a patient with decompensated OH- cirrhosis showing hyocoagulable state with prolonged CT, R and K and reduced MCF and MA and decreased A10, MCF on FIBTEM showing hypofibrinogenemia.
Fig. 3
Fig. 3
Role of prophylactic and therapeutic anticoagulation in the natural history of cirrhosis.

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