- defined as INR >1.5 due to liver dysfunction
- patients are not ‘auto-anticoagulated’ – they are often in a procoagulant state!
Hemostasis is rebalanced, but at a lower level and thus prone to tipping over into hemorrhage or thrombosis
- decreased Factor 2,7,9,10 and 5 -> anticoagulant effect
- decreased Protein C and S -> procoagulant effect
- decreased ADAMTS13 -> increased platelet microthrombi -> worse liver/ MOF and thrombocytopenia
- decreased plasminogen and alpha2-antiplasmin; increased tissue plasminogen activator and plasmin activiating inhibitor-1 -> mixed fibrinolytic and antifribrinloytic effect
- patients with INR >1.5 due to liver dysfunction are not necessarily at increased risk of bleeding
- avoid prophylactic FFP and platelets
- only give haemostatic agents if actively bleeding
- can use viscoelastic tests such as TEG or thrombin generation assays (+/- thrombomodulin or Protec) to demonstrate hypercoagulability
- consider thromboprophylaxis
References and Links
- Schaden E, Saner FH, Goerlinger K. Coagulation pattern in critical liver dysfunction. Curr Opin Crit Care. 2013 Apr;19(2):142-8. PMID: 23400090.
- Tripodi A, Mannucci PM. The coagulopathy of chronic liver disease. N Engl J Med. 2011 Jul 14;365(2):147-56. PMID: 21751907.