Coagulopathy in Liver Dysfunction
OVERVIEW
- defined as INR >1.5 due to liver dysfunction
- patients are not ‘auto-anticoagulated’ – they are often in a procoagulant state!
FEATURES
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
APPROACH
- 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.
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
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