Viscoelastic Tests as Point-of-Care Tests in the Assessment and Management of Bleeding and Thrombosis in Liver Disease

2020 ◽  
Vol 46 (06) ◽  
pp. 704-715
Author(s):  
Natasha Janko ◽  
Ammar Majeed ◽  
William Kemp ◽  
Stuart K. Roberts
Keyword(s):  
Liver Disease ◽  
Chronic Liver Disease ◽  
Blood Product ◽  
Point Of Care ◽  
Bleeding Risk ◽  
Chronic Liver ◽  
Current Evidence ◽  
Blood Component ◽  
Blood Product Transfusion ◽  
Coagulation Tests

AbstractViscoelastic point-of-care (VET POC) tests provide a global assessment of hemostasis and have an increasing role in the management of bleeding and blood component delivery across several clinical settings. VET POC tests have a rapid turnaround time, provide a better overall picture of hemostasis, predict bleeding more accurately than conventional coagulation tests, and reduce blood component usage and health care costs. Despite commonly having abnormal conventional coagulation tests, most patients with chronic liver disease have a “rebalanced” hemostasis. However, this hemostatic balance is delicate and these patients are predisposed to both bleeding and thromboembolic events. Over recent years, VET POC tests have been increasingly studied for their potential as better functional tests of hemostasis in liver disease patients. This review provides a background on the most common VET POC tests (thromboelastography and rotational thromboelastometry) and discusses the current evidence for these tests in the prediction and management of bleeding and thrombosis in patients with chronic liver disease, and in liver resection and transplant. With the recent publication of several randomized controlled trials, there is growing evidence that VET POC tests may be used to improve bleeding risk assessment and reduce blood product use in liver disease patients outside of the transplant setting. However, consensus is still lacking regarding the VET POC tests' thresholds that should be used to trigger blood product transfusion. VET POC tests also show promise in predicting thrombosis in patients with liver disease, but further research is needed before they can be used to guide anticoagulant therapy.

Periprocedural Bleeding Risk Assessment in Chronic Liver Disease

2017 ◽  
Vol 01 (04) ◽  
pp. 306-312
Author(s):  
Brett Fortune ◽  
David Madoff ◽  
Benjamin May
Keyword(s):  
Liver Disease ◽  
Chronic Liver Disease ◽  
Blood Product ◽  
Bleeding Risk ◽  
International Normalized Ratio ◽  
Chronic Liver ◽  
Alternative Methods ◽  
Advanced Liver Disease ◽  
Potential Harm ◽  
Clotting Disorder

AbstractInvasive procedures are common in the management of cirrhosis-related chronic liver disease (CLD). Assessing bleeding risk prior to these procedures is challenging because of commonly seen laboratory abnormalities among traditional testing used to evaluate bleeding risk in patients with advanced liver disease. However, this ‘coagulopathy’ seen in advanced liver disease is not a true bleeding or clotting disorder. The prothrombin time/international normalized ratio (PT/INR) test is frequently elevated in CLD patients, but has been shown to poorly correlate with bleeding risk in this population. A traditional interpretation of this laboratory test can lead to unnecessary transfusion of blood product, procedure delay, or even potential harm to the patient. An understanding of the ‘coagulopathy’ of advanced liver disease and alternative methods, to more accurately assess bleeding risk, allows clinicians to treat safely CLD patients.

Chronic liver disease, thrombocytopenia and procedural bleeding risk; are novel thrombopoietin mimetics the solution?

Platelets ◽  
2018 ◽  
Vol 30 (6) ◽  
pp. 796-798 ◽  
Author(s):  
Sven R. Olson ◽  
Steven Koprowski ◽  
Justine Hum ◽  
Owen J.T. McCarty ◽  
Thomas G. DeLoughery ◽  
...  
Keyword(s):  
Liver Disease ◽  
Chronic Liver Disease ◽  
Bleeding Risk ◽  
Chronic Liver

Thrombopoietin Receptor Agonists in Patients with Chronic Liver Disease

2020 ◽  
Vol 46 (06) ◽  
pp. 682-692
Author(s):  
Saro Khemichian ◽  
Norah A. Terrault
Keyword(s):  
Liver Disease ◽  
Chronic Liver Disease ◽  
Invasive Procedure ◽  
Bleeding Risk ◽  
Chronic Liver ◽  
Bleeding Complications ◽  
Invasive Procedures ◽  
Platelet Counts ◽  
Receptor Agonists ◽  
Platelet Transfusions

AbstractThrombocytopenia is one of the most common hematologic complications in cirrhosis. Despite limited data linking platelet count and bleeding risk in patients with cirrhosis, the use of platelets transfusions for invasive procedures has been a common practice. Recently, thrombopoietin (TPO) receptor agonists have been approved for use in patients with chronic liver disease (CLD) undergoing invasive procedures. The aim of this study was to review current literature on bleeding risk in patients with cirrhosis and the use of platelet transfusions and TPO receptor agonists in the context of invasive procedures. PubMed search was conducted to find articles relating to cirrhosis, thrombocytopenia, and new novel treatments for this condition. Search terms included CLD, cirrhosis, thrombocytopenia, bleeding, thrombosis, coagulopathy, hemostasis, and TPO receptor agonists. Romiplostim, eltrombopag, avatrombopag, and lusutrombopag are approved TPO receptor agonists, with avatrombopag and lusutrombopag specifically approved for use in patients with CLD undergoing invasive procedures. In patients with platelet counts < 50,000/mm3, avatrombopag and lusutrombopag increased the platelet counts above this threshold in the majority of treated patients and reduced the frequency of platelet transfusions. At the approved doses, incidence of thrombosis was not increased and therapies were well tolerated. Studies were not powered to assess whether risk of bleeding complications was reduced and the fundamental question of whether correction of thrombocytopenia is warranted in patients undergoing invasive procedures remains unanswered. The use of TPO receptor agonists has resulted in less requirement for platelet transfusions. In patients with cirrhosis undergoing invasive procedures for whom platelet transfusion is planned, TPO receptor agonists are an alternative and avoid the risks associated with transfusions. However, there is need for a thoughtful approach to manage bleeding risk in patients with cirrhosis undergoing procedures, with the consideration of a comprehensive hemostatic profile, the severity of portal hypertension, and the complexity of the invasive procedure to guide decisions regarding transfusions or use of TPO receptor agonists.

scholarly journals Ultrasound-based liver elastography: current results and future perspectives

2020 ◽  
Vol 45 (11) ◽  
pp. 3463-3472
Author(s):  
Cheng Fang ◽  
Paul S. Sidhu
Keyword(s):  
Liver Disease ◽  
Liver Fibrosis ◽  
Liver Biopsy ◽  
Chronic Liver Disease ◽  
Research Direction ◽  
Chronic Liver ◽  
Current Evidence ◽  
Diffuse Liver Disease ◽  
Disease Spectrum ◽  
Liver Elastography

Abstract Chronic liver disease affects 185 million population worldwide. It encompasses a heterogenous disease spectrum, but all can lead to the development of liver fibrosis. The degree of liver fibrosis is not only a prognosticator, but has also been used to guide the treatment strategy and to evaluate treatment response. Traditionally, staging of liver fibrosis is determined on histological analysis using samples obtained from an invasive liver biopsy. Ultrasound-based liver elastography is a non-invasive method of assessing diffuse liver disease in patients with known chronic liver disease. The use of liver elastography has led to a significant reduction in the number of liver biopsies performed to assess the severity of liver fibrosis and a liver biopsy is now reserved for only select sub-groups of patients. The aim of this review article is to discuss the key findings and current evidence for ultrasound-based elastography in diffuse liver disease as well as the technical challenges and to evaluate the potential research direction.

Point-of-Care Testing in Liver Disease and Liver Surgery

2017 ◽  
Vol 43 (04) ◽  
pp. 407-415 ◽  
Author(s):  
Lasitha Abeysundara ◽  
Susan Mallett ◽  
Ben Clevenger
Keyword(s):  
Liver Disease ◽  
Blood Product ◽  
Point Of Care ◽  
Massive Bleeding ◽  
Point Of Care Testing ◽  
Hemostatic System ◽  
Coagulation Tests ◽  
Postoperative Thrombosis ◽  
Coagulation Status ◽  
Point Of Care Tests

AbstractThe alterations in coagulation and hemostasis that accompany liver disease are complex, and while patients with this disease have traditionally been perceived as having a bleeding diathesis, it is now understood that in stable patients hemostasis is “re-balanced.” Hepatic surgery, and particularly liver transplantation, can be associated with large fluid shifts, massive bleeding, and coagulopathy, as well as postoperative thrombosis. Point-of-care tests (POCTs) of coagulation facilitate goal-directed treatments and hemostatic monitoring in dynamic environments where the coagulation status can alter rapidly and often unpredictably. POCTs reflect more accurately the re-balanced hemostatic system than do conventional coagulation tests (CCTs). Viscoelastic POCT-guided transfusion algorithms permit a reduction in blood product administration and are a key component of patient blood management programs. Moreover, viscoelastic POCTs are better able to identify patients with hypercoagulability than CCTs. With thrombosis increasingly recognized to be a problem in patients with liver disease, POCTs hold promise for both individualized bleeding and thrombosis management.

Prevalence of bleeding and thrombosis in critically ill patients with chronic liver disease

2021 ◽  
Author(s):  
Tsai-Wing Ow ◽  
Evangelia Fatourou ◽  
Liane Rabinowich ◽  
Bente Pernille van den Boom ◽  
Shirjit Nair ◽  
...  
Keyword(s):  
Risk Factors ◽  
Hepatocellular Carcinoma ◽  
Liver Disease ◽  
Chronic Liver Disease ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Retrospective Cohort ◽  
Blood Product ◽  
Chronic Liver ◽  
Present On Admission

Introduction: Haemorrhage and venous thromboembolism (VTE) are recognised complications of chronic liver disease (CLD), but their prevalence and risk factors in critically ill patients is uncertain. Patients and methods: We studied a retrospective cohort of patients with CLD non-electively admitted to a specialist intensive care unit determining the prevalence and timing of major bleeding and VTE (early, present on admission/diagnosed within 48h; later diagnosed >48h post ICU admission). Associations with baseline clinical and laboratory characteristics, multi-organ failure (MOF), blood product administration and mortality were explored. Odds ratios (OR) and 95% CIs were calculated using logistic regression. Results: Of 623 patients with median age 52, bleeding (>48 hours after admission) occurred in 87 (14%) patients. Bleeding was associated with greater illness severity and increased mortality. Gastrointestinal bleeding accounted for 72% of events, secondary to portal hypertension in >90%. Procedure-related bleeding was uncommon. VTE occurred in 125 (20%) patients: Early VTE in 80 (13%) and involving the portal vein (PVT) in 85%. Later VTE affected 45 (7.2%) patients. Hepatocellular Carcinoma (HCC) and non-alcoholic liver disease were independently associated with early VTE (OR 2.79, (95% CI 1.5 -5.2) and 2.32, (1.4 -3.9) respectively), and HCC, sepsis and cryoprecipitate use with late VTE (OR 2.45, (1.11-5.43), 2.26 (1.2-4.3) and 2.60 (1.3-5.1). Conclusion: VTE was prevalent on admission to critical care and less commonly developed later. Bleeding was associated with MOF and increased mortality. Severe MOF was not associated with an increased rate of VTE which was linked with HCC, and specific etiologies of CLD.

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