Potential applications of thromboelastography in patients with acute and chronic liver disease.

Patients with acute and chronic liver disease have long been assumed to have a bleeding tendency on the basis of abnormal results for standard tests of hemostasis. However, recent studies have suggested that hemostasis in patients with liver disease exists in a state of rebalance, in which defects in prohemostatic drivers are compensated for by commensurate changes in antihemostatic drivers. Standard assays of hemostasis cannot evaluate this potential state of rebalance because they only assess components of clot formation and, therefore, may provide misleading information regarding the risk of bleeding, possibly leading clinicians to administer unneeded or even harmful prohemostatic factors. Thromboelastography (TEG) is a commercially available, rapid, point-of-care assay that assesses clot formation in whole blood, including plasmatic and cellular components. Studies using TEG in patients with cirrhosis and acute liver failure have suggested that rebalanced hemostasis exists in many patients, even in the presence of thrombocytopenia and an elevated prothrombin time/international normalized ratio. TEG has also been used to study mechanisms of rebalanced hemostasis and the pathogenesis of specific complications of liver disease, such as variceal rebleeding and infection. Finally, TEG has become widely used to guide factor repletion and fibrinolytic therapy during liver transplantation. The present clinical review will summarize these potential applications of TEG in patients with liver disease.