Hepatic coagulopathy-intricacies and challenges; a cross-sectional descriptive study of 110 patients from a superspecialty institute in North India with review of literature.

Hemostatic defect in chronic liver disease (CLD) is complex involving opposing factors of primary hemostasis, coagulation, and fibrinolysis. The concept of causal relationship between abnormal tests and clinical bleeding is unclear. This study was undertaken to evaluate and correlate clinical bleeding and the commonly used laboratory tests for hemostasis in CLD patients including the subgroup of acute on chronic liver failure (ACLF) patients and test the reproducibility of international normalized ratio (INR) using different reagents. This was a cross-sectional descriptive study wherein clinical records and laboratory data from 110 patients (95 CLD, 15 ACLF) over a 6-month period were analysed. Variceal bleeding (33.3%) was the commonest followed by mucosal/skin bleeds (5.4%). Thrombocytopenia seen in 70.9% patients was mostly mild (48.2%) to moderate (14.5%). Prothrombin time (PT) prolongation was seen in 81.8% with significant variation in PT/INR using different reagents. Adverse outcome in the form of disseminated intravascular coagulation, septic shock or death was seen in 13.6% patients (eight ACLF and seven CLD). There was no correlation of bleeding with prolonged PT/INR, decreased platelet count and adverse clinical outcome. However, individually, there was significant but weak correlation between variceal bleeding and lower platelet count and superficial bleeding and prolonged PT. Correction of PT/INR post-fresh frozen plasma was significant but platelet count postplatelet concentrate transfusion was not. ACLF patients compared with CLD patients had greater PT prolongation and adverse outcome but no increase in bleeding. Routine tests, although globally deranged inadequately reflect haemostatic imbalance in CLD and poorly predict bleeding risk.