Nekisa Zakeri1, Emmanuel A Tsochatzis2. 1. Sheila Sherlock Liver Unit and UCL Institute for Liver and Digestive Health, Royal Free Hospital and UCL, London, NW3 2QG, UK. 2. Sheila Sherlock Liver Unit and UCL Institute for Liver and Digestive Health, Royal Free Hospital and UCL, London, NW3 2QG, UK. e.tsochatzis@ucl.ac.uk.
Abstract
PURPOSE OF REVIEW: Previous perceptions of cirrhosis as a hypocoagulable state have resulted in empirical blood product transfusions prior to invasive procedures. We evaluate procedure-related bleeding risks in patients with cirrhosis, assess the utility of conventional and newer global coagulation tests, and explore evidence surrounding prophylactic transfusion strategies. RECENT FINDINGS: Recent literature supports the concept of a rebalanced, albeit fragile, haemostasis equilibrium in cirrhosis, with a potential hypercoagulable tendency in stable patients. Standard coagulation tests provide a poor reflection of bleeding risks and yet are relied upon for transfusion thresholds. Consequently, a sizeable proportion of patients receive unnecessary blood products. The role of viscoelastic tests to guide transfusions requires further evaluation. In stable cirrhotic patients, procedure-related bleeding rates appear low. Prophylactic transfusion strategies based on arbitrary thresholds lack evidence of clinical benefit. There is a pressing need for point-of-care coagulation tests that represent the complex coagulopathy of cirrhosis and well-powered randomised controlled trials to develop evidence-based pre-procedure transfusion guidelines.
PURPOSE OF REVIEW: Previous perceptions of cirrhosis as a hypocoagulable state have resulted in empirical blood product transfusions prior to invasive procedures. We evaluate procedure-related bleeding risks in patients with cirrhosis, assess the utility of conventional and newer global coagulation tests, and explore evidence surrounding prophylactic transfusion strategies. RECENT FINDINGS: Recent literature supports the concept of a rebalanced, albeit fragile, haemostasis equilibrium in cirrhosis, with a potential hypercoagulable tendency in stable patients. Standard coagulation tests provide a poor reflection of bleeding risks and yet are relied upon for transfusion thresholds. Consequently, a sizeable proportion of patients receive unnecessary blood products. The role of viscoelastic tests to guide transfusions requires further evaluation. In stable cirrhotic patients, procedure-related bleeding rates appear low. Prophylactic transfusion strategies based on arbitrary thresholds lack evidence of clinical benefit. There is a pressing need for point-of-care coagulation tests that represent the complex coagulopathy of cirrhosis and well-powered randomised controlled trials to develop evidence-based pre-procedure transfusion guidelines.
Authors: Patryck Lloyd-Donald; Abhinav Vasudevan; Peter Angus; Paul Gow; Johan Mårtensson; Neil Glassford; Glenn M Eastwood; Graeme K Hart; Rinaldo Bellomo Journal: J Crit Care Date: 2016-11-04 Impact factor: 3.425
Authors: Norah A Terrault; Tarek Hassanein; Charles D Howell; Shobha Joshi; John Lake; Linda Sher; Hugo Vargas; Joe McIntosh; Shande Tang; Tim M Jenkins Journal: J Hepatol Date: 2014-07-15 Impact factor: 25.083
Authors: Lesley De Pietri; Marcello Bianchini; Roberto Montalti; Nicola De Maria; Tommaso Di Maira; Bruno Begliomini; Giorgio Enrico Gerunda; Fabrizio di Benedetto; Guadalupe Garcia-Tsao; Erica Villa Journal: Hepatology Date: 2015-12-09 Impact factor: 17.425
Authors: James Neuberger; Jai Patel; Helen Caldwell; Susan Davies; Vanessa Hebditch; Coral Hollywood; Stefan Hubscher; Salil Karkhanis; Will Lester; Nicholas Roslund; Rebecca West; Judith I Wyatt; Mathis Heydtmann Journal: Gut Date: 2020-05-28 Impact factor: 23.059
Authors: Helena B Thomaides-Brears; Naim Alkhouri; Daniela Allende; Mukesh Harisinghani; Mazen Noureddin; Nancy S Reau; Marika French; Carlos Pantoja; Sofia Mouchti; Donna R H Cryer Journal: Dig Dis Sci Date: 2021-06-15 Impact factor: 3.487