Gulara&Hajiyeva,&MD

2Intact'thrombin'generation'and'decreased'fibrinolytic'capacity'in'patients'with'acute'liver'injury'or'acute'liver'failure,'Lisman et'al,'Journal'of'Thrombosis'and'Haemostasis 2012'10;'1312D9

1ThrombinDActivatable'Fibrinolysis'Inhibitor'Deficiency'in'Cirrhosis'Is'Not'Associated'With'Increased'Plasma'Fibrinolysis'Lisman et'al,'Gastroenterology'2001

Rebalanced)Coagulation)in)Chronic)Liver)Disease

• Basic&laboratory&tests&PT/PTT&correlate&poorly&with&bleeding&from&various&invasive&procedures&or&gastrointestinal&hemorrhage

• Fresh&frozen&plasma&administration&does&not&prevent&or&minimize&procedural&bleeding

• Elevated&PT/INR&in&patients&with&liver&cirrhosis&does&not&mean&&“autoBanticoagulation”

A. Start'the'patient'on'furosemide'and'spironolactoneB. Transfuse'2'units'of'FFPs,'then'perform'paracentesisC. Perform'diagnostic'and'therapeutic'paracentesisD. Transfuse'one'unit'of'platelets,'then'perform'paracentesis

Bleeding(After(Liver(Biopsy(Does(not(Correlate(with(Indices(of(Peripheral(Coagulation.((Ewe(K.((May(1981(

Bleeding(After(Liver(Biopsy

Large&Volume&Paracentesis&in&Coagulopathy

Grabau&M&et&al&Hepatology&2004;&40:&484@488

Central(Venous(Catheterization(in(Patients(With(Coagulopathy(Foster(et(al(JAMA(Surgery(March(1992

Central(Venous(Cannulation(in(Patients(with(Liver(Disease(and(Coagulopathy(–A(Prospective(Audit,(Fisher(et(al,(Intensive(Care(Medicine(May(1999

Bleeding(After(Invasive(Procedures(is(Rare(and(Unpredicted(by(Platelet(Counts(in(Cirrhotic(Patients(with(Thrombocytopenia(Napolitano(et(al,(European(Journal(of(Internal(Medicine,(December(2016(

• Because'bleeding'is'sufficiently'uncommon,'the'routine'prophylactic'use'of'fresh'frozen'plasma'or'

platelets'before'paracentesis'is'not'recommended by'AASLD

• Uptodate recommends'against'transfusion'based'on'INR,'rather'use'the'value'as'prognostic'marker.'Also'

recommends'PLT'>50H55'for'active,'severe'or'central'nervous'system'bleeding

*Transfusion'Rate'for'500'Consecutive'Liver'Transplantations:'Experience'of'One'Liver'Transplantation'Center,'Massicotte et'al,'

Transplantation'June'2012

• Platelet'transfusion'should'be'considered'when'levels'are'less'than'50,000H60,000/mL'for'transcutaneous'

or'transvenous liver'biopsy. The'use'of'prophylactic'or'rescue'strategies'such'as'plasma,'fibrinolysis'

inhibitors,'or'recombinant'factors'should'be'considered'in'specific'situations,'although'their'effectiveness'

remains'to'be'established'H AASLD

• More'and'more'centers'report'transfusionHfree'liver'transplantation'in'a'substantial'proportion'of'

patients'*

What'Do'the'Guidelines'Say?

A. Knee&high&sequential&compression&deviceB. Subcutaneous&heparin&5000&Units&twice&dailyC. Subcutaneous&enoxaparin&40&mg&dailyD. Graduated&compression&stockings

Risk%of%%Venous%Thromboembolism%in%Patients%with%Liver%Disease:%A%Nationwide%Population%Based%Case%Control%Study%Sogaard et%al%%The%American%Journal%ofGastroenterology%Jan%2009

The$Risk$of$Venous$Thromboembolism$in$Patients$with$Cirrhosis,$Ambrosino et$al,$Thrombosis$and$Hemostasis$Issue$1$2017$

Effects'of'Anticoagulants'in'Patients'With'Cirrhosis'and'Portal'Vein'Thrombosis:'A'Systematic'Review'and'MetaAanalysis'L.'Loffredoet'al''Gastroenterology'August'2017

*Transfusion+related0Acute0Lung0Injury0in0ICU0Patients0Admitted0with0Gastrointestinal0Bleeding,0Benson0et0al00Intensive0Care0Medicine,July02010

• Aminocaproic acid+or+tranexamic+acid+in+hyperfibrinolysis

• Desmopressin+in+uremia

• Prothrombin+complex+concentrate

• Fibrinogen+concentrate