Management of Severe Bleeding in Liver Disease and Transplantation

The concept that patients with cirrhosis are at increased risk of bleeding events is probably out of date. Liver failure is accompanied by multiple changes in the hemostatic system, because of reduced plasma levels of procoagulative and anticoagulative clotting factors synthesized by the intact liver. Thrombocytopenia is very frequent ranking first among the altered hematological tests but Von Willebrand factor is elevated and ADAMTS-13 instead decreased, counterbalancing/compensating in some way the thrombocytopenia. The hemostatic system is then in a delicate balance between prothrombotic and antithrombotic processes. Since the global effect of liver disease on the hemostatic system is complex, patients with end-stage liver disease (ESLD) can experience severe bleeding or, at the opposite, thrombotic complications. Conventional coagulation tests such as prothrombin time (PT) and international normalized ratio (INR) are not able to provide information on the actual coagulation status of the patient as well as to predict possible bleeding or thrombotic events in patients with liver disease. Standard hemostatic tests which are inadequate to evaluate the so-called rebalanced hemostatic profile of the cirrhotic patient may provide misleading information regarding the risk of bleeding: in particular, clinicians have to be aware that unneeded, useless, or even dangerous pro-hemostatic factors might be administered with no demonstrated benefit. Because of the limits of conventional coagulation tests, in recent years, the viscoelastic tests (Thromboelastography/thromboelastomatry) have gained increasing importance. A more dynamic and targeted approach to the overall hemostatic process is at the base of their success providing a visual information on fibrinolysis, on the presence of endogenous heparinoids and tendency to hypercoagulability: these characteristics make these tests ideal for a rapid diagnosis of the type of coagulopathy and for an appropriate choice of the therapeutic option in patients with acute or chronic liver disease