medigraphic.com
Órgano Oficial de la Asociación Mexicana de Hepatología

2018, Number 2

<< Back Next >>

Ann Hepatol 2018; 17 (2)

Viscoelastic Testing in Liver Disease

Davis JPE, Northup PG, Caldwell SH, Intagliata NM

Language: English
References: 45
Page: 205-213
PDF size: 160.67 Kb.


ABSTRACT

Long thought to be hypocoagulable, new evidence suggests cirrhosis patients have “rebalanced” coagulation in the setting of decreased synthesis of both pro- and anti-coagulant factors. Traditional testing like PT/INR reflects only the decreased synthesis of pro-coagulant factors and thus does not correspond to bleeding or clotting risk in this population. In this review, we discuss the use of viscoelastic testing (VET), an assay of global hemostasis in cirrhosis patients. We describe the technique and interpretation of commercially available VET and assess the application of VET in both transplant and non-transplant cirrhosis populations. VET largely correlates well with traditional testing including platelet count and fibrinogen level, however, is potentially less accurate in patients with low fibrinogen levels. VET may be useful in identifying patients at higher risk of hypercoagulable complications post-transplant and reflects changes in hemostasis in decompensated patients. While VET has been associated with decreased transfusion support in multiple studies, the lack of bleeding in patients who avoided prophylactic transfusion suggests a “rescue” rather than prophylactic approach to transfusion may be ideal and further studies with a “rescue” arm are needed. Additional prospective studies of VET should include clinically relevant endpoints of bleeding and thrombosis.


REFERENCES

  1. Tripodi A, Mannucci PM. The coagulopathy of chronic liver disease. N Engl J Med 2011; 365: 147-56.

  2. Tripodi A, Primignani M, Mannucci PM, Caldwell SH. Changing Concepts of Cirrhotic Coagulopathy. Am J Gastroenterol 2017; 112: 274-81.

  3. Sogaard KK, Horvath-Puho E, Gronbaek H, Jepsen P, Vilstrup H, Sorensen HT. Risk of venous thromboembolism in patients with liver disease: a nationwide population-based case-control study. Am J Gastroenterol 2009; 104: 96-101.

  4. Ambrosino P, Tarantino L, Di Minno G, Paternoster M, Graziano V, Petitto M, Nasto A, et al. The risk of venous thromboembolism in patients with cirrhosis. A systematic review and metaanalysis. Thromb Haemost 2017; 117: 139-48.

  5. Segal JB, Dzik WH, Transfusion Medicine/Hemostasis Clinical Trials N. Paucity of studies to support that abnormal coagulation test results predict bleeding in the setting of invasive procedures: an evidence-based review. Transfusion 2005; 45: 1413-25.

  6. de Boer MT, Molenaar IQ, Hendriks HG, Slooff MJ, Porte RJ. Minimizing blood loss in liver transplantation: progress through research and evolution of techniques. Dig Surg 2005; 22: 265-75.

  7. Garcia-Tsao G, Bosch J. Varices and Variceal Hemorrhage in Cirrhosis: A New View of an Old Problem. Clin Gastroenterol Hepatol 2015; 13: 2109-17.

  8. Boks AL, Brommer EJ, Schalm SW, Van Vliet HH. Hemostasis and fibrinolysis in severe liver failure and their relation to hemorrhage. Hepatology 1986; 6: 79-86.

  9. Lentschener C, Flaujac C, Ibrahim F, Gouin-Thibault I, Bazin M, Sogni P, Samama CM. Assessment of haemostasis in patients with cirrhosis: Relevance of the ROTEM tests?: A prospective, cross-sectional study. Eur J Anaesthesiol 2016; 33: 126-33.

  10. Kleinegris MC, Bos MH, Roest M, Henskens Y, Ten Cate- Hoek A, Van Deursen C, Spronk HM, et al. Cirrhosis patients have a coagulopathy that is associated with decreased clot formation capacity. J Thromb Haemost 2014; 12: 1647-57.

  11. Chau TN, Chan YW, Patch D, Tokunaga S, Greenslade L, Burroughs AK. Thrombelastographic changes and early rebleeding in cirrhotic patients with variceal bleeding. Gut 1998; 43: 267-71.

  12. Papatheodoridis GV, Patch D, Webster GJ, Brooker J, Barnes E, Burroughs AK. Infection and hemostasis in decompensated cirrhosis: a prospective study using thrombelastography. Hepatology 1999; 29: 1085-90.

  13. Stravitz RT, Lisman T, Luketic VA, Sterling RK, Puri P, Fuchs M, Ibrahim A, et al. Minimal effects of acute liver injury/acute liver failure on hemostasis as assessed by thromboelastography. J Hepatol 2012; 56: 129-36.

  14. Rossetto V, Spiezia L, Senzolo M, Rodriguez-Castro KI, Maggiolo S, Simioni P. Whole blood rotation thromboelastometry (ROTEM(R)) profiles in subjects with non-neoplastic portal vein thrombosis. Thromb Res 2013; 132: e131-e134.

  15. Montalto P, Vlachogiannakos J, Cox DJ, Pastacaldi S, Patch D, Burroughs AK. Bacterial infection in cirrhosis impairs coagulation by a heparin effect: a prospective study. J Hepatol 2002; 37: 463-70.

  16. Hartert H. [Not Available]. Klin Wochenschr 1948; 26: 577-83.

  17. Kang YG, Martin DJ, Marquez J, Lewis JH, Bontempo FA, Shaw BW, Jr., Starzl TE, et al. Intraoperative changes in blood coagulation and thrombelastographic monitoring in liver transplantation. Anesth Analg 1985; 64: 888-96.

  18. Gorlinger K, Shore-Lesserson L, Dirkmann D, Hanke AA, Rahe-Meyer N, Tanaka KA. Management of hemorrhage in cardiothoracic surgery. J Cardiothorac Vasc Anesth 2013; 27: S20-S34.

  19. Hanke AA, Horstmann H, Wilhelmi M. Point-of-care monitoring for the management of trauma-induced bleeding. Curr Opin Anaesthesiol 2017; 30: 250-6.

  20. Ganter MT, Hofer CK. Coagulation monitoring: current techniques and clinical use of viscoelastic point-of-care coagulation devices. Anesth Analg 2008; 106: 1366-75.

  21. Raviv G, Cramer DB, Epstein M, Zuckerman L, Caprini JA. Electronic readout for three-channel thrombelastograph. J Med 1978; 9: 17-31.

  22. Ferrante EA, Blasier KR, Givens TB, Lloyd CA, Fischer TJ, Viola F. A Novel Device for the Evaluation of Hemostatic Function in Critical Care Settings. Anesth Analg 2016; 123: 1372-9.

  23. Abuelkasem E, Mazzeffi MA, Lu SY, Planinsic RM, Sakai T, Tanaka KA. Ex vivo evaluation of 4 different viscoelastic assays for detecting moderate to severe coagulopathy during liver transplantation. Liver Transpl 2016; 22: 468-75.

  24. Anderson L, Quasim I, Steven M, Moise SF, Shelley B, Schraag S, Sinclair A. Interoperator and intraoperator variability of whole blood coagulation assays: a comparison of thromboelastography and rotational thromboelastometry. J Cardiothorac Vasc Anesth 2014; 28: 1550-7.

  25. Seo H, Choi JH, Moon YJ, Jeong SM. FIBTEM of Thromboelastometry does not Accurately Represent Fibrinogen Concentration in Patients with Severe Hypofibrinogenemia During Liver Transplantation. Ann Transplant 2015; 20: 342-50.

  26. Jeong SM, Song JG, Seo H, Choi JH, Jang DM, Hwang GS. Quantification of Both Platelet Count and Fibrinogen Concentration Using Maximal Clot Firmness of Thromboelastometry During Liver Transplantation. Transplant Proc 2015; 47: 1890-5.

  27. Wang SC, Shieh JF, Chang KY, Chu YC, Liu CS, Loong CC, Chan KH, et al. Thromboelastography-guided transfusion decreases intraoperative blood transfusion during orthotopic liver transplantation: randomized clinical trial. Transplant Proc 2010; 42: 2590-3.

  28. Wang SC, Lin HT, Chang KY, Mandell MS, Ting CK, Chu YC, Loong CC, et al. Use of higher thromboelastogram transfusion values is not associated with greater blood loss in liver transplant surgery. Liver Transpl 2012; 18: 1254-8.

  29. Blasi A, Beltran J, Pereira A, Martinez-Palli G, Torrents A, Balust J, Zavala E, et al. An assessment of thromboelastometry to monitor blood coagulation and guide transfusion support in liver transplantation. Transfusion 2012; 52: 1989-98.

  30. De Pietri L, Bianchini M, Montalti R, De Maria N, Di Maira T, Begliomini B, Gerunda GE, et al. Thrombelastography-guided blood product use before invasive procedures in cirrhosis with severe coagulopathy: A randomized, controlled trial. Hepatology 2016; 63: 566-73.

  31. Roullet S, Pillot J, Freyburger G, Biais M, Quinart A, Rault A, Revel P, et al. Rotation thromboelastometry detects thrombocytopenia and hypofibrinogenaemia during orthotopic liver transplantation. Br J Anaesth 2010; 104: 422-8.

  32. Song JG, Jeong SM, Jun IG, Lee HM, Hwang GS. Five-minute parameter of thromboelastometry is sufficient to detect thrombocytopenia and hypofibrinogenaemia in patients undergoing liver transplantation. Br J Anaesth 2014; 112: 290- 7.

  33. Yang Lu S, Tanaka KA, Abuelkasem E, Planinsic RM, Sakai T. Clinical applicability of rapid thrombelastography and functional fibrinogen thrombelastography to adult liver transplantation. Liver Transpl 2014; 20: 1097-105.

  34. De Pietri L, Bianchini M, Rompianesi G, Bertellini E, Begliomini B. Thromboelastographic reference ranges for a cirrhotic patient population undergoing liver transplantation. World J Transplant 2016; 6: 583-93.

  35. Abuelkasem E, Lu S, Tanaka K, Planinsic R, Sakai T. Comparison between thrombelastography and thromboelastometry in hyperfibrinolysis detection during adult liver transplantation. Br J Anaesth 2016; 116: 507-12.

  36. Trzebicki J, Flakiewicz E, Kosieradzki M, Blaszczyk B, Kolacz M, Jureczko L, Pacholczyk M, et al. The use of thromboelastometry in the assessment of hemostasis during orthotopic liver transplantation reduces the demand for blood products. Ann Transplant 2010; 15: 19-24.

  37. Zahr Eldeen F, Roll GR, Derosas C, Rao R, Khan MS, Gunson BK, Hodson J, et al. Preoperative Thromboelastography as a Sensitive Tool Predicting Those at Risk of Developing Early Hepatic Artery Thrombosis After Adult Liver Transplantation. Transplantation 2016; 100: 2382-90.

  38. Krzanicki D, Sugavanam A, Mallett S. Intraoperative hypercoagulability during liver transplantation as demonstrated by thromboelastography. Liver Transpl 2013; 19: 852-61.

  39. Hendriks HG, Meijer K, de Wolf JT, Porte RJ, Klompmaker IJ, Lip H, Slooff MJ, et al. Effects of recombinant activated factor VII on coagulation measured by thromboelastography in liver transplantation. Blood Coagul Fibrinolysis 2002; 13: 309-13.

  40. Shin KH, Kim IS, Lee HJ, Kim HH, Chang CL, Hong YM, Yoon KT, et al. Thromboelastographic Evaluation of Coagulation in Patients With Liver Disease. Ann Lab Med 2017; 37: 204-12.

  41. Lloyd-Donald P, Vasudevan A, Angus P, Gow P, Martensson J, Glassford N, Eastwood GM, et al. Coagulation in acutely ill patients with severe chronic liver disease: Insights from thromboelastography. J Crit Care 2017; 38: 215-24.

  42. Tripodi A, Primignani M, Chantarangkul V, Viscardi Y, Dell'Era A, Fabris FM, Mannucci PM. The coagulopathy of cirrhosis assessed by thromboelastometry and its correlation with conventional coagulation parameters. Thromb Res 2009; 124: 132-6.

  43. Vucelic D, Jesic R, Jovicic S, Zivotic M, Grubor N, Trajkovic G, Canic I, et al. Comparison of standard fibrinogen measurement methods with fibrin clot firmness assessed by thromboelastometry in patients with cirrhosis. Thromb Res 2015; 135: 1124-30.

  44. Clayton DG, Miro AM, Kramer DJ, Rodman N, Wearden S. Quantification of thrombelastographic changes after blood component transfusion in patients with liver disease in the intensive care unit. Anesth Analg 1995; 81: 272-8.

  45. Intagliata NM, Caldwell SH, Porte RJ, Lisman T. Prediction of bleeding in cirrhosis patients: Is the forecast any clearer? Hepatology 2016; 64: 989-90.




2020     |     www.medigraphic.com