Coagulopathy in Cirrhosis¶

John Laurenzano

Background¶

The liver is responsible for production of both pro- (factor II, V, VII, IV, X, and XI) and anti-coagulants (protein C, S) in hemostasis. Factor VIII is the only one not made by the liver.
Thrombocytopenia is caused by splenic sequestration from portal HTN, failure to produce thrombopoietin (TPO), and bone marrow failure
Hemostatic changes in cirrhotics are incredibly complex, as they involve both procoagulant and anticoagulants. The current thought is that cirrhosis is NO LONGER considered a condition associated with an overall increased bleeding tendency, as the pro-hemostatic and anti-hemostatic pathways are deranged in a way that counterbalance each other.

Pre-procedural FFP is not recommended, as it has potential harm w/o proven benefit
Low risk procedures (i.e., paracentesis) do not require pre-procedural blood products and per guidelines there is no established INR or platelet cut off
In bleeding pts, the following are recommended per AASLD and AGA guidelines
- IV Vitamin K 10mg x 3 days
- FFP: Not recommended, unless as part of a balanced transfusion effort to avoid transfusion related coagulopathy, or if a TEG screen suggests potential benefit
- Cryoprecipitate: if fibrinogen < 120
- Platelets: No specific targets regardless of bleeding. Pre-procedurally, recommend >50
Appropriate DVT ppx should be given with few exceptions (plts <50k, active hemorrhage)
For TEG transfusion recommendations are as follows:
- 10 mg/kg FFP if R-time >10 minutes
- 1u Plts if maximum amplitude <55 mm
- 5u cryo if alpha angle <45