Coagulation abnormalities, bleeding, thrombosis, and management of patients with acute liver failure in Australia and New Zealand

Stephen Warrillow, Caleb Fisher, Heath Tibballs, Michael Bailey, Colin McArthur, Pia Lawson-Smith, Bheemasenachar Prasad, Matthew Anstey, Bala Venkatesh, Gemma Dashwood, James Walsham, Andrew Holt, Ubbo Wiersema, David Gattas, Matthew Zoeller, Mercedes Garcia Alvarez, Rinaldo Bellomo

Research output: Contribution to journalArticleResearchpeer-review

Abstract

Background and Aim: To study the management of coagulation and hematological derangements among severe acute liver failure (ALF) patients in Australia and New Zealand liver transplant intensive care units (ICUs). Methods: Analysis of key baseline characteristics, etiology, coagulation and hematological tests, use of blood products, thrombotic complications, and clinical outcomes during the first ICU week. Results: We studied 62 ALF patients. The first day median peak international normalized ratio was 5.5 (inter-quartile range [IQR] 3.8–8.7), median longest activated partial thromboplastin time was 62 s (IQR 44–87), and median lowest fibrinogen was 1.1 (IQR 0.8–1.6) g/L. Fibrinogen was only measured in 85% of patients, which was less than other tests (P < 0.0001). Median initial lowest platelet count was 83 (IQR 41–122) × 109/L. Overall, 58% of patients received fresh frozen plasma, 40% cryoprecipitate, 35% platelets, and 15% prothrombin complex concentrate. Patients with bleeding complications (19%) had more severe overall hypofibrinogenemia and thrombocytopenia. Thrombotic complications were less common (10% of patients), were not associated with consistent patterns of abnormal hemostasis, and were not immediately preceded by clotting factor administration and half occurred only after liver transplantation surgery. Conclusion: In ALF patients admitted to dedicated Australia and New Zealand ICUs, fibrinogen was measured less frequently than other coagulation parameters but, together with platelets, appeared more relevant to bleeding risk. Blood products and procoagulant factors were administered to most patients at variable levels of hemostatic derangement, and bleeding complications were more common than thrombotic complications. This epidemiologic information and practice variability provide baseline data for the design and powering of interventional studies.

Original languageEnglish
Pages (from-to)846-854
Number of pages9
JournalJournal of Gastroenterology and Hepatology
Volume35
Issue number5
DOIs
Publication statusPublished - May 2020

Keywords

  • acute liver failure
  • bleeding
  • coagulopathy
  • encephalopathy emergency liver transplant
  • thrombosis

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