Coagulation in acutely ill patients with severe chronic liver disease

Insights from thromboelastography

Patryck Lloyd-Donald, Abhinav Vasudevan, Peter Angus, Paul Gow, Johan Mårtensson, Neil Glassford, Glenn M. Eastwood, Graeme K Hart, Rinaldo Bellomo

Research output: Contribution to journalArticleResearchpeer-review

Abstract

Background and aims There is controversy about the true coagulation state of acutely ill patients with chronic liver disease (CLD) due to simultaneous pro- and anticoagulant factor deficits and limitations of conventional coagulation tests (CCTs). Thromboelastography (TEG) may provide more physiologically relevant insights. Methods In acutely ill patients with severe (Child-Pugh C) CLD, we conducted a prospective observational study of daily coagulation assessment with both CCTs and TEG. Results We studied 34 patients with CLD on a total of 109 occasions (median of 3 samples per patient), comparing findings with 157 healthy controls. Conventional coagulation tests and TEG both demonstrated clear hypocoagulability. Thromboelastography-confirmed delayed clot formation was demonstrated by longer reaction time (1.1 minutes vs 0.6 minutes on rapid TEG; P < .01), longer kinetic time (2.9 minutes vs 1.3; P < .01), more acute α angle (65° vs 72.2° P < .01), and longer activated clotting time (157 seconds vs 105 seconds; P < .01). Patients with CLD demonstrated weaker thrombus strength (maximum amplitude, 43.3 mm vs 61.8 mm; P < .01) and reduced clot lysis (0% vs 1% on rapid TEG; P < .01). Conclusions In acutely ill patients with CLD, TEG demonstrates delayed clot formation and weaker thrombus strength despite decreased clot lysis. This challenges the notion that such patients experience a balanced coagulation state, highlighting the complexity of their coagulopathies.

Original languageEnglish
Pages (from-to)215-224
Number of pages10
JournalJournal of Critical Care
Volume38
DOIs
Publication statusPublished - 1 Apr 2017
Externally publishedYes

Keywords

  • Coagulopathy
  • Global coagulation assays
  • Hepatic cirrhosis
  • Thromboelastography

Cite this

Lloyd-Donald, Patryck ; Vasudevan, Abhinav ; Angus, Peter ; Gow, Paul ; Mårtensson, Johan ; Glassford, Neil ; Eastwood, Glenn M. ; Hart, Graeme K ; Bellomo, Rinaldo. / Coagulation in acutely ill patients with severe chronic liver disease : Insights from thromboelastography. In: Journal of Critical Care. 2017 ; Vol. 38. pp. 215-224.
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abstract = "Background and aims There is controversy about the true coagulation state of acutely ill patients with chronic liver disease (CLD) due to simultaneous pro- and anticoagulant factor deficits and limitations of conventional coagulation tests (CCTs). Thromboelastography (TEG) may provide more physiologically relevant insights. Methods In acutely ill patients with severe (Child-Pugh C) CLD, we conducted a prospective observational study of daily coagulation assessment with both CCTs and TEG. Results We studied 34 patients with CLD on a total of 109 occasions (median of 3 samples per patient), comparing findings with 157 healthy controls. Conventional coagulation tests and TEG both demonstrated clear hypocoagulability. Thromboelastography-confirmed delayed clot formation was demonstrated by longer reaction time (1.1 minutes vs 0.6 minutes on rapid TEG; P < .01), longer kinetic time (2.9 minutes vs 1.3; P < .01), more acute α angle (65° vs 72.2° P < .01), and longer activated clotting time (157 seconds vs 105 seconds; P < .01). Patients with CLD demonstrated weaker thrombus strength (maximum amplitude, 43.3 mm vs 61.8 mm; P < .01) and reduced clot lysis (0{\%} vs 1{\%} on rapid TEG; P < .01). Conclusions In acutely ill patients with CLD, TEG demonstrates delayed clot formation and weaker thrombus strength despite decreased clot lysis. This challenges the notion that such patients experience a balanced coagulation state, highlighting the complexity of their coagulopathies.",
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Coagulation in acutely ill patients with severe chronic liver disease : Insights from thromboelastography. / Lloyd-Donald, Patryck; Vasudevan, Abhinav; Angus, Peter; Gow, Paul; Mårtensson, Johan; Glassford, Neil; Eastwood, Glenn M.; Hart, Graeme K; Bellomo, Rinaldo.

In: Journal of Critical Care, Vol. 38, 01.04.2017, p. 215-224.

Research output: Contribution to journalArticleResearchpeer-review

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N2 - Background and aims There is controversy about the true coagulation state of acutely ill patients with chronic liver disease (CLD) due to simultaneous pro- and anticoagulant factor deficits and limitations of conventional coagulation tests (CCTs). Thromboelastography (TEG) may provide more physiologically relevant insights. Methods In acutely ill patients with severe (Child-Pugh C) CLD, we conducted a prospective observational study of daily coagulation assessment with both CCTs and TEG. Results We studied 34 patients with CLD on a total of 109 occasions (median of 3 samples per patient), comparing findings with 157 healthy controls. Conventional coagulation tests and TEG both demonstrated clear hypocoagulability. Thromboelastography-confirmed delayed clot formation was demonstrated by longer reaction time (1.1 minutes vs 0.6 minutes on rapid TEG; P < .01), longer kinetic time (2.9 minutes vs 1.3; P < .01), more acute α angle (65° vs 72.2° P < .01), and longer activated clotting time (157 seconds vs 105 seconds; P < .01). Patients with CLD demonstrated weaker thrombus strength (maximum amplitude, 43.3 mm vs 61.8 mm; P < .01) and reduced clot lysis (0% vs 1% on rapid TEG; P < .01). Conclusions In acutely ill patients with CLD, TEG demonstrates delayed clot formation and weaker thrombus strength despite decreased clot lysis. This challenges the notion that such patients experience a balanced coagulation state, highlighting the complexity of their coagulopathies.

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