Minimal effects of acute liver injury/acute liver failure on hemostasis as assessed by thromboelastography

R. Todd Stravitz, Ton Lisman, Velimir A. Luketic, Richard K. Sterling, Puneet Puri, Michael Fuchs, Ashraf Ibrahim, William M. Lee, Arun J. Sanyal

Research output: Contribution to journalArticle

125 Citations (Scopus)

Abstract

Background & Aims: Patients with acute liver injury/failure (ALI/ALF) are assumed to have a bleeding diathesis on the basis of elevated INR; however, clinically significant bleeding is rare. We hypothesized that patients with ALI/ALF have normal hemostasis despite elevated INR. Methods: Fifty-one patients with ALI/ALF were studied prospectively using thromboelastography (TEG), which measures the dynamics and physical properties of clot formation in whole blood. ALI was defined as an INR ≥1.5 in a patient with no previous liver disease, and ALF as ALI with hepatic encephalopathy. Results: Thirty-seven of 51 patients (73%) had ALF and 22 patients (43%) underwent liver transplantation or died. Despite a mean INR of 3.4 ± 1.7 (range 1.5-9.6), mean TEG parameters were normal, and 5 individual TEG parameters were normal in 32 (63%). Low maximum amplitude, the measure of ultimate clot strength, was confined to patients with platelet counts <126 × 10 9/L. Maximum amplitude was higher in patients with ALF than ALI and correlated directly with venous ammonia concentrations and with increasing severity of liver injury assessed by elements of the systemic inflammatory response syndrome. All patients had markedly decreased procoagulant factor V and VII levels, which were proportional to decreases in anticoagulant proteins and inversely proportional to elevated factor VIII levels. Conclusions: Despite elevated INR, most patients with ALI/ALF maintain normal hemostasis by TEG, the mechanisms of which include an increase in clot strength with increasing severity of liver injury, increased factor VIII levels, and a commensurate decline in pro- and anticoagulant proteins.

Original languageEnglish (US)
Pages (from-to)129-136
Number of pages8
JournalJournal of Hepatology
Volume56
Issue number1
DOIs
StatePublished - Jan 2012

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Thrombelastography
Acute Liver Failure
Hemostasis
International Normalized Ratio
Liver
Wounds and Injuries
Factor VIII
Anticoagulants
Hemorrhage
Systemic Inflammatory Response Syndrome
Factor VII
Factor V
Hepatic Encephalopathy
Disease Susceptibility
Platelet Count
Ammonia
Liver Transplantation
Liver Diseases
Proteins

Keywords

  • Acute liver failure
  • Coagulopathy
  • Hemostasis
  • Hepatic encephalopathy
  • Thromboelastography

ASJC Scopus subject areas

  • Hepatology

Cite this

Stravitz, R. T., Lisman, T., Luketic, V. A., Sterling, R. K., Puri, P., Fuchs, M., ... Sanyal, A. J. (2012). Minimal effects of acute liver injury/acute liver failure on hemostasis as assessed by thromboelastography. Journal of Hepatology, 56(1), 129-136. https://doi.org/10.1016/j.jhep.2011.04.020

Minimal effects of acute liver injury/acute liver failure on hemostasis as assessed by thromboelastography. / Stravitz, R. Todd; Lisman, Ton; Luketic, Velimir A.; Sterling, Richard K.; Puri, Puneet; Fuchs, Michael; Ibrahim, Ashraf; Lee, William M.; Sanyal, Arun J.

In: Journal of Hepatology, Vol. 56, No. 1, 01.2012, p. 129-136.

Research output: Contribution to journalArticle

Stravitz, RT, Lisman, T, Luketic, VA, Sterling, RK, Puri, P, Fuchs, M, Ibrahim, A, Lee, WM & Sanyal, AJ 2012, 'Minimal effects of acute liver injury/acute liver failure on hemostasis as assessed by thromboelastography', Journal of Hepatology, vol. 56, no. 1, pp. 129-136. https://doi.org/10.1016/j.jhep.2011.04.020
Stravitz, R. Todd ; Lisman, Ton ; Luketic, Velimir A. ; Sterling, Richard K. ; Puri, Puneet ; Fuchs, Michael ; Ibrahim, Ashraf ; Lee, William M. ; Sanyal, Arun J. / Minimal effects of acute liver injury/acute liver failure on hemostasis as assessed by thromboelastography. In: Journal of Hepatology. 2012 ; Vol. 56, No. 1. pp. 129-136.
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AU - Sterling, Richard K.

AU - Puri, Puneet

AU - Fuchs, Michael

AU - Ibrahim, Ashraf

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