Complications from both pro- and antithrombotic states are seen in patients with cirrhosis. Therefore, a common scenario for the clinician is considering anticoagulation in a patient while worrying about bleeding risk.
Four experts reviewed the current and evolving data on coagulation in this population and provided clinical practice advice, including the following:
- Clinicians should not routinely correct thrombocytopenia and coagulopathy for low-risk procedures such as band ligation of varices, paracentesis, and thoracentesis.
- For active bleeding and to minimize bleeding in high-risk procedures:
- A platelet count target >50,000 is still advised.
- Less reliance on international normalized ratio (INR) as a measure of hemostasis is advised.
- New measures of hemostasis including fibrinogen level (target >120 mg/dL) and viscoelastic tests that are global tests of clot formation, such as thromboelastography (TEG), are becoming a part of routine practice.
- The use of procoagulants, typically platelets and fresh frozen plasma, can lead to infectious, transfusion-related, and immunologic complications if overutilized. Alternatives to consider include:
- Anticoagulation considerations:
- In patients with symptomatic deep venous thrombosis (DVT) or portal vein thrombosis (PVT), systemic heparin infusion is recommended.
- Treatment of incidental PVT should be considered in transplantation candidates, as extensive thrombosis could impact surgical candidacy.
- For PVT therapy, low-molecular-weight heparin, direct-acting anticoagulants, and vitamin K antagonists are recommended.
- Once anticoagulation for PVT is started, 6-month follow-up imaging is recommended to assess efficacy.