Hemostasis in patients with liver disease

In patients with liver disease alterations in the hemostatic system frequently occur. Although it was generally believed that these changes result in a bleeding tendency, laboratory models and clinical data have shown evidence for a rebalanced hemostasis in liver disease, as a result of a concomitant decrease in both pro- and antihemostatic systems. The rebalanced system presumably has much narrower margins as compared to healthy individuals and therefore can more easily turn to either a hypo- or hypercoagulable state. Bleeding does occur in patients with liver disease but this is frequently related to non-hematological factors, for example bleeding from ruptured esophageal varices. Further clinical data supporting the concept of rebalanced hemostasis include the lack of major blood loss in a great proportion of patients during liver transplantation and the fact that patients with liver disease are not fully protected from thromboembolic complications including venous thrombosis and thrombosis of the hepatic vessels. It is still common practice to prophylactically treat patients with liver disease prior to invasive procedures to prevent bleeding. Because of a lack of data supporting the effectiveness of this management and the proven side-effects of transfusion of blood products, we believe transfusion of blood products can and should be restricted. The most important thrombotic problem after liver transplantation is hepatic artery thrombosis, a potentially devastating complication. Since the bleeding tendency in patients with liver disease may not be primarily caused by a deranged hemostatic system, the restricted use of anticoagulant drugs in the post-transplant setting should be reconsidered.