Bleeding complications in acute liver failure

Area of Science:

• Hepatology
• Critical Care Medicine
• Transfusion Medicine

Background:

• Patients with acute liver failure (ALF) often exhibit elevated prothrombin time and thrombocytopenia, leading to a perceived bleeding tendency.
• However, the actual incidence, sources, risk factors, and clinical impact of bleeding complications in ALF have not been well-defined in large patient cohorts.

Purpose of the Study:

• To quantify the incidence, sources, risk factors, and clinical significance of bleeding complications in a large cohort of adult patients with ALF.
• To assess the relationship between bleeding complications and 21-day mortality in ALF patients.

Main Methods:

• Analysis of data from 1,770 adult patients enrolled in the ALF Study Group Registry (1998-2016).
• Collection of data on bleeding complications and blood component transfusions for 7 days post-admission.
• Assessment of the association between bleeding complications and 21-day mortality.

Main Results:

• Bleeding complications occurred in 11% of ALF patients (187/1770), with 84% of spontaneous bleeds originating from the upper gastrointestinal tract.
• Intracranial bleeds occurred in 20 patients, with mortality significantly higher in those with post-procedural bleeds (50% vs 20%).
• Bleeding complications were associated with lower platelet counts and were markers of severe extrahepatic organ system failure, not hepatocellular failure; transfusion of any blood component increased 21-day mortality or need for liver transplantation.

Conclusions:

• Clinically significant bleeding is uncommon in ALF, despite coagulopathy.
• Bleeding complications in ALF are indicators of severe systemic inflammation and portend a poor prognosis.
• Bleeding is the proximate cause of death in only 5% of ALF cases, but transfusion is associated with increased mortality.