Algorithms for managing coagulation disorders in liver disease

Patients with advanced liver disease have traditionally been considered at risk for bleeding complications. However, although bleeding in patients with cirrhosis frequently occurs due to complications of portal hypertension, research performed within the last 15 years has increasingly shown that hemostasis in patients with liver failure generally achieves a state of "rebalance", whereby compensatory systems restore a relatively neutral or even slightly pro-thrombotic state. Much recent clinical and in vitro research has, in fact, shown over-compensation, such that patients with acute and stable chronic liver failure may have a thrombotic tendency, which may participate in the progression of liver disease and cause systemic and portal thrombosis. Investigators have started to identify differences in hemostasis in patients with unstable cirrhosis, the newly defined syndrome of acute-on-chronic liver failure (ACLF), compared to those with stable cirrhosis. The following discussion will summarize much of the background of rebalanced hemostasis in patients with cirrhosis and acute liver failure (ALF), and suggest management algorithms for coagulation abnormalities before invasive procedures, during active bleeding, and for prophylaxis and treatment of thrombotic complications.