Viscoelastic tests in liver disease: where do we stand now?

Area of Science:

• Physiology
• Hematology
• Hepatology

Background:

• Hemostasis involves a balance between pro-coagulant and anticoagulant systems.
• Traditional views considered cirrhotic patients to have a bleeding disorder.
• The rebalanced hemostasis theory posits a fragile equilibrium in liver disease.

Purpose of the Study:

• To evaluate the utility of viscoelastic tests (VET) in assessing hemostasis in liver disease.
• To compare VET with standard coagulation tests for predicting bleeding risk.
• To explore the role of VET in managing cirrhotic patients undergoing interventions.

Main Methods:

• Review of standard coagulation tests (INR, platelet count, fibrinogen).
• Analysis of point-of-care viscoelastic tests (VET) like ROTEM and TEG.
• Comparison of VET findings with clinical bleeding outcomes in liver disease patients.

Main Results:

• Standard tests do not fully represent the complex hemostatic balance in liver disease.
• VET provides dynamic, real-time hemostasis information, including clot initiation, kinetics, strength, and lysis.
• Despite abnormal standard tests, VET can be normal in many liver disease patients, yet still predicts bleeding risk better than conventional methods.
• Inappropriate clotting is a subtle but significant risk in these patients.

Conclusions:

• VET offers a more accurate assessment of bleeding risk in liver disease than standard coagulation tests.
• VET may help guide transfusion strategies, potentially reducing blood product use.
• Further research is needed to establish VET cut-off values and standardize transfusion guidelines for cirrhotic patients, especially before invasive procedures and liver transplantation.