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Viscoelastic haemostatic assays in chronic liver disease-Profiling coagulation in the emergency department
Akmez Latona1,2,3,4, Kate Hill5,6, Lara Roberts7
1Emergency Department, Ipswich Hospital, Ipswich, Queensland, Australia.
Insights
Viscoelastic haemostatic assays (VHAs) reveal predominant hypocoagulability in chronic liver disease (CLD) patients, often due to fibrinogen deficiency. Significant discordance with conventional coagulation tests (CCTs) highlights the need for CLD-specific transfusion guidelines.
Area of Science:
- Hepatology
- Coagulation Science
- Emergency Medicine
Background:
- The utility of viscoelastic haemostatic assays (VHAs) compared to conventional coagulation tests (CCTs) in managing chronic liver disease (CLD) patients in emergency departments (EDs) remains unclear.
- Characterizing VHA profiles and assessing their concordance with CCTs in this population is crucial for optimizing patient care.
Purpose of the Study:
- To investigate the role of VHAs versus CCTs in patients with CLD presenting to the ED.
- To characterize VHA profiles, including hypocoagulability, normocoagulability, and hypercoagulability.
- To evaluate the concordance between VHA results and CCT findings.
Main Methods:
- A retrospective analysis of CLD patients presenting to EDs between January 2016 and August 2023.
- Exclusion of post-transfusion results to ensure baseline coagulation assessment.
- Categorization of VHA results (rotational thromboelastometry and thromboelastography) as hypo/normo/hypercoagulable using manufacturer ranges.
- Definition of CCT-defined coagulopathy based on international normalized ratio (INR), platelet count, and fibrinogen levels.
Main Results:
- VHA utilization showed a significant increasing trend over the study period.
- Rotational thromboelastometry (ROTEM) predominantly indicated hypocoagulability (69%), primarily due to fibrinogen deficiency (55%) and factor deficiency (37%).
- Significant discordance was observed between VHA and CCT, particularly in identifying coagulation factor deficiency, with CCT alone detecting it in 42% of paired results versus VHA alone in 3%.
Conclusions:
- Hypocoagulability, driven by reduced fibrin-based clot strength, is the predominant finding in CLD patients assessed by VHAs.
- A marked discordance exists between VHA and CCT results, especially concerning coagulation factor deficiencies.
- The development of CLD-specific thresholds for VHAs and CCTs is essential for guiding transfusion strategies effectively.
Background And Objectives:
The role of viscoelastic haemostatic assays (VHAs) versus conventional coagulation tests (CCTs) in chronic liver disease (CLD) in the emergency department (ED) is undefined. We aimed to characterize VHA profiles and concordance with CCT.
Materials And Methods:
Patients with CLD presenting to EDs (January 2016-August 2023) were included. Post-transfusion results were excluded. VHA was categorized as hypo/normo/hypercoagulable using manufacturer ranges. CCT-coagulopathy was defined as international normalized ratio (INR) >1.5, platelets <50 × 109/L or fibrinogen <1.0 g/L.
Results:
VHA use increased over time (incidence rate ratio [IRR] 1.23, 95% confidence interval [CI]: 1.19-1.28; p < 0.001). Of 438 patients, 397 underwent rotational thromboelastometry (ROTEM) and 41 thromboelastography (TEG). ROTEM showed hypocoagulability in 275 patients (69%), normocoagulability in 84 (21%), hypercoagulability in 18 (5%) and mixed profiles in 14 (4%). Deficits were fibrinogen deficiency in 220 patients (55%), factor deficiency in 148 (37%), hyperfibrinolysis in 42 (11%) and platelet deficiency in 33 (8%). TEG showed hypocoagulability in 22 (54%), normocoagulability in 13 (32%), hypercoagulability in 3 (7%) and mixed profiles in 3 (7%). Deficits included fibrinogen deficiency in 19 patients (46%), factor deficiency in 6 (15%), hyperfibrinolysis in 5 (12%) and platelet deficiency in 3 (7%). In 120 VHA-CCT paired results, fibrinogen deficiency was detected by both in 18%, VHA alone 26%, CCT alone 2%; platelet deficiency by both 5%, VHA alone 5%, CCT alone 5%; factor deficiency by both 22%, VHA alone 3% and CCT alone 42%.
Conclusion:
Hypocoagulability from reduced fibrin-based clot strength was predominant. Marked discordance between VHA and CCT was observed in coagulation factor deficiency. CLD-specific thresholds are required to guide transfusion.
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