Beyond the INR: Thromboelastography Carries Prognostic Information in Critically Ill Patients With Cirrhosis

In patients with cirrhosis, prolonged international normalized ratio (INR) is primarily driven by liver synthetic dysfunction. Thromboelastography more accurately reflects coagulability and can also predict short-term mortality. Nevertheless, INR is used to define coagulation failure in the European Foundation for the Study of Chronic Liver Failure criteria for acute-on-chronic liver failure (ACLF).

To evaluate the association between TEG parameters and mortality in critically ill patients with cirrhosis and to justify future investigation into TEG as a prognostic tool in ACLF.

We performed a retrospective study of 52 patients with cirrhosis admitted to the intensive care unit (ICU) who had TEG performed during their ICU admission prior to the administration of any blood products. We assessed the association between TEG parameters and 28-day mortality.

Patients who did not survive beyond 28 days generally had more hypocoagulable TEG parameters (R time: 10.0 vs. 7.6, p = 0.03; K time: 3.4 vs. 2.2, p = 0.003; alpha angle: 53.1 vs. 63.5, p = 0.002; MA: 49.2 vs. 60.2, p = 0.001). Although global assessment of TEG demonstrated a state of rebalanced hemostasis among critically ill patients with cirrhosis, patients meeting diagnostic criteria for ACLF tended to have more hypocoagulable TEG parameters as compared to those who did not (coagulation index: 0.2 vs. 2.0, p = 0.004). As proof of concept, MA was incorporated into the definition of ACLF to replace INR as a marker of coagulation failure (TEG-ACLF). The area under the curve (AUC) for TEG-ACLF was 0.83 (0.72-0.95) compared to 0.8 (0.68-0.92) for the current ACLF-CLIF grading, with 9.6% (5/52) of patients being reclassified into a different ACLF grade.

Hypocoagulable TEG parameters are associated with increased 28-day mortality in critically ill patients with cirrhosis, and incorporation of TEG parameters into a modified definition for ACLF may result in improved prediction of short-term mortality.