Managing bleeding risk in cirrhotic patients

• Coagulopathy in liver disease is distinctly altered compared to patients with normal liver function
• The INR in liver disease patients does not correlate with bleeding risk
• FFP transfusions can do more harm than benefit, and therefore should not be routinely used to correct abnormal INR levels in patients with  advanced liver disease
• cryoprecipitate is the correct method for treating coagulopathic patients with liver disease, to address the underlying hyperfibrinolysis – IF the fibrinogen is low.

Suggested algorithm for Patients with Cirrhosis

Low-risk procedures: Proceed regardless of lab values

Moderate-/High-Risk Procedures

Proceed if:

Stable INR <= 2.5*

Negative for new or worsening mucocutaneous bleeding.

No high-risk clinical events suggestive of acute on chronic liver failure (ACLF)

Actions for INR >2.5

INR is acutely elevated from baseline or INR > 2.5*: Check fibrinogen. If fibrinogen < 120 mg/dL (< 150 mg/dL if very high risk), give cryoprecipitate 1u/10kg IV over 30 minutes. fibrinogen replacement product.

Suspicion for ACLF (high-risk clinical events such as recent new portosystemic shunt, acute portal vein or large mesenteric venous thrombosis, infection, acutely worsening renal function, acute hepatic injury (acute alcohol- or drug-induced toxicity, acute viral hepatitis), new bacterial infection)

Amicar 4g IV or PO 30 mins prior to procedure then 2g q4hrs x 3

If concern for DIC< consult hematology.

REFERENCE
DeAngelis GA, Khot R, Haskal ZJ, Maitland HS, Northup PG, Shah NL, Caldwell SH. Bleeding Risk and Management in Interventional Procedures in Chronic Liver Disease. J Vasc Interv Radiol. 2016 Nov;27(11):1665-1674. PMID: 27595469

(also reviewed with Carl Berg, Andrew Muir, and Stuart Knectle)