130 Hemostatic Alterations in Liver Diseases and Liver Transplantation Flashcards

1
Q

Liver parenchymal cells are the site of synthesis of most coagulation factors except

A

Factor VIII [FVIII]

Liver parenchymal cells are the site of synthesis of most coagulation factors (except factor VIII [FVIII]); the natural inhibitors of coagulation, including protein C, protein S, and antithrombin; and essential components of the fibrinolytic system, such as plasminogen, α 2 -antiplasmin, and thrombin activatable fibrinolysis inhibitor (TAFI).

The liver also regulates hemostasis and fibrinolysis by clearing activated coagulation factors and coagulation factor–inhibitor complexes from the circulation.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

TRUE OR FALSE

More than 75% of patients with chronic liver disease, especially in moderate to severe cirrhosis (Child B and C), have reduced platelet counts (<150,000/ μL)

A

TRUE

More than 75% of patients with chronic liver disease, especially in moderate to severe cirrhosis (Child B and C), have reduced platelet counts (< 150,000/ μL)

13% have platelet counts between 50,000 and 75,000/μL

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

vWF antigen levels are strongly (elevated or reduced) in patients with liver disease.

A

Elevated

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Causes of thrombocytopenia in liver disease

A
  • Splenomegaly resulting in sequestration of platelets in the spleen
  • Reduced synthesis of thrombopoietin by the diseased liver
  • Consumption coagulopathy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

FVIII is synthesized primarily in ______________ , whose function is preserved in liver disease.

A

Hepatic sinusoidal endothelial cells

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

TRUE OR FALSE

Fibrinogen levels are frequently in the normal range in patients with chronic liver disease but may be decreased in patients with decompensated cirrhosis or acute liver failure.

A

TRUE

Fibrinogen levels are frequently in the normal range in patients with chronic liver disease but may be decreased in patients with decompensated cirrhosis or acute liver failure.

Qualitative changes in fibrinogen : both defects in speed of clot formation and a thrombogenic clot structure once the clot has matured

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

A more sophisticated test of coagulation measuring the total amount of thrombin generated during coagulation

A

Total thrombin generation test

  • These results suggest that thrombin generation in vivo can be normal in patients with liver failure and that a prolonged PT does not per se indicate a bleeding risk.
  • These findings indicate that a concomitant decrease of pro- and anticoagulant factors results in a rebalanced hemostatic system.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Coagulation test still used in prognostic scores for patients with acute or chronic liver disease

A

International normalized ratio (INR)

The model of end-stage liver disease (MELD) score is used to prioritize patients for liver transplantation.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

All proteins involved in fibrinolysis, both pro- and antifibrinolytic, are synthesized by the liver EXCEPT

A

Tissue plasminogen activator (t-PA) and plasminogen-activator inhibitor (PAI)-1

  • Therefore, chronic liver disease leads to decreased plasma levels of plasminogen, α 2 -antiplasmin, TAFI, and factor XIII.
  • Plasma levels of t-PA are elevated as a result of increased secretion from endothelial cells and/or reduced clearance by the diseased liver.
  • Plasma levels of PAI-1 also are increased but not to the same extent as t-PA, which may lead to a shift in balance in the fibrinolytic system.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Changes That Impair
Hemostasis/ Contribute to Bleeding

A

Primary Hemostasis
* Thrombocytopenia
* Platelet function defects
* Enhanced production of nitric oxide and prostacyclin

Secondary Hemostasis
* Low levels of factors II, V, VII, IX, X, and XI
* Vitamin K deficiency
* Dysfibrinogenemia

Fibrinolysis
* Low levels of α2-antiplasmin, factor XIII, and TAFI
* Elevated t-PA levels

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Changes That Promote
Hemostasis/ Contribute to Thrombosis

A

Primary Hemostasis
* Elevated levels of vWF
* Decreased levels of ADAMTS13

Secondary Hemostasis
* Elevated levels of factor VIII
* Decreased levels of protein C, protein S, antithrombin, α2-macroglobulin, and heparin
cofactor II

Fibrinolysis
* Low levels of plasminogen
* Increase in PAI-1 levels

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

TRUE OR FALSE

Spontaneous bleeding is not frequently encountered in patients with acute liver failure.

A

TRUE

Spontaneous bleeding is not frequently encountered in patients with acute liver failure.

  • A severe decrease of coagulation factors is observed, with strongly increased INR.
  • In contrast to chronic liver disease, patients with acute liver failure frequently have near-normal platelet counts.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

The most severe hemostatic changes during liver transplantation occur when

A

Immediately after reperfusion of the donor liver

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

The most severe bleeding manifestation in patients with liver disease is

A

Bleeding from ruptured esophageal varices

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

TRUE OR FALSE

Abnormal coagulation tests in patients with liver disease are not necessarily associated with a bleeding risk.

A

TRUE

Abnormal coagulation tests in patients with liver disease are not necessarily associated with a bleeding risk.

The current guideline of the American Association for the Study of Liver Diseases (AASLD) and the “Choosing wisely” campaigns of the AASLD and the Canadian Association for the Study of Liver Disease do not recommend the routine use of FFP transfusion for prophylactic correction of an abnormal PT before interventions, such as liver biopsy, whereas other guidelines advise the use of FFP with a low grade of evidence.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Recent guidelines advocate the use of fibrinogen concentrate or cryoprecipitate to achieve fibrinogen levels above

A

120 mg/dL

Vitamin K is generally recommended in patients with liver disease and prolonged INR; however, its clinical benefit has been questioned.

16
Q

TRUE OR FALSE

If platelet counts are below 50,000/μL, platelet transfusion is recommended before any intervention, as in other patients without underlying liver disease.

A

TRUE

If platelet counts are below 50,000/μL, platelet transfusion is recommended before any intervention, as in other patients without underlying liver disease.

In case of neurosurgical interventions, platelets should be transfused up to a level of 100,000/μL.

17
Q

Drug used to improve primary hemostasis in patients with hepatitis C

A

Thrombopoietin analogues (eltrombopag, avatrombopag, and lusutrombopag)

In the Eltrombopag Evaluated for its Ability to Overcome Thrombocytopenia and Enable Procedures (ELEVATE) study, a short course of eltrombopag was used to elevate the platelet count before invasive procedures.

18
Q

It is thought to contribute significantly to impaired hemostasis during the anhepatic and reperfusion phases.

A

Hyperfibrinolysis

19
Q

TRUE OR FALSE

Liver disease should not be considered a contraindication for thromboprophylaxis with low-molecularweight heparin (LMWH).

A

TRUE

Liver disease should not be considered a contraindication for thromboprophylaxis with low-molecularweight heparin (LMWH).