Procedure-related bleeding in advanced chronic liver disease does not increase without pre-emptive use of prothrombin complex concentrates.

L. Skladany; P. Molcan; E. Cellarova; D. Jancekova; J. Svac

Volume : VII, Issue : XII, December - 2018

Procedure-related bleeding in advanced chronic liver disease does not increase without pre-emptive use of prothrombin complex concentrates.

L. Skladany, P. Molcan, E. Cellarova, D. Jancekova, J. Svac

Abstract :

BACKGROUND. Procedure–related bleeding (PRB) in patients (pts) with liver cirrhosis (advanced chronic liver disease, ACLD) is a serious problem. Standard protocol (SP) for prevention of PRB usualy consists of three steps: 1) consultation of haematologist before the procedure; 2) standard panel of in vitro haemocoagulation tests (HT); 3) preemptive haematological therapy based on results of these tests and calculated by haematologist. In step 3, haemocoagulation factors (HF) administered with intent to correct abnormalities in HT. The understanding of haemostasis in ACLD has changed in recent years, however. It is believed, that: i) the haemostatic balance is re–set to equiliium (albeit fragile), or even to a slight pro–coagulant state; ii) standard HT has questionable (if any) role in guiding the prevention of PRB; iii) administering HF prophylactically based on the results of HT does not decrease the rate of PRB, and may lead to increase in portal hypertension, serious adverse events and considerable cost. Therefore, authorities have discouraged universal use of HF based on the results of HT (i.e. ommission of step 3); rather, they advised on either watchfull waiting with HF administered only on demand – in cases of PRB, or using HF based on new generation HT such as thromboelastometry.

AIMS. To compare the rates of PRB between two groups of pts with ACLD: those managed according to 3–step SP (Group A) to 2–step modified protocol (MP, Group B).

METHODS. Retrospective study. Analysis of charts from the hospital information system database. Group A (SP): consecutive pts admitted for between January 1^st, 2011 and August 31^st, 2012; these pts were administered full doses of HF as calculated by haematologist based on HT (step 3) before procedures. Group B (MP, ommision of step 3): consecutive pts hospitalized between september 1^st, 2012 and december 31^st, 2013; HF were administered only in cases of PRB.

Whole cohort consisted of consecutive patients referred to consider LTx candidacy.

Inclusion criteria: ACLD considered as an indication for LTx; requirement of invasive procedure according to pre–LTx protocol. Recorded variables: gender, etiology of ACLD, Model of end–stage liver disease (MELD), Child–Pugh score, prothrombin time, INR, platelet count, aPTT, fiinogen, PRB, use of HF.

RESULTS. PRB has been recorded in 23% of pts from SP and in 21% from MP (ns). The average expenditures per patient in Group A and B were �536.58 and �384.53 (p = 0.02), resulting in overall savings of �152per patient.

CONCLUSION In pts with ACLD considered for LTx, withelding HF before procedures did not increase the rate of PRB and led to consederable costs–savings.