The liver plays a central role in hemostasis, as it is the site of synthesis of
clotting factors, coagulation inhibitors, and fibrinolytic
proteins. The most common coagulation disturbances occurring in
liver disease include
thrombocytopenia and impaired humoral coagulation.
Therapy's overall goal is not to achieve complete correction of laboratory value abnormalities but to gain hemostasis.
Therapy with
vitamin K may be a useful option in patients with increased prothrombin time due to
vitamin K deficiency; in patients with
malnutrition; in patients using
antibiotics; and in patients with cholestatic
liver disease, particularly prior to invasive procedures. Infusion of fresh frozen plasma is more often effective and is recommended in patients with
liver disease before invasive procedures or surgery, as such patients require transient correction in their prothrombin time.
Therapy with
plasma exchange may be considered in patients who cannot be treated with fresh frozen plasma due to volume overload risk. In patients with severe coagulopathy and hypofibrinogenemia, cryoprecipitate
therapy is ideal.
Therapy with
prothrombin-complex concentrate is seldom pursued in patients with
liver disease due to high risk of thrombotic complications. Transfusions of platelets are appropriate for patients with
thrombocytopenia (< 50,000/mm(3)) associated with active
bleeding or before invasive procedures in which a short-term platelet count increase is noted. Trial with
desmopressin may be considered before invasive procedures in patients with
liver disease and with refractory and prolonged bleeding time. Recombinant activated
factor VIIa administration is suggested for patients with significantly prolonged prothrombin time and
contraindications to fresh frozen plasma
therapy; however, this is expensive.
Thrombopoietin and
interleukin-11 are currently investigational for patients with
thrombocytopenia of chronic
liver disease.
Liver transplantation completely restores impaired coagulation abnormalities and is the ultimate intervention that corrects coagulopathy of advanced
liver disease and
liver failure.