Blonski Wojciech, Siropaides Timothy, Reddy K Rajender
K. Rajender Reddy, MD Division of Gastroenterology, Hospital of the University of Pennsylvania, 3400 Spruce Street, 2 Dulles, Philadelphia, PA 19104, USA.
Curr Treat Options Gastroenterol. 2007 Dec;10(6):464-73. doi: 10.1007/s11938-007-0046-7.
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.
肝脏在止血过程中起着核心作用，因为它是凝血因子、凝血抑制剂和纤维蛋白溶解蛋白的合成场所。肝病中最常见的凝血障碍包括血小板减少和体液凝血受损。治疗的总体目标不是完全纠正实验室值异常，而是实现止血。对于因维生素K缺乏、营养不良、使用抗生素以及患有胆汁淤积性肝病的患者（尤其是在进行侵入性操作之前），维生素K治疗可能是一种有用的选择。输注新鲜冰冻血浆通常更有效，对于肝病患者在进行侵入性操作或手术前推荐使用，因为这类患者需要暂时纠正其凝血酶原时间。对于因容量超负荷风险而无法用新鲜冰冻血浆治疗的患者，可以考虑血浆置换治疗。对于患有严重凝血病和低纤维蛋白原血症的患者，冷沉淀治疗是理想的选择。由于血栓形成并发症风险高，肝病患者很少采用凝血酶原复合物浓缩物治疗。对于有活动性出血或在进行侵入性操作前血小板计数短期升高的血小板减少患者（血小板计数<50,000/mm³），输注血小板是合适的。对于肝病患者且出血时间难治性延长的患者，在进行侵入性操作前可考虑试用去氨加压素。对于凝血酶原时间显著延长且有新鲜冰冻血浆治疗禁忌证的患者，建议使用重组活化因子VIIa；然而，这很昂贵。血小板生成素和白细胞介素-11目前正在对慢性肝病血小板减少患者进行研究。肝移植可完全恢复受损的凝血异常，是纠正晚期肝病和肝衰竭凝血病的最终干预措施。
