van der Werf J, Porte R J, Lisman T
Surgical Research Laboratory, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
Acta Gastroenterol Belg. 2009 Oct-Dec;72(4):433-40.
In patients with liver disease alterations in the hemostatic system frequently occur. Although it was generally believed that these changes result in a bleeding tendency, laboratory models and clinical data have shown evidence for a rebalanced hemostasis in liver disease, as a result of a concomitant decrease in both pro- and antihemostatic systems. The rebalanced system presumably has much narrower margins as compared to healthy individuals and therefore can more easily turn to either a hypo- or hypercoagulable state. Bleeding does occur in patients with liver disease but this is frequently related to non-hematological factors, for example bleeding from ruptured esophageal varices. Further clinical data supporting the concept of rebalanced hemostasis include the lack of major blood loss in a great proportion of patients during liver transplantation and the fact that patients with liver disease are not fully protected from thromboembolic complications including venous thrombosis and thrombosis of the hepatic vessels. It is still common practice to prophylactically treat patients with liver disease prior to invasive procedures to prevent bleeding. Because of a lack of data supporting the effectiveness of this management and the proven side-effects of transfusion of blood products, we believe transfusion of blood products can and should be restricted. The most important thrombotic problem after liver transplantation is hepatic artery thrombosis, a potentially devastating complication. Since the bleeding tendency in patients with liver disease may not be primarily caused by a deranged hemostatic system, the restricted use of anticoagulant drugs in the post-transplant setting should be reconsidered.
在肝病患者中，止血系统经常发生改变。尽管人们普遍认为这些变化会导致出血倾向，但实验室模型和临床数据表明，由于促凝血和抗凝血系统同时下降，肝病患者的止血功能已重新平衡。与健康个体相比，这种重新平衡的系统可能具有更窄的安全范围，因此更容易转变为低凝或高凝状态。肝病患者确实会出血，但这通常与非血液学因素有关，例如食管静脉曲张破裂出血。支持止血重新平衡概念的进一步临床数据包括，很大一部分患者在肝移植期间没有大量失血，以及肝病患者不能完全预防包括静脉血栓形成和肝血管血栓形成在内的血栓栓塞并发症。在侵入性操作前预防性治疗肝病患者以预防出血仍是常见做法。由于缺乏支持这种治疗有效性的数据以及输血制品已证实的副作用，我们认为输血制品可以而且应该受到限制。肝移植后最重要的血栓问题是肝动脉血栓形成，这是一种潜在的毁灭性并发症。由于肝病患者的出血倾向可能并非主要由止血系统紊乱引起，因此应重新考虑在移植后限制使用抗凝药物。
