Department of General, Visceral and Transplantation Surgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany.
Digestion. 2013;88(3):135-44. doi: 10.1159/000354400. Epub 2013 Sep 5.
Liver transplantation in cirrhotic patients is accompanied by severe bleeding. Indeed, the first 100 recipients of liver allografts transplanted by Thomas E. Starzl died mainly by uncontrolled bleeding. Since then, much progress has been made as to the understanding of the pathophysiology and the treatment of hemostatic disorders in cirrhotic patients. The aim of this review is to provide a state-of-the-art overview on recent developments and treatment options for hemostatic disorder in cirrhotic patients. Patients with end-stage-liver disease (ESLD) do not suffer only from procoagulant deficiency; there is also a lack of natural anticoagulants (i.e. proteins C and S) and profibrinolytics. Conventional laboratory methods such as the determination of the international normalized ratio or the activated partial thromboplastin time cannot predict bleeding complications in these patients. Progressive diagnostic techniques reveal that cirrhotic patients have the same capacity to produce thrombin like healthy volunteers. Moreover, cirrhotic patients--and particularly those with primary biliary cirrhosis or primary sclerosing cholangitis-- are at a higher risk for developing thrombosis as compared with healthy controls. Hemostatic alterations are common in cirrhotic patients; they involve both the pro- and the anticoagulant pathways. However, this is a very delicate balance, which may be shifted to either of these pathways by different treatments thereby causing bleeding or thrombosis, respectively.
肝移植治疗肝硬化患者常伴随严重出血。实际上，Thomas E. Starzl 移植的第一批 100 例肝移植受体主要死于无法控制的出血。自此，人们对肝硬化患者止血障碍的病理生理学和治疗有了更多的了解。本篇综述旨在提供关于肝硬化患者止血障碍的最新进展和治疗选择的最新概况。终末期肝病（ESLD）患者不仅存在促凝因子缺乏，还缺乏天然抗凝剂（即蛋白 C 和 S）和纤溶抑制剂。常规实验室方法，如国际标准化比值或部分活化凝血酶时间的测定，不能预测这些患者的出血并发症。不断发展的诊断技术表明，肝硬化患者产生凝血酶的能力与健康志愿者相同。此外，与健康对照组相比，肝硬化患者（尤其是原发性胆汁性胆管炎或原发性硬化性胆管炎患者）发生血栓的风险更高。止血异常在肝硬化患者中很常见；它们涉及促凝和抗凝途径。然而，这是一个非常微妙的平衡，不同的治疗方法可能会使这种平衡向任一途径倾斜，从而分别导致出血或血栓形成。
