Bienholz A, Canbay A, Saner F H
Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Deutschland.
Klinik für Nephrologie, Universitätsklinikum Essen, Universität Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Deutschland.
Med Klin Intensivmed Notfmed. 2016 Apr;111(3):224-34. doi: 10.1007/s00063-015-0027-x. Epub 2015 May 5.
End-stage liver disease is associated with complex alterations in hemostasis. Whereas prognosis is essentially affected by life-threatening bleeding complications in some patients, others, especially those with cholestatic liver diseases, suffer from thromboembolic complications. Standard laboratory values (SLVS; prothrombin time, activated partial thrombin time, platelet count) cannot sufficiently reflect the altered balance of pro- and anticoagulatory factors. Moreover, a couple of studies indicated that SLVS are not able to predict bleeding complications in patients with acute liver failure or decompensated liver cirrhosis.
Use of bed-side coagulation diagnostics such as thrombelastometry/-graphy, detection of thrombocyte function by multiple electrode aggregometry and selective measurement of single factors allows a targeted and causal therapy of hepatic coagulopathies especially in the context of bleeding complications or surgical interventions. In recent years, coagulation management guided by these new devices has contributed to a reduction in transfusion of allogenic blood products, which may be associated with undesirable side effects.
The current review summarizes the complex pathophysiological alterations of hemostasis associated with advanced liver insufficiency and discusses recent upcoming diagnostics and coagulation management in this patient cohort.
终末期肝病与止血功能的复杂改变有关。在一些患者中，预后主要受危及生命的出血并发症影响，而其他患者，尤其是患有胆汁淤积性肝病的患者，则会出现血栓栓塞并发症。标准实验室指标（SLVS；凝血酶原时间、活化部分凝血活酶时间、血小板计数）不能充分反映促凝血和抗凝因子平衡的改变。此外，一些研究表明，SLVS无法预测急性肝衰竭或失代偿期肝硬化患者的出血并发症。
使用床旁凝血诊断方法，如血栓弹力图/血栓弹力描记法、通过多电极聚集法检测血小板功能以及选择性测量单个因子，能够对肝脏凝血障碍进行有针对性的病因治疗，尤其是在出血并发症或手术干预的情况下。近年来，由这些新设备指导的凝血管理有助于减少异体血制品的输注，而异体血制品可能会带来不良副作用。
本综述总结了与晚期肝功能不全相关的止血复杂病理生理改变，并讨论了该患者群体近期出现的诊断方法和凝血管理。
