Department of Anaesthesia, Royal Free London NHS Trust, London, United Kingdom.
Semin Thromb Hemost. 2015 Jul;41(5):527-37. doi: 10.1055/s-0035-1550434. Epub 2015 Jun 6.
The concept that patients with stable liver disease are at an increased risk of bleeding, based solely on abnormalities of conventional coagulation tests such as prothrombin time (PT) and international normalized ratio (INR), is now recognized to be an overly simplistic interpretation of an extremely complex situation. These tests are in fact very poor predictors of bleeding in patients with liver disease who undergo invasive or surgical procedures. Commercially available whole blood viscoelastic tests (thromboelastography [TEG] and thromboelastometry [ROTEM]) evaluate the kinetics of coagulation from initial clot formation to final clot strength. These dynamic tests provide a composite picture reflecting the interaction of plasma, blood cells, and platelets, and more closely reflect the situation in vivo than do PT/INR, which are performed on plasma samples and measure isolated end points. Despite prolonged PT/INR and low platelet counts, viscoelastic tests are within normal range in many patients with both acute and chronic liver disease, commensurate with the concept of rebalanced hemostasis, and in keeping with the fact that an increasing number of these patients undergo liver transplantation without the need for blood or blood products. In addition, these tests reveal important additional information, such as the presence of hypercoagulability and a prothrombotic state, and also information about the presence of endogenous heparinoids associated with vascular endothelial damage, due to sepsis or acute inflammation. This review provides an overview of the current literature on the potential clinical utility of viscoelastic tests of coagulation in patients with liver disease.
目前认为，仅根据凝血常规检测（如凝血酶原时间 [PT] 和国际标准化比值 [INR]）的异常来判断稳定期肝病患者存在出血风险，这种观念过于简单化，无法准确反映极其复杂的实际情况。对于即将接受有创或外科手术的肝病患者，这些检测实际上对出血风险的预测效果极差。目前已有商品化的全血粘弹性检测（血栓弹力图 [TEG] 和血栓弹力描记法 [ROTEM]），可评估从初始血栓形成到最终血栓强度的凝血动力学。这些动态检测提供了综合信息，反映了血浆、血细胞和血小板的相互作用，与仅在血浆样本中检测孤立终点的 PT/INR 相比，更能反映体内实际情况。尽管 PT/INR 延长且血小板计数降低，在许多急性和慢性肝病患者中，粘弹性检测仍处于正常范围内，这与重新平衡止血的概念相符，也与越来越多的患者无需输血或血制品即可接受肝移植这一事实相符。此外，这些检测还揭示了重要的附加信息，如存在高凝状态和血栓前状态，以及与血管内皮损伤相关的内源性肝素样物质的存在情况，这可能与脓毒症或急性炎症有关。本文综述了目前关于肝病患者凝血粘弹性检测潜在临床应用价值的相关文献。
