Anesthesiology Department, Hospital Clínic, and University of Barcelona, Spain.
Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS) y Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD).
Hepatology. 2018 Dec;68(6):2325-2337. doi: 10.1002/hep.30103. Epub 2018 Nov 9.
Balanced hemostasis with hypocoagulable and hypercoagulable features may occur in acute-on-chronic liver failure (ACLF). The characteristics and prognostic impact of the coagulation profile in ACLF are unknown. Consecutive patients with ACLF (n = 36) and acute decompensation (AD; n = 24) were included. Blood samples for thromboelastometry (TE) were obtained at admission and 72 hours thereafter. The coagulation profile was evaluated in patients with and without ACLF and in those with and without systemic inflammatory response syndrome. The impact of the coagulation profile on transfusion requirements, bleeding events, and short-term survival was assessed. At admission, patients with ACLF showed more hypocoagulable characteristics compared to AD subjects, with prolonged time to initial fibrin formation and clot formation time and decreased maximum clot firmness and alpha-angle values. TE parameters worsened at 72 hours in ACLF but improved in patients with AD. Prevalence of a hypocoagulable profile (three or more TE parameters outside range) was significantly higher in patients with ACLF either at admission (61% versus 29% in AD; P = 0.03) or during follow-up. Hypocoagulability correlated with systemic inflammation and was associated with higher 28-day (45% versus 16%; P = 0.02) and 90-day (52% versus 19%; P = 0.01) mortality rates but not with transfusion requirements or bleeding. Prolonged time to initial fibrin formation (extrinsic TE assay >80 seconds) and Model for End-Stage Liver Disease score at baseline were independent predictors of 28-day mortality. Conclusion: Patients with ACLF frequently show hypocoagulable features with prolonged time to initial fibrin formation and clot formation time and reduced clot firmness; these alterations worsen after admission, correlate with systemic inflammation, and translate into higher short-term mortality; hypofibrinolysis could contribute to organ failure in ACLF.
在慢加急性肝衰竭（ACLF）中可能会出现低凝和高凝并存的平衡止血状态。ACLF 的凝血特征及其对预后的影响尚不清楚。本研究纳入了连续的 ACLF 患者（n=36）和急性失代偿（AD；n=24）患者。在入院时和此后 72 小时采集血栓弹力图（TE）血液样本。评估了 ACLF 患者和非 ACLF 患者以及有无全身炎症反应综合征（SIRS）患者的凝血特征。评估了凝血特征对输血需求、出血事件和短期生存的影响。入院时，与 AD 患者相比，ACLF 患者表现出更多的低凝特征，初始纤维蛋白形成时间和凝块形成时间延长，最大凝块硬度和 α 角值降低。在 ACLF 患者中，TE 参数在 72 小时时恶化，但在 AD 患者中得到改善。入院时或随访期间，具有 3 项或更多 TE 参数异常的低凝谱的患者在 ACLF 中更为常见（分别为 61%和 29%；P=0.03）。低凝与全身炎症相关，与较高的 28 天（45%比 16%；P=0.02）和 90 天（52%比 19%；P=0.01）死亡率相关，但与输血需求或出血无关。初始纤维蛋白形成时间延长（TE 试验中 80 秒）和基线时终末期肝病模型评分是 28 天死亡率的独立预测因素。结论：ACLF 患者常表现出低凝特征，初始纤维蛋白形成时间和凝块形成时间延长，凝块硬度降低；这些改变在入院后恶化，与全身炎症相关，导致短期死亡率增加；纤溶不足可能导致 ACLF 中的器官衰竭。
