Department of General, Visceral and Transplant Surgery, Medical Center, Universitätsklinikum Essen, University Duisburg-Essen, Essen, Germany.
Department of Anesthesia and Perioperative Medicine, Penn State College of Medicine, Penn State University, Hershey, Pennsylvania, USA.
Curr Opin Crit Care. 2019 Apr;25(2):179-186. doi: 10.1097/MCC.0000000000000591.
This review provides insight into our current understanding of the pathophysiology and treatment of coagulopathy associated with liver failure, and bleeding risk assessment.
Patients with end-stage liver disease (ESLD) have a rebalanced coagulation profile and are at risk for both excessive clotting and bleeding. Hypercoagulability is associated with profound endothelial dysfunction and an increased concentration of liver-independent coagulation factors. Because of this rebalanced coagulation profile, standard laboratory tests have been demonstrated to be ineffective in either predicting and/or guiding the management of coagulopathy. Viscoelastic testing, however, is able to provide a dynamic assessment of clot formation in whole blood and has been demonstrated to be invaluable in both monitoring and management of coagulation problems associated with liver failure. More recently, there is increasing interest in thrombin generation tests to monitor coagulation in patients with ESLD.Multiple institutional protocols for prophylaxis and treatment of ESLD-related thromboses have been developed. High-quality studies evaluating these approaches are lacking.
Patients with ESLD are at risk for excessive bleeding and clotting. Treatment of any significant coagulopathy should not be based solely on standard laboratory tests. Thrombosis prophylaxis has to be considered in susceptible populations.
本文综述了肝衰竭相关凝血功能障碍及出血风险评估的病理生理学和治疗的最新进展。
终末期肝病（ESLD）患者凝血谱失衡，存在过度凝血和出血风险。高凝状态与严重的内皮功能障碍和肝脏非依赖性凝血因子浓度增加有关。由于这种凝血谱的改变，标准实验室检测在预测和/或指导凝血功能障碍的管理方面已被证明无效。然而，黏弹性检测能够对全血中的血栓形成进行动态评估，并且在监测和管理肝衰竭相关的凝血问题方面具有重要价值。最近，人们对凝血酶生成试验监测 ESLD 患者凝血功能的兴趣日益增加。已经制定了针对 ESLD 相关血栓形成的多种机构预防和治疗方案，但缺乏高质量的研究来评估这些方法。
ESLD 患者有过度出血和凝血的风险。任何明显的凝血功能障碍的治疗不应仅基于标准实验室检测。应考虑易感人群的血栓预防。
