Wilson Samantha, Joseph Joanne, Danta Mark, Rabbolini David J
Gastroenterology and Hepatology, School of Clinical Medicine, St. Vincent's Healthcare Campus, Faculty of Medicine, University of New South Wales, Sydney, AUS.
Hematology, School of Clinical Medicine, St. Vincent's Healthcare Campus, Faculty of Medicine, University of New South Wales, Sydney, AUS.
Cureus. 2023 Jul 5;15(7):e41401. doi: 10.7759/cureus.41401. eCollection 2023 Jul.
A state of "re-balanced haemostasis" describes complex coagulation changes that arise in patients with liver disease. Changes include alterations in procoagulant and anticoagulant proteins, platelets and von Willebrand factor, as well as the fibrinolytic system. Various circumstances including infection, trauma, or surgery may disrupt this balance and predispose an individual to bleeding or thrombosis. The prothrombin time, international normalised ratio, and activated partial thromboplastin time are conventional coagulation screening tests that are routinely employed by clinicians to investigate unexplained bleeding, monitor anticoagulation, and inform preoperative assessments of bleeding risk. These standard coagulation tests assess quantitative defects in procoagulant clotting factors and are insensitive to levels of natural anticoagulants, which together with procoagulant factors, are often perturbed in liver disease. Therefore, the prolongation of clotting times measured by these tests often does not reflect the multifaceted alterations of haemostasis in these patients. Viscoelastic testing (VET) provides a more encompassing assessment of clotting function by recording real-time viscoelastic changes in whole blood and includes parameters that provide information on coagulation factor function, platelet contribution to clot formation, as well as fibrinolysis. To date, VET has been employed to predict and inform transfusion support in obstetric, trauma, and cardiac surgical fields, and its use in patients undergoing liver transplantation is well established. The ability of VET to accurately predict bleeding risk and precisely guide transfusion algorithms for patients with liver disease undergoing other invasive procedures or experiencing bleeding complications has been the topic of research over the last decade. This review is a critical summary of this data and provides a detailed snapshot of the position of VET as a clinical tool in patients with liver disease.
“重新平衡的止血状态”描述了肝病患者出现的复杂凝血变化。这些变化包括促凝和抗凝蛋白、血小板和血管性血友病因子以及纤维蛋白溶解系统的改变。包括感染、创伤或手术在内的各种情况可能会破坏这种平衡，使个体易发生出血或血栓形成。凝血酶原时间、国际标准化比值和活化部分凝血活酶时间是传统的凝血筛查试验，临床医生经常使用这些试验来调查不明原因的出血、监测抗凝情况以及告知术前出血风险评估。这些标准凝血试验评估促凝凝血因子的定量缺陷，对天然抗凝剂的水平不敏感，而天然抗凝剂与促凝因子一起在肝病中经常受到干扰。因此，通过这些试验测得的凝血时间延长往往不能反映这些患者止血的多方面改变。粘弹性检测（VET）通过记录全血中的实时粘弹性变化，对凝血功能提供了更全面的评估，并且包括提供有关凝血因子功能、血小板对凝块形成的贡献以及纤维蛋白溶解信息的参数。迄今为止，VET已被用于预测和指导产科、创伤和心脏手术领域的输血支持，并且其在肝移植患者中的应用已经得到充分确立。在过去十年中，VET准确预测出血风险并精确指导接受其他侵入性手术或出现出血并发症的肝病患者输血算法的能力一直是研究的主题。这篇综述是对这些数据的批判性总结，并详细概述了VET作为肝病患者临床工具的地位。
