LE11 MANAGEMENT OF HEMOSTASIS ABNORMALITIES IN CIRRHOSIS: FROM BRANCH TO BEDSIDE

Common interventions in patients with cirrhosis include infusion of platelets, fresh-frozen-plasma (FFP) or recombinant-activated-factor VII (rFVIIa). They are, however, based on biological plausibility, rather than on evidence from practice or trials. Thrombocytopenia is a distinct feature of cirrhosis. However, an in-vitro study showed that increased levels of von Willebrand factor make platelets to adhere normally. Another study showed that platelets from cirrhotics are able to support thrombin-generation if counts are in the range of 50-60x10(9)/L. These observations suggest that thrombocytopenia should not be an issue if patients are not severely thrombocytopenic. The coagulation balance is restored as the reduction of procoagulants is counteracted by a reduction of anticoagulants. In-vitro experiments showed that cirrhotics generate normal amounts of thrombin, despite the prolongation of the PT, indicating that PT does not truly represent coagulation in-vivo. However, the above observations were not taken into consideration and FFP has been (and is still) used based on arbitrary PT-INR cut-off. A recent study attempted to evaluate the value of FFP. Plasma from cirrhotics was added with a pooled-normal-plasma in a proportion to achieve that obtained upon infusion of 15mL/kg. PT was shortened, but thrombin-generation was unaffected. rFVIIa showed a poor efficacy in patients with variceal bleeding or undergoing hepatectomy. The above observations cast doubt on the value of FFP or rFVIIa. The culprit(s) for the bleeding should be searched for elsewhere (portal-hypertension, bacterial-infections, endothelial-dysfunction, etc.). Perhaps, interventions aimed at treating the above conditions might be more effective than platelets, FFP or rFVIIa.