The coagulation changes associated with acute variceal bleeding in patients with HCV-induced cirrhosis as assessed by rotational thromboelastometry

Abstract

Alterations of hemostasis in patients with decompensated cirrhosis are complex. Accordingly, standard coagulation tests are not feasible to evaluate bleeding risk in these patients. The aim of this study was to assess the coagulation kinetics in cirrhotic patients with variceal bleeding using rotational thromboelastometry (ROTEM). ROTEM including EXTEM, INTEM, and FIBTEM which represent extrinsic, intrinsic pathways, and fibrinogen activity, respectively, was measured in 60 cirrhotic patients with variceal bleeding who were compared to 60 patients with stable cirrhosis. APTEM was optionally performed to evaluate fibrinolysis. Overall, cirrhosis patients displayed features of hypofibrinolysis, whereas the state of hypocoagulability was significantly higher in cirrhotic patients with variceal bleeding (61.7% versus 30%, p = 0.001). Values of clot formation time (CFT) by EXTEM and INTEM correlated positively with those of model for end-stage liver disease score (r = 0.529, p = 0.001, and r = 0.595, p < 0.001, respectively). Furthermore, in a multivariate analysis, values of CFT in both assays were significantly associated with increased risk of 1.9 (95% CI = 1.04–2.45, p = 0.02) and of 1.78 (95% CI = 1.02–2.14, p = 0.01), respectively, for occurrence of variceal bleeding. Cirrhotic patients with variceal bleeding frequently showed a hypocoagulable state that is triggered by thrombocytopenia and/or hypofibrinogenemia. CFT by EXTEM and INTEM seemed to be an extra marker for disease severity and prognosis in cirrhosis patients, in addition to its valuable role in prediction of variceal bleeding in these patients. However, large multicenter studies have yet been required.