Haemostatic Balance and Transfusion Strategies in Acute Liver Failure and Acute-On-Chronic Liver Failure: A Systematic Review

Abstract

Patients with acute-on-chronic liver failure (ACLF) and acute liver failure (ALF) exhibit complex hemostatic changes with a ‘rebalanced’ but fragile equilibrium, predisposing them to both bleeding and thrombosis. This review assesses hemostatic profiles, bleeding and thrombotic complications, and management strategies involving blood products in both ACLF and ALF. We conducted a systematic review in PubMed, EMBASE, and Web of Science, identifying 57 studies that addressed the coagulation status and the use of blood products and anticoagulants in ACLF and ALF. Study selection, data extraction and quality assessment were performed by two independent reviewers. In ACLF, global hemostatic assays reveal preserved thrombin generation (TG) alongside hypocoagulability on viscoelastic testing (VETs). Bleeding incidence varies widely (7.35%–67%), as do thrombotic events (4,7%–20%). Prophylactic correction of coagulation abnormalities is discouraged with bleeding management prioritized based on individualized risk assessment, guided by VET. Prophylactic anticoagulation remains controversial, while direct oral anticoagulants are contraindicated. In ALF, despite markedly elevated INR, TG assay and VET indicated preserved hemostatic balance, with hypercoagulability in some patients and true hypocoagulability rarely observed. Bleeding complications occur in 7,4%–18%, while thrombotic complications occur in 6%–21%. Routine INR correction is not recommended; VET may guide procedural/therapeutic decisions. No clear recommendations can be given for thromboprophylaxis. In conclusion, the complex coagulation landscape in ACLF and ALF underscores the need for individualized management balancing hemorrhagic and thrombotic risks. The absence of reliable hemostatic assays to guide prophylactic anticoagulation remains a critical gap. In these high-risk patients, the integration of VET into personalized coagulation assessment might be considered to support individualized bleeding management and transfusion strategies, although further investigation is warranted.