Assessment of coagulopathy by rotational thromboelastometry in patients with cirrhosis and portal hypertension

Background and Aims Patients with advanced chronic liver disease(ACLD) display complex coagulopathies, and the actual state of hemostasis is often not reflected by conventional coagulation tests. Rotational thromboelastometry (ROTEM) measures clot formation and dissolution in real-time. This study aims to assess the relation of portal hypertension (PH) with ROTEM.

Methods ROTEM data, serum levels of C-reactive protein(CRP), lipopolysaccharide binding protein(LBP), procalcitonin(PCT), and epinephrine-stimulated platelet function assay(Epi-PFA) were analyzed in 159 prospectively recruited patients with a hepatic venous pressure gradient(HVPG) ≥ 6mmHg. Patients with clinically stable ACLD and without pre-/posthepatic portal hypertension, previous liver transplantation, or hepatocellular carcinoma were included.

Results Patients were stratified by PH severity, i.e. HVPG 6-9mmHg vs.10-19mmHg vs.≥ 20mmHg. Neither EXTEM clot formation time (CFT, P = 0.804), EXTEM maximum clot firmness (MCF, P = 0.347), INTEM clotting time (CT,P = 0.561),INTEM CFT (P = 0.653), INTEM MCF (P = 0.271), or FIBTEM MCF (P = 0.921) differed between different degrees of PH. Patients with stage Child-C showed higher EXTEM CFT, INTEM CT, INTEM CFT, while EXTEM MCF, INTEM MCF, and FIBTEM MCF were significantly lower as compared to Child-A and/or Child-B patients (all P < 0.05; Figure A-E*p < 0.05,**p < 0.01,***p < 0.001). In Child-A patients MCF decreased with rising severity of PH (EXTEM MCF: 6-9mmHg: 59[54-68] vs. 10-19mmHg: 56[48-59] vs. ≥ 20mmHg: 54[45-58], P = 0.023; INTEM MCF:6-9mmHg:57[53-67] vs. 10-19mmHg: 55[48-59] vs. ≥ 20mmHg: 52[44-55],P = 0.009). Conversely, ROTEM results were similar in Child-B and Child-C patients across HVPG strata. Patients with shortest CFT (EXTEM and INTEM, lowest quintile) had higher levels of LBP, CRP and PCT as well as shorter closing time on Epi-PFA (all P < 0.05). Similarly, serum levels of LBP (Figure F-J), CRP and PCT were higher and Epi-PFA closing time was shorter (all P < 0.05) in patients with highest MCF values (EXTEM and INTEM, highest quintile).

Conclusion Results of ROTEM link the severity of portal hypertension to coagulation in Child-A patients.Increased CFT and reduced MCF are in line with previously reported bleeding propensity in Child-C patients.Bacterial translocation and systemic inflammation are associated with a procoagulant state.

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Publication History

Article published online:
26 May 2020