In vitro efficacy of pro‐ and anticoagulant strategies in compensated and acutely ill patients with cirrhosis

BACKGROUND & AIMS: A simultaneous decline in pro‐ and anticoagulant drivers in patients with liver diseases results in a “rebalanced” haemostatic system, even in acutely ill patients. Nevertheless, both bleeding and thrombotic events are common. Here, we explored efficacy of pro‐ and antihaemostatic strategies in compensated and acutely ill cirrhotics which may be unpredictable given the profound haemostatic changes. METHODS: We tested the effects in vitro of the addition of clinically relevant doses of commonly used pro‐ and antihaemostatic strategies in plasma from healthy individuals (n = 30) and patients with compensated (n = 18) and acutely decompensated cirrhosis (n = 18), and acute‐on‐chronic liver failure (n = 10). We used thrombin generation tests and fibrin clot permeability assays to assess potency of various approaches. RESULTS: Fresh frozen plasma and recombinant factor VIIa modestly increased thrombin generation (10%‐20%). Prothrombin complex concentrate increased thrombin generation two‐fold in controls and 2‐4‐fold in patients. Clot permeability decreased after addition of fibrinogen concentrate by 51% in controls and by 50%‐60% in patients. Low molecular weight heparin decreased thrombin generation by 18% in controls and by 23%‐54% in patients. Similarly, dabigatran decreased thrombin generation by 33% in controls and by 47%‐100% in patients. In contrast, rivaroxaban decreased thrombin generation by 55% in controls, but only by 11%‐38% in patients. CONCLUSIONS: These in vitro data suggest little prohaemostatic effect of fresh frozen plasma and recombinant factor VIIa in acutely ill cirrhotics, whereas prothrombin complex concentrate and fibrinogen concentrate clearly improved haemostasis. Furthermore, our data suggest the requirement for dose adjustments of commonly used anticoagulants in these patients.