New insights into the coagulopathy of liver disease and liver transplantation.

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New insights into the coagulopathy

of liver disease and liver transplantation.

World J Gastroenterol 2006 December;12(48):7725-7736

New insights into the coagulopathy

of liver disease and liver transplantation

Senzolo M,

Burra P, Cholongitas E, Burroughs AK.

Department of Surgical and Gastroenterological Sciences, Padua, Italy.

The liver is an essential player in the pathway of coagulation in both primary

and secondary haemostasis. Only

von Willebrand factor is not synthetised

by the liver, thus liver failure is associated with impairment of coagulation. However, recently it has been shown that the delicate

balance between pro and antithrombotic factors synthetised by the liver might be reset to a lower level in

patients with chronic liver disease. Therefore, these

patients might not be really anticoagulated in stable

condition and bleeding may be caused only when additional factors, such as

infections, supervene. Portal hypertension plays an

important role in coagulopathy in liver disease,

reducing the number of circulating platelets, but platelet function and

secretion of thrombopoietin have been also shown to

be impaired in patients with liver disease. Vitamin K

deficiency may coexist, so that abnormal clotting factors are produced due to

lack of gamma carboxylation. Moreover

during liver failure, there is a reduced capacity to clear activated

haemostatic proteins and protein inhibitor complexes from the circulation. Usually therapy for coagulation disorders in liver disease

is needed only during bleeding or before invasive procedures.

When end stage liver disease occurs, liver transplantation is the only

treatment available, which can restore normal haemostasis,

and correct genetic clotting defects, such as haemophilia

or factor V Leiden mutation. During

liver transplantation haemorrage may occur due to the

pre-existing hypocoagulable state, the collateral

circulation caused by portal hypertension and increased fibrinolysis

which occurs during this surgery.