title: Assessment of haemostasis in patients with cirrhosis: Relevance of the ROTEM tests?: A prospective, cross-sectional study.
abstract: BACKGROUND
  In patients with cirrhosis, decreased rotational thromboelastometry (ROTEM) parameters suggest hypocoagulability secondary to liver dysfunction. However, observed normal or increased thrombin generation suggests preserved haemostasis and/or a procoagulant state. The correlated levels of both coagulation factors and inhibitors also support preserved haemostasis.
  
  
  OBJECTIVE
  The objective of this study is to investigate the correlation between three specific approaches of haemostasis (ROTEM, thrombin generation and coagulation factors/inhibitors) on the same plasma sample from patients with cirrhosis.
  
  
  METHODS
  A prospective, observational study.
  
  
  METHODS
  Single university hospital.
  
  
  METHODS
  Forty patients with cirrhosis.
  
  
  METHODS
  Measurement of the following factors: model for end-stage liver disease (MELD) scores; ROTEM maximum clot firmness (ROTEM-MCF) in EXTEM, INTEM, FIBTEM assays; fibrinogen; factors V and VIII; von Willebrand factor; protein C; protein S; antithrombin; and the thrombin generation test (TGT) enabling the calculation of endogenous thrombin potential without and with thrombomodulin, and the ratio of endogenous thrombin potential with-to-without thrombomodulin (regarded as an index of hypercoagulability).
  
  
  RESULTS
  ROTEM-MCF values were distributed within the normal and hypocoagulation ranges; were correlated to variations in factor V, fibrinogen, protein C and S and antithrombin; and were inversely correlated to MELD scores (ρ > 0.5; P < 0.05). Levels of von Willebrand factor were above normal and were not correlated with any other factor levels. After addition of thrombomodulin, endogenous thrombin potential values were distributed within or above normal values. Factor V variation was correlated to the ratio of endogenous thrombin potential with-to-without thrombomodulin.
  
  
  CONCLUSIONS
  ROTEM indicated hypocoagulability correlated to liver dysfunction. In contrast, the TGT indicated a preserved or even increased coagulation profile (which was supported by the correlation between coagulant factors and inhibitors) and a potential for hypercoagulability inversely correlated to the degree of liver dysfunction. ROTEM may not be appropriate for haemostasis assessment in patients with liver cirrhosis and could lead to the unnecessary transfusion of fresh frozen plasma.
  
  
  BACKGROUND
  S.C. 3024 - ID RCB: 2012-A01728-35.
authors.affiliation: From the Department of Anaesthesia and Intensive Care (CL, MB, C-MS), Department of Biological Haematology (CF, FI, IG-T), and Hepatology Unit (PS), Paris Descartes University, Faculty of Medicine, Assistance Publique Hôpitaux de Paris, Cochin University Hospital, Paris Cedex, France.
authors.forename: Claude
authors.initials: C
authors.lastname: Lentschener
authors.forename: Claire
authors.initials: C
authors.lastname: Flaujac
authors.forename: Firas
authors.initials: F
authors.lastname: Ibrahim
authors.forename: Isabelle
authors.initials: I
authors.lastname: Gouin-Thibault
authors.forename: Marie
authors.initials: M
authors.lastname: Bazin
authors.forename: Philippe
authors.initials: P
authors.lastname: Sogni
authors.forename: Charles-Marc
authors.initials: CM
authors.lastname: Samama
mesh_terms: D000368:Aged; D015415:Biomarkers / Q000097:blood; D001777:Blood Coagulation; D001779:Blood Coagulation Factors / Q000378:metabolism; D003430:Cross-Sectional Studies; D005260:Female; D006487:Hemostasis; D006785:Hospitals, University; D006801:Humans; D008103:Liver Cirrhosis / Q000097:blood / Q000175:diagnosis*; D008297:Male; D008875:Middle Aged; D010297:Paris; D011237:Predictive Value of Tests; D011446:Prospective Studies; D015203:Reproducibility of Results; D013916:Thrombelastography; D013917:Thrombin / Q000378:metabolism
chemical_list: D015415:Biomarkers; D001779:Blood Coagulation Factors; D013917:Thrombin