title: Anticoagulation in cirrhosis: a new paradigm?
abstract: The liver plays a crucial role in coagulation cascade. Global hemostatic process is profoundly influenced by the presence of liver disease and its complications. Patients with cirrhosis have impaired synthesis of most of the factors involved in coagulation and fibrinolysis process due to a reduced liver function and altered platelet count secondary to portal hypertension. Altered routine tests and thrombocytopenia were considered in the past as associated with increased risk of bleeding. These concepts explain both the routine use of plasma and/or platelets transfusion in patients with liver cirrhosis, especially before invasive procedures, and why these patients were considered "auto-anticoagulated". New recent evidences show that patients with liver cirrhosis have a more complex hemostatic alteration. Despite the presence of altered levels of factors involved in primary hemostasis, coagulation and fibrinolysis, patients with stable cirrhosis have a rebalanced hemostatic, which however can easily be altered by decompensation or infection, both in hemorrhagic or thrombotic direction. Patients with cirrhosis have an increased risk of venous thrombotic events (namely portal vein thrombosis) while bleeding seems to be related to the grade of portal hypertension rather than to a hemostatic imbalance. The use of anticoagulants both as treatment or prophylaxis is safe, reduces the rate of portal vein thrombosis and decompensation, and improves survival. Standard laboratory coagulation tests are unable to predict bleeding and are inadequate for the assessment of hemostatic status in these patients, hence more comprehensive tests are required to guide the management of thrombotic and bleeding complications.
authors.affiliation: Department of Internal Medicine, Gastroenterology Unit, Azienda Ospedaliero-Universitaria Policlinico di Modena, Modena, Italy.
authors.forename: Filippo
authors.initials: F
authors.lastname: Leonardi
authors.affiliation: Department of Internal Medicine, Gastroenterology Unit, Azienda Ospedaliero-Universitaria Policlinico di Modena, Modena, Italy.
authors.forename: Nicola De
authors.initials: N
authors.lastname: Maria
authors.affiliation: Department of Internal Medicine, Gastroenterology Unit, Azienda Ospedaliero-Universitaria Policlinico di Modena, Modena, Italy.
authors.forename: Erica
authors.initials: E
authors.lastname: Villa
mesh_terms: D000925:Anticoagulants / Q000494:pharmacology* / Q000627:therapeutic use; D001777:Blood Coagulation / Q000187:drug effects*; D006495:Heparin, Low-Molecular-Weight / Q000494:pharmacology / Q000627:therapeutic use; D006801:Humans; D008103:Liver Cirrhosis / Q000150:complications / Q000188:drug therapy / Q000473:pathology*; D054556:Venous Thromboembolism / Q000150:complications / Q000188:drug therapy / Q000453:epidemiology; D020246:Venous Thrombosis / Q000150:complications / Q000188:drug therapy
chemical_list: D000925:Anticoagulants; D006495:Heparin, Low-Molecular-Weight
keywords: Anticoagulation; Cirrhosis; Hemostasis