Coagulation failure is associated with bleeding events and clinical outcome during systemic inflammatory response and sepsis in acute‐on‐chronic liver failure: An observational cohort study

• Published in: Liver international 2019-04, Vol.39 (4), p.694-704
• Main Authors: Premkumar, Madhumita, Saxena, Priyanka, Rangegowda, Devaraja, Baweja, Sukriti, Mirza, Roshni, Jain, Priyanka, Bhatia, Puja, Kumar, Guresh, Bihari, Chhagan, Kalal, Chetan, Vyas, Tanmay, Choudhury, Ashok, Sarin, Shiv K.
• Format: Article
• Language: English
• Subjects: Acute-On-Chronic Liver Failure - complications; Acute-On-Chronic Liver Failure - physiopathology; acute‐on‐chronic liver failure; Adult; Antithrombin; Bleeding; Blood Coagulation; Blood Coagulation Tests; Case-Control Studies; Coagulation; Coagulation factors; Cohort analysis; Ethanol; Failure; Female; Hemorrhage - etiology; Hemorrhage - mortality; Humans; Inflammation; Inflammatory response; Liver; Liver failure; Lysis; Male; Middle Aged; Mortality; Observational studies; Patients; Proportional Hazards Models; Prospective Studies; Protein C; Proteins; Sepsis; Sepsis - epidemiology; Sepsis - etiology; Severity of Illness Index; Systemic Inflammatory Response Syndrome - epidemiology; Systemic Inflammatory Response Syndrome - etiology; t-Plasminogen activator; thromboelastography; Time Factors; Tissue factor; Tissues; Von Willebrand factor
• ISSN: 1478-3223; 1478-3231
• DOI: 10.1111/liv.14034

Background Patients with acute‐on‐chronic liver failure (ACLF) have coagulation failure in the setting of systemic inflammatory syndrome (SIRS), sepsis and extra‐hepatic organ failures. Methods Consecutive ACLF patients without sepsis at baseline were assessed at days 0, 3 and 7 with thromboelastography (TEG) and specific assays (Factor VIII, von Willebrand factor [vWF], protein C and antithrombin III [ATIII]) and followed for development of sepsis, bleeding and outcome. Results Of 243 patients, 114 (63% ethanol related; mean age 44.3 ± 11.7 years; 90% male) were recruited. SIRS was noted in 39 (34.2%), 45 (39.5%) and 46 (40%) patients at days 0, 3 and 7 and sepsis in 28 (24%) and 52 (56.1%) patients at days 3 and 7 respectively. The 28‐ and 90‐day survivals were 62% and 51% respectively. A hypocoagulable TEG at baseline was a predictor of bleeding (hazard ratio [HR] 2.1; CI 1.6‐4.9; P = 0.050) and mortality (HR 1.9; CI 1.3‐7.9; P = 0.043). ACLF patients had increased Factor VIII, vWF, tissue factor levels and tissue plasminogen activator (tPA) activity with reduced protein C and ATIII. Coagulation parameters like Coagulation Index (HR 2.1; CI 1.1‐4.5; P = 0.044),clot lysis (HR 3.2; CI 1.9‐3.4; P = 0.033), low protein C