This document summarizes research on coagulation in patients with cirrhosis. It finds that cirrhosis is associated with higher levels of procoagulant factors like factor VIII and lower levels of anticoagulant factors like protein C. Tests of thrombin generation show a procoagulant imbalance that increases with severity of cirrhosis. Rather than a generalized coagulopathy, cirrhosis involves a shifting balance between altered pro- and anti-coagulant systems. This challenges views of cirrhosis bleeding risk based on conventional coagulation tests.

1. La Coagulazione nel Cirrotico: Mito e Realtà
La coagulazione nel
cirrotico: mito o realtà?
Prof. Armando Tripodi
Angelo Bianchi Bonomi
Hemophilia and Thrombosis Center
Dept. of Clinical Sciences and Community Health
A.TRIPODI
University of Milano

2. Alteration of Hemostasis in Cirrhosis
Potential Implicated Mechanisms
• Primary Hemostasis
• Fibrinolysis
• Coagulation
A.TRIPODI

3. Dual Role of Platelets in Hemostasis
• Primary hemostasis
­ Adhesion to the subendothelium
­ Aggregation one another
• Coagulation
­ Support thrombin generation
A.TRIPODI

4. vWF
High levels of VWF in cirrhosis
A.TRIPODI

5. Alteration of Hemostasis in Cirrhosis
Potential Implicated Mechanisms
• Primary Hemostasis
• Fibrinolysis
• Coagulation
A.TRIPODI

6. Fibrinolysis in Cirrhosis
Background
• Cirrhosis is characterized by
hyperfibrinolysis (?)
• This complex defect can be documented in
plasma through global fibrinolytic tests or
through the measurement of individual
components
A.TRIPODI

7. Cirrhosis and Fibrinolysis
• Decreased levels • Increased levels
­ Plasminogen ­ tPA
­ Anti­plasmin ­ PAI­1
­ FXIII
- TAFI
A.TRIPODI

8. Hyperfibrinolysis and Cirrhosis
• Deficiency of TAFI in cirrhotics is not
associated with increased plasma
fibrinolysis
Lisman T et al. Gastroenterology 2001; 121: 131
• Deficiency of TAFI in cirrhotics is
associated with increased plasma
fibrinolysis
Colucci M, et al, Hepatology 2003; 38: 230
A.TRIPODI

9. Alteration of Hemostasis in Cirrhosis
Potential Implicated Mechanisms
• Primary Hemostasis
• Fibrinolysis
• Coagulation
A.TRIPODI

10. Coagulation in Chronic Liver Disease
The Facts….
• Cirrhosis is characterized by an
impaired synthesis of all clotting
factors (except FVIII and VWF)
• This complex defect has historically
been documented through the
prolongation of PT & APTT
A.TRIPODI

11. Coagulation in Chronic Liver Disease
The Dogma…
• The concept of a causal relationship between
abnormal coagulation and bleeding is widely
accepted
• Common practice of screening patients with
hemostasis tests
• Treating patients with abnormal values in
order to correct the identified abnormalities
prior to liver biopsy
A.TRIPODI

12. Te Challenge of the Dogma (1)
• Liver transplantation was initially associated
with dramatic transfusion requirements
but…
• The need of transfusion declined dramatically in
the last 20 years, despite no major change in
medication
A.TRIPODI

13. Transplantation 2008; 85: 956
A.TRIPODI

14. Te Challenge of the Dogma (2)
Conventional hemostasis tests do correlate
poorly with gastrointestinal bleeding or after
biopsy
A.TRIPODI

15. Poor Correlation between Global Conventional
Hemostasis Tests and Bleeding
Review of the Literature
• Ewe K. Dig Dis Sci 1981; 26; 388
• Segal JB & Dzik WH. Transfusion 2005; 45:1413
• Boks AL, et al. Hepatology 1986; 6: 79
• Diaz LK &Teruya J. New Engl J Med 2001;344:2030
• Grabau CM et al. Hepatology 2004;40:484
• Terjung B et al. Digestion 2003; 67: 138
• Mc Gill DB et al. Gastroenterology 1990; 99: 1396
• Vieira da Rocha E et al.Clin Gastroenterology and
Hepatol 2009; 7: 988
A. TRIPODI

16. A.TRIPODI Ewe, 1981

17. Why Conventional Coagulation Tests
do not Correlate with Bleeding in
Cirrhosis ?
A.TRIPODI

18. Coagulation in Liver Disease
Considerations on the value of PT & APTT
• PT & APTT might be inadequate to
reflect the coagulation balance as it
occurs in vivo especially in cirrhosis
- Protein C and antithrombin are reduced
in cirrhosis
- Protein C in vitro is activated to a limited
extent in the absence of thrombomodulin
A.TRIPODI

19. PROTEIN C is activated by THROMBIN
T
PS
Va Vi
PC VIIIa VIIIi
T E PS
E PC APC APC
P P
TM
C C membrane
R R
It should be noted that plasma and reagents
needed to perform PT & APTT do not contain TM
A.TRIPODI

20. PT & APTT are responsive only to
procoagulant factors
A.TRIPODI

21. …and much less to the anticoagulant
factors
A.TRIPODI

22. PT & APTT as Tools to Investigate the
Balance of Coagulation
• PT & APTT can tell us whether a patient is
deficient in one (or more) pro-coagulants
• ….but not whether this deficiency is
counterbalanced by a concomitant
deficiency of the anti-coagulants
A.TRIPODI

23. Thrombin Generation ETP (FUXmin)
700 Platelet-free Plasma
Tripodi et al, Hepatology 2005; 41: 553
600
500
400
300
200
100
0
Controls Cirrhotics Controls Cirrhotics
without with
A.TRIPODI thrombomodulin thrombomodulin

24. Thrombin Generation in Platelet-free
Plasmas
Summary of findings
• Plasma coagulation is not abnormal in cirrhosis
when assessed with global tests reflecting the
function of both pro- and anti-coagulants
• The findings question
- The usefulness of traditional coagulation tests in
assessing hemorrhagic risk in cirrhosis
- And the use of procoagulant agents to correct
the coagulopathy
A.TRIPODI

25. Poor Efficacy of Activated FVII to
Stop Bleeding in Cirrhosis
• Bosch J et al, 2004
• Lodge JP et al, 2005
• Planinsic RM et al, 2005
• Bosch J et al, 2008
A.TRIPODI

26. Platelets & Thrombin Generation
A.TRIPODI

27. Platelet-Rich Plasma
(Plt.s count adjusted to 100,000/µL)
P<0.001 N.S.
3,500
ETP (Thrombin) nM X min
3,000
2,500
2,000 1,965
1,500 1,365
1,140 1,117
1,000
500
0
Controls Cirrhotics Controls Cirrhotics
Without Thrombomodulin With Thrombomodulin
Tripodi et al,
A. TRIPODI Hepatology 2006

28. Platelet-Rich Plasma
(Plt.s adjusted to the original patient’s count)
P<0.001 P<0.001
3,500
ETP (Thrombin) nM X min
3,000
2,500
2,000 1,919
1,500
1,280 1,221
1,000 929
500
0
Controls Cirrhotics Controls Cirrhotics
Without Thrombomodulin With Thrombomodulin
Tripodi et al,
A. TRIPODI Hepatology 2006

29. Thrombin Generation and Platelet Numbers
2500
ETP (thrombin) nM
2000
1500
1000
500
Rho=0.50, p<.001
0
0 60 100 200 300
Platelet numbers (X 109/L)
Tripodi et al
A.TRIPODI
Hepatology, 2006

30. Thrombin Generation in Platelet-Rich
Plasma
Summary of Findings
• Platelets from cirrhotics are qualitatively
suitable to support thrombin generation
• The numbers of platelets in cirrhosis
might be the limiting factor for thrombin
generation
A.TRIPODI

31. Why do Patients with Cirrhosis
Occasionally Bleed?
• The “restored” hemostatic balance in
cirrhosis may not be as stable as in
healthy individuals and, therefore, slight
alterations may lead to hemorrhage or
thrombosis
• Conditions underlying bleeding
A.TRIPODI

32. Conditions Underlying Bleeding in Cirrhosis
• Portal Hypertension
• Endothelial dysfunction
• Bacterial infections
• Renal failure
Therapeutic interventions correcting these
abnormalities might be more effective
than correcting coagulopathy
A.TRIPODI

33. The Balance of Hemostasis
Hemorrhage Thrombosis
Healthy subject
Excess pro- & Cirrhosis
anti-coagulants Relative deficit pro-
A.TRIPODI & anti-coagulants

34. A.TRIPODI Am J Gastroenterol 2006;101:1524

35. Am J Gastroenterol 2009; 104: 96
These observations suggest a
procoagulant imbalance
in plasma from patients with cirrhosis
A.TRIPODI

36. Is there any biomarker to identify the
procoagulant imbalance in cirrhosis?
A.TRIPODI

37. 58% 32% Difference
700
Difference
600
500
ETP (FUXmin)
450
400
300 300
200 210
200
100
0
No TM TM No TM TM
Controls Cirrhotics
A.TRIPODI
A.Tripodi et al, Hepatology 2005

38. 200/450 = 0.44 210/300 = 0.70
700
600
500
ETP (FUXmin)
450
400
300 300
200 210
200
100
0
No TM TM No TM TM
Controls Cirrhotics
A.TRIPODI
A.Tripodi et al, Hepatology 2005

39. Study on the Procoagulant
Imbalance in Cirrhosis
• Aim of the Study
- To detect biochemical signs of
procoagulant imbalance
• Laboratory tools
- Measurement of pro- and anti-coagulants
- Measurement of thrombin generation
assessed as ratio of values with/without
thrombomodulin
A.TRIPODI

40. A.TRIPODI

41. Case Material
• Patients
- 134 patients with cirrhosis with graded
severity according to the Child-Pugh
score
• Controls
- 131 healthy subjects matched for age
and gender to the patients
A.TRIPODI

42. Results
A.TRIPODI

43. Pro-coagulant Drivers in Cirrhosis
ts
Pr
la n
o-
u
ag
co
co
ag
nt i-
ul
an
A
ts
A.TRIPODI

44. Factor II
150 p < 0.001
100
Factor II (%) p < 0.001
50
0
A.TRIPODI et al, Healthy CHILD CHILD CHILD
Gastroenterology 2009 subjects A B C

45. Factor VIII p < 0.001
p = 0.02
300
Factor VIII (%)
200
100
0
Healthy CHILD CHILD CHILD
subjects A B C
A.TRIPODI et al,
Gastroenterology 2009

46. Anti-coagulant Drivers in Cirrhosis
Pr ts
o-
co ul an
ag
o ag
ul c
an i-
ts
Ant
A.TRIPODI

47. Protein C 150
p < 0.001
100 p < 0.001
Protein C (%)
p = 0.03
50
0
Healthy CHILD CHILD CHILD Protein C
subjects A B C deficiency
A.TRIPODI et al,
Gastroenterology 2009

48. Antithrombin p < 0.001
120
p < 0.001
100
Antithrombin (%) 80
60
40
20
0
Healthy CHILD CHILD CHILD
A.TRIPODI et al,
subjects A B C
Gastroenterology 2009

49. Balance of Pro- vs Anti-coagulant
Drivers in Cirrhosis
ts
an
Pr
ul
o-
o ag
co
c
i-
ag
nt
u
A
la
nt
s
Assessed as ratio
of thrombin generation
A.TRIPODI with/without thrombomodulin

50. Ratio of thrombin generation (with/without TM)
p < 0.001
1.2
p = 0.03
Ratio ETP (with/without thrombomodulin) 1.0
0.8
0.6
0.4
0.2
0.0
A.TRIPODI et al, Healthy CHILD CHILD CHILD Protein C
Gastroenterology 2009 subjects A B C deficiency

51. Summary of Findings
• Cirrhotics present with significantly
higher ratios of thrombin generation
with/without thrombomodulin than
controls
• These ratios increase progressively
from Child A to Child C
A.TRIPODI

52. ….how can this procoagulant
imbalance be explained?
A.TRIPODI

53. Ratio FVIII/protein C p < 0.001
p < 0.001
15
Ratio (Factor VIII/Protein C) 10
5
0
A.TRIPODI et al, Healthy CHILD CHILD CHILD
Gastroenterology 2009 subjects A B C

54. Summary of findings
• Cirrhotics present with
- High factor VIII (pro-coagulant driver)
- Low protein C (anti-coagulant driver)
• The ratio of pro- vs anti-coagulant drivers is much
higher than the unity and increases progressively
from Child A to C
The increased ratios are consistent
with the procoagulant imbalance detected
by thrombin generation
A.TRIPODI

55. Procoagulant Imbalance in Patients with
Chronic Liver Disease
• Tripodi et al, Hepatology 2010
• Lisman et al, J Hepatol 2010
• Gatt et al, J Thromb Haemost 2010
A.TRIPODI

56. Overall Conclusions
• The re-assessment of hemostasis in cirrhosis
questions consolidated therapeutic strategies
• “Correcting” abnormal traditional hemostasis tests
prior to invasive procedure should be reconsidered
• While platelet transfusion may be useful, plasma,
anti-fibrinolytics, or pro-coagulants should be used
on individual basis
• Patients with cirrhosis are not auto-anticoagulated
• Hyper- rather than hypo-coagulability might be the
distinctive feature of cirrhosis
A.TRIPODI

57. Practical Implications of the Procoagulant
Imbalance in Chronic Liver Disease
• Secondary prevention of VTE (VKA or LMWH)
should be more extensively used in cirrhosis
• Primary PVT prevention should be considered
in patients awaiting liver transplantation
- Villa E. et al, Gastroenterology 2012
• Other (non coagulation) thrombin effect should
be considered in patients with cirrhosis
- Tripodi et al, J Thromb Haemost 2010
A.TRIPODI

58. A.TRIPODI

59. Acknowledgements
• M. Primignani • Patients Care
• A. Dell’Era
• V. Chantarangkul • Data management
• M. Clerici • Testing
• P.M. Mannucci • Advice
• F. Salerno
• M. Colombo
• R. de Franchis
A.TRIPODI