Hemostasis in patients with cirrhosis: a hazardous balance

Liver cirrhosis is a chronic disease with multiple causes and increased mortality. Hepatocytes are the site of synthesis of all coagulation factors and their inhibitors and that is the reason why patients with cirrhosis have a variety of hemostatic abnormalities, resulting in “rebalanced” hemostasis. The spontaneously elevated INR values in patients with cirrhosis have led to the theory of “autoanticoagulation” and to the idea that these patients may not benefit from the venous thromboembolism risk-reduction therapies. In fact, patients with severe liver disease should not be assumed to be auto-anticoagulated. Standard coagulation testing does not assess prothrombotic and fibrinolytic changes. In case of orthopaedic surgery, immobilization and liver resection, the risk of venous thrombembolism is high. Low molecular weight heparins (LMWH) seem to be relatively safe for patients with liver cirrhosis. If there is a high risk of bleeding, with contraindications to antithrombotic treatment, graduated compression stockings or intermittent pneumatic compression are recommended. The use of new antithrombotic agents, such as direct factor Xa inhibitors (rivaroxaban and apixaban) will need careful evaluation, because these agents are metabolized in the liver and they may increase the risk of haemorrhagic complications.