Summary of hemostatic changes in CLD and laboratory evidence supporting rebalanced hemostasis
| Characteristic . | Factors associated with bleeding . | Factors associated with thrombosis . | Laboratory evidence to support rebalanced hemostasis . |
|---|---|---|---|
| Platelets | • Thrombocytopenia • Platelet dysfunction • Anemia | • ↑ vWF • ↓ADAMTS13 • ↑Platelet activation • Endothelial activation | • Weak • Difficult to replicate platelet- endothelial interaction in laboratory setting |
| Coagulation | • ↓FII, V, VII, IX, X, XI • ↓Fibrinogen (in AD, ACLF) • ↓FXIII • ↓Rates of fibrin polymerization | • ↓Protein C, protein S, antithrombin • ↑FVIII • ↓Fibrin clot permeability | • Thrombin generation normal to increased when measured with protein C pathway activation • Weak evidence for rebalancing of fibrin clot strength/stability |
| Fibrinolysis | • ↑tPA (not rebalanced by ↑PAI-1) • ↓α2-Antiplasmin • ↓TAFI | • ↓Plasminogen | • Uncertain; both hyper/hypofibrinolysis seen in ACLF, potentially reflecting the delicate nature of rebalance |
| Characteristic . | Factors associated with bleeding . | Factors associated with thrombosis . | Laboratory evidence to support rebalanced hemostasis . |
|---|---|---|---|
| Platelets | • Thrombocytopenia • Platelet dysfunction • Anemia | • ↑ vWF • ↓ADAMTS13 • ↑Platelet activation • Endothelial activation | • Weak • Difficult to replicate platelet- endothelial interaction in laboratory setting |
| Coagulation | • ↓FII, V, VII, IX, X, XI • ↓Fibrinogen (in AD, ACLF) • ↓FXIII • ↓Rates of fibrin polymerization | • ↓Protein C, protein S, antithrombin • ↑FVIII • ↓Fibrin clot permeability | • Thrombin generation normal to increased when measured with protein C pathway activation • Weak evidence for rebalancing of fibrin clot strength/stability |
| Fibrinolysis | • ↑tPA (not rebalanced by ↑PAI-1) • ↓α2-Antiplasmin • ↓TAFI | • ↓Plasminogen | • Uncertain; both hyper/hypofibrinolysis seen in ACLF, potentially reflecting the delicate nature of rebalance |
Adapted from Northup et al20 with permission from Wiley.
ADAMTS13, a disintegrin and metalloproteinase thrombospondin type 1 motif; F, factor; PAI-1, plasminogen activator inhibitor 1; TAFI, thrombin activatable fibrinolysis inhibitor; tPA, tissue plasminogen activator; vWF, von Willebrand factor.