Liver failure

Coagulopathy in liver disease

Reviewed Nov 2026·2 references
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Rebalanced haemostasis: why INR misleads, when to give products, viscoelastic testing, and VTE prophylaxis.

Definition
Chronic liver disease causes 'rebalanced haemostasis': reduced pro- and anticoagulant factors, thrombocytopenia offset by high von Willebrand factor. INR/PT does not predict procedural bleeding and patients remain at risk of thrombosis.

At the bedside

  1. 1

    Do not correct INR prophylactically

    No FFP before low-risk procedures (paracentesis, thoracocentesis, central lines with ultrasound) regardless of INR.

  2. 2

    High-risk procedures

    Assess case by case; viscoelastic tests (TEG/ROTEM) reduce product use. Platelets if < 50 × 10⁹/L for high-risk procedures (or thrombopoietin agonists electively).

  3. 3

    Active bleeding

    Treat portal hypertension first (vasoactive, endoscopy); correct fibrinogen (< 100-120 mg/dL: cryoprecipitate), platelets > 50, guided by viscoelastic testing; restrictive RBC transfusion.

  4. 4

    Vitamin K

    10 mg IV if cholestasis, malnutrition or antibiotics; little effect in parenchymal failure.

  5. 5

    Correct triggers

    Infection, AKI/uraemia, hypothermia, acidosis and hypocalcaemia worsen bleeding.

  6. 6

    VTE prophylaxis

    Give LMWH prophylaxis to immobile cirrhotic ICU patients without active bleeding or very low platelets; a high INR is not protective.

Suspected deficiency

Vitamin K1 (phytomenadione)

IV
Dose
10 mg slowly

Bleeding with low fibrinogen

Cryoprecipitate

IV
Dose
1 unit/10 kg (about 8-10 units)
Target
Fibrinogen > 120 mg/dL (or viscoelastic target)
Red flag · call your senior now
Unexplained bleeding with hyperfibrinolysis (oozing from puncture sites, ROTEM lysis): consider tranexamic acid after specialist input.
Pitfall
Giving 4 units of FFP before an ascitic tap: no benefit, volume overload and higher portal pressure.
Pearl
Portal vein thrombosis is common in cirrhosis; check Doppler in decompensation.

References

  1. 1

    European Association for the Study of the Liver. EASL Clinical Practice Guidelines on prevention and management of bleeding and thrombosis in patients with cirrhosis. J Hepatol 2022;76:1151-84.

  2. 2

    de Franchis R, Bosch J, Garcia-Tsao G, et al. Baveno VII - Renewing consensus in portal hypertension. J Hepatol 2022;76:959-74.

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