Hematological abnormalities in liver cirrhosis

Table 2 Summary of blood products and/or drugs recommendations in bleeding in cirrhosis

Choice of agent	Recommendations			Guidelines/evidence
Platelet transfusion	Prophylaxis	Common gastrointestinal procedures1	AGA suggests against the routine use of blood products for bleeding prophylaxis	AGA[116,121]
		High risk procedures	Decisions about prophylactic blood transfusions should include discussions about potential benefits and risks in consultation with a hematologist. Threshold: > 50 × 109/L
	Acute bleeding	Platelet transfusions should not be administered based on platelet count targets because there is no evidence of benefit of such transfusions in AVH		AASLD[122]
		In patients with cirrhosis and active bleeding (out of the setting of AVH), thrombocytopenia (if platelet count < 50 × 109/L)		Clinical Gastroenterology and Hepatology[123], 2023
TPO-RA	Prophylaxis	Common gastrointestinal procedures1	AGA suggests against the routine use of TPO-RAs for bleeding prophylaxis	AGA[121]
		High risk procedures	Patients who place a high value on the uncertain reduction of procedural bleeding events and a low value on the increased risk for PVT can reasonably select a TPO-RA
	Acute bleeding	Not appropriate for acute setting		Clinical Gastroenterology and Hepatology[123], 2023
FFP	Prophylaxis	Common gastrointestinal procedures1	AGA suggests against the routine use of blood products for bleeding prophylaxis	AGA[121]
		High risk procedures	Decisions about prophylactic blood transfusions should include discussions about potential benefits and risks in consultation with a hematologist
	Acute bleeding	Fresh frozen plasma should not be administered based on INR because there is no evidence of benefit of such transfusions in AVH		AASLD[122]
		Restricted to hemorrhagic shock to compensate blood loss		Clinical Gastroenterology and Hepatology[123], 2023
Fibrinogen	Prophylaxis	No routine preprocedure correction		AASLD[89]
	Acute bleeding	The following transfusion thresholds for management of active bleeding or high-risk procedures may optimize clot formation in advanced liver disease: Fibrinogen > 120 mg/dL		AGA[116]
rFVIIa	Not recommended for bleeding episodes in patients with Child-Pugh A cirrhosis. Efficacy of rFVIIa was considered uncertain in bleeding episodes in patients with Child-Pugh B and C cirrhosis			European Consensus Critical Care[124], 2006
PCC	The role of PCC is not yet defined. Limited data based on retrospective studies			AGA[116]
Desmopressin	The agent lacks a sound evidence-based foundation but may be useful in patients with concomitant renal failure			AGA[116]
Antifibrinolytic agents	Anti-fibrinolytic therapy may be considered in patients with persistent bleeding from mucosal oozing or puncture wound bleeding consistent with impaired clot integrity			AGA[125]
	RCT shows tranexamic acid reduces failure to control bleeding and rebleeding in advanced cirrhosis with UGIB. However, further studies and robust evidence are needed to make a definitive recommendation			Hepatology[125], 2024

¹Paracentesis, thoracentesis, variceal banding.

FFP: Fresh frozen plasma; TPO-RA: Thrombopoietin receptor agonists; INR: International normalized ratio; AVH: Acute variceal hemorrhage; PCC: Prothrombin complex concentrates; rFVIIa: Recombinant activated factor VII; RCT: Randomized controlled trial; UGIB: Upper gastrointestinal bleeding; AGA: American Gastroenterological Association; AASLD: American Association for the Study of Liver Disease; PVT: Portal vein thrombosis.