Abstract
Over a four-month period, three patients with ascites and hyponatraemia secondary to decompensated cirrhosis were admitted to the Intensive Care unit (ICU) of a quaternary referral centre for liver disease and transplantation for further management. Each had a stable documented coagulopathy without bleeding on ICU admission. Following commencement of anticoagulant-free continuous renal replacement therapy (CRRT), a severe bleeding diathesis developed in all three patients necessitating transfusion of large volumes of blood products. The clinical presentation and results of detailed coagulation profiles and thromboelastography (TEG) were consistent with the development of disseminated intravascular coagulation (DIC) with hyperfibrinolysis. The onset of DIC in all three cases was associated with significant morbidity. One patient went on to receive an orthotopic liver transplant (OLT) and death was the end result in the subsequent two cases. Due to the temporal relationship, we hypothesise that the initiation of CRRT may have contributed to the derangement in coagulation status in these patients. Though the exact mechanism is uncertain, it may be related to a higher rate of adsorption of high molecular weight kinins or the CRRT membrane’s ability to bind endogenous heparinoids. These cases highlight the precarious nature of the coagulation cascade in patients with decompensated cirrhosis. Initiation of CRRT may profoundly disrupt that tenuous balance and should be preceded by careful consideration of the potential complications including DIC and its associated morbidity.
Highlights
Cirrhosis is a significant cause of morbidity and mortality and is thought to affect up to 0.1% of the European population [1]
A 55-year-old lady with decompensated cirrhosis secondary to alcoholic liver disease, being assessed for liver transplantation was admitted to the Intensive Care unit (ICU) requiring continuous renal replacement therapy (CRRT) for management of fluid overload and pulmonary oedema
A 39 year old gentleman with decompensated cirrhosis and refractory ascites secondary to hepatitis C virus (HCV) awaiting orthotopic liver transplant (OLT), was admitted to the ICU for CRRT for treatment of hyponatraemia resistant to medical therapy. He had a history of Haemophilia A and a preexisting coagulopathy in keeping with advanced liver disease but no clinically evident bleeding
Summary
Cirrhosis is a significant cause of morbidity and mortality and is thought to affect up to 0.1% of the European population [1]. A 55-year-old lady with decompensated cirrhosis secondary to alcoholic liver disease, being assessed for liver transplantation was admitted to the ICU requiring CRRT for management of fluid overload and pulmonary oedema She had a pre-existing but stable coagulopathy. A 39 year old gentleman with decompensated cirrhosis and refractory ascites secondary to HCV awaiting OLT, was admitted to the ICU for CRRT for treatment of hyponatraemia resistant to medical therapy He had a history of Haemophilia A and a preexisting coagulopathy in keeping with advanced liver disease but no clinically evident bleeding. Despite aggressive replacement of blood products and other interventions to reduce blood loss including administration of tranexamic acid 1 gm 24 hours after admission, the patient continued to bleed profusely and remained severely coagulopathic He became profoundly hypotensive, requiring increasing doses of vasoactive medication.
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