Hematologic Manifestations of Liver Disease

Question 1

taken from Seminars in Hematology journal (2013; voluem 50; issue 3) article titled “Hematologic Manifestations of Liver Disease”

Answer 1

:)

Question 2

which clotting factors are not made by hepatocytes?

Answer 2

Factors VIII and XIII

Question 3

which anticoagulant proteins are made in hepatocytes?

Answer 3

protein C, protein S, and antithrombin

Question 4

what is liver’s role in platelet production?

Answer 4

primary site of thrombopoietin production

Question 5

how does liver’s role in lipid metabolism affect hematologic function?

Answer 5

RBC cell membrane composition affected by lipids

abnormalities in lipoprotein metabolism -> cholesterol loading in cell membrane ->increase in surface area -> macrocytosis and target cell formation.

Further cholesterol loading -> reduced deformability of RBC cell membrane -> creation of RBC that appear spiculated (spur cells = acanthocytes)

Question 6

how does liver disease cause cytopenias?

Answer 6

portal HTN can increase fraction of cells that must go through the spleen d/t hypersplenism.

in normal physiology, at any given time, a quarter to a third of leukocytes and platelets are essentially sequestered during their passage through the spleen

Question 7

how can HCV cause thrombocytopenia?

Answer 7

immune-mediated thrombocytopenia

also can be direct effect of antiviral tx

Question 8

what is spur cell anemia

Answer 8

a complication of advanced cirrhosis. hemolysis can be severe. usually unresponsive to typical tx for hemolytic dz

Cure = liver transplant

Question 9

when does leukopenia generally occur in cirrhosis?

Answer 9

leukopenia is generally a late development in cirrhotics, usually seen w/ other cytopenias

may be 2/2 hypersplenism 2/2 severe portal HTN

Question 10

what thrombotic event is well-documented complication of liver dz?

Answer 10

portal vein thrombosis

Question 11

what is the relative risk of VTE for liver dz pts vs general hospitalized population?

Answer 11

2x the risk of VTE in liver dz pts compared to general population

Question 12

a pt w/ liver dz has INR of 2.5. are they “auto-anticoagulated”?

Answer 12

no! there is discordance b/w INR and bleed risk in pts w/ liver dz

Question 13

pt w/ liver dz has normal fibrinogen levels. thoughts?

Answer 13

pts w/ liver dz often have excess sialic acid, impairing function of fibrinogen to polymerize (dyfibrinogenemia)

Question 14

what is the INR of FFP?

Answer 14

1.3 approx

Question 15

role of recombinant factor VIIa?

Answer 15

none. associated w/ thrombotic risk

Question 16

role of prothrombin comple concentrates?

Answer 16

can replace some or all of the vitK-dependent factors, but frank bleeding in liver dz is almost never simply the result of deficiency in vitK-dependent factors.

a/w thrombotic risk.

Question 17

role of FFP in coagulopathy of liver dz/

Answer 17

reasonable if pt can handle the volume. the mainstay of replacing soluble coagulation factors for bleeding pts w/ liver dz, but a sufficient volume is required for optimum effect.

Question 18

role of TXA for variceal bleeding and liver transplantation?

Answer 18

TXA may reduce variceal bleeding, but no clear impact on mortality.

TXA for pts undergoing liver transplant - reduces blood loss and transfusion requirement.