Reply
Authors: Lesley De Pietri, Marcello Bianchini, Guadalupe Garcia‐Tsao, Erica Villa
Journal: Hepatology (2015)

Potential conflict of interest: Nothing to report. We thank Dr. Desborough for his comments. The rationale behind our study was the ongoing misconception among physicians that altered coagulation tests in cirrhosis lead to increased risk of bleeding when performing invasive procedures, thereby leading to the common practice of correcting these coagulation alterations even prior to low‐risk procedures. As we showed in our study and underlined in the Discussion, postprocedural bleeding risk is not related to coagulopathy or to its effective (or attempted) correction, but rather to the occurrence of local complications of the procedure. In this sense, we agree with Dr. Desborough that the breakdown of procedures that present a high or low risk of bleeding is meaningless given that even a paracentesis can lead to significant bleeding, whereas a thoracotomy might not. That said, many recent guidelines still recommend international normalized ratio (INR) and platelets (PLTs) correction in patients with cirrhosis even before procedures that present a low risk of bleeding.1 In designing our study, we simply considered (without agreeing with them) the routine requirements put forward by endoscopists or radiologists. We have demonstrated that—at least in patients with the characteristics defined in the study—INR and PLTs correction is not necessary. With regard to more technical issues, we agree that thrombin generation assays offer a more comprehensive assessment of coagulation in cirrhosis than routine tests or thromboelastography (TEG); however, they are not readily available and are therefore impractical in a routine clinical setting. TEG may not be a perfect test, but it reflects the interaction between plasma, blood cells, and platelets and provides a more complete evaluation of coagulation than conventional coagulation tests that are only performed in plasma. Furthermore, TEG also provides comprehensive information on clot strength maximum amplitude (MA), which results from von Willenbrand factor (vWF) and ADMTS13 balance, far beyond the platelet count. Kim et al.2 showed that the rebalanced hemostasis in idiopathic thrombocytopenic purpura (ITP) due to elevated levels of vWF and fibrinogen was properly evaluated by thromboelastography and concluded that TEG could guide the treatment in ITP. In cirrhosis, the clot strength—as a reflection of the interaction between platelets, vWF/ADAMT13, and fibrinogen—can be better identified with TEG than with conventional clotting tests or single factor quantification. It is important to note that prothrombin time (PT) and partial thromboplastin time (PTT) are not equivalent to the R time. Coakley et al.3 showed that the correlation between PT/INR and R time is poor (r = 0.24‐0.37). This is probably due to different activators, the specimens used (whole blood versus plasma), and the fact that R, unlike PT and activated partial thromboplastin time (aPPT), reflects the balance of both pro‐ and anticoagulants.4 In conclusion, we agree with Dr. Desborough that patients with cirrhosis, particularly those with more severe disease, are more likely to be hypercoagulable than hypocoagulable and that guidelines that recommend correcting conventional coagulation tests prior to any invasive procedure should be reevaluated according to the results of our study.