{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,11,6]],"date-time":"2025-11-06T12:18:16Z","timestamp":1762431496472},"reference-count":53,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"8","license":[{"start":{"date-parts":[[2018,8,24]],"date-time":"2018-08-24T00:00:00Z","timestamp":1535068800000},"content-version":"vor","delay-in-days":23,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"},{"start":{"date-parts":[[2018,8,1]],"date-time":"2018-08-01T00:00:00Z","timestamp":1533081600000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Liver Transpl"],"published-print":{"date-parts":[[2018,8]]},"abstract":"<jats:p>Hemostasis is a complex balance of clot formation and dissolution that is largely modulated by protein synthesis and degradation in the liver. In the state of end\u2010stage liver disease, there is a disruption of the hemostatic system due to hepatic protein synthetic dysfunction. Because historical clinical laboratory testing often only analyzes a portion of the hemostasis system, the clinician may be misled into believing that cirrhosis patients are imbalanced with a tendency toward bleeding. The modern understanding of hemostasis in cirrhosis involves a rebalance of hemostasis with a tenuous equilibrium between clotting and bleeding, but an equilibrium nonetheless. The clinician should be aware of this rebalance and not depend on limited and flawed laboratory testing in making judgments about the tendency for bleeding or clotting based on these values alone. Prophylactic protocol transfusions including large doses of fresh frozen plasma to \u201ccorrect\u201d the international normalized ratio are good examples of ineffective and potentially harmful interventions based on an outdated understanding of hemostasis in cirrhosis. Conversely, a thrombotic state is increasingly recognized in patients with cirrhosis, and conditions such as portal vein thrombosis are now becoming important therapeutic targets in many liver transplantation (LT) candidates and other patients with chronic liver disease. This article will introduce the reader to the modern understanding of hemostasis in cirrhosis, describe the common pitfalls and opportunities in treating hemostasis system abnormalities in the LT candidate particularly in regards to preprocedural prophylactic transfusions, and discuss therapeutic targets and interventions for thrombotic complications in the end\u2010stage liver disease population.<\/jats:p>","DOI":"10.1002\/lt.25198","type":"journal-article","created":{"date-parts":[[2018,8,29]],"date-time":"2018-08-29T22:42:57Z","timestamp":1535582577000},"page":"1119-1132","update-policy":"http:\/\/dx.doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":34,"title":["Management of Coagulation and Anticoagulation in Liver Transplantation Candidates"],"prefix":"10.1097","volume":"24","author":[{"given":"Patrick","family":"Northup","sequence":"first","affiliation":[{"name":"Center for the Study of Coagulation in Liver Disease, Division of Gastroenterology and Hepatology,University of Virginia Health System, University of Virginia,Charlottesville,VA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Bethany","family":"Reutemann","sequence":"additional","affiliation":[{"name":"Center for the Study of Coagulation in Liver Disease, Division of Gastroenterology and Hepatology,University of Virginia Health System, University of Virginia,Charlottesville,VA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"276","published-online":{"date-parts":[[2018,8,24]]},"reference":[{"key":"lt25198-bib-0001-20240115","doi-asserted-by":"crossref","first-page":"147","DOI":"10.1056\/NEJMra1011170","article-title":"The coagulopathy of chronic liver disease","volume":"365","year":"2011","journal-title":"N Engl J Med"},{"key":"lt25198-bib-0002-20240115","doi-asserted-by":"crossref","first-page":"1524","DOI":"10.1111\/j.1572-0241.2006.00588.x","article-title":"Coagulopathy does not fully protect hospitalized cirrhosis patients from peripheral venous thromboembolism","volume":"101","year":"2006","journal-title":"Am J Gastroenterol"},{"key":"lt25198-bib-0003-20240115","doi-asserted-by":"crossref","first-page":"440","DOI":"10.1002\/hep.21266","article-title":"Thrombin generation in patients with cirrhosis: the role of platelets","volume":"44","year":"2006","journal-title":"Hepatology"},{"key":"lt25198-bib-0004-20240115","doi-asserted-by":"crossref","first-page":"53","DOI":"10.1002\/hep.21231","article-title":"Elevated levels of von Willebrand Factor in cirrhosis support platelet adhesion despite reduced functional capacity","volume":"44","year":"2006","journal-title":"Hepatology"},{"key":"lt25198-bib-0005-20240115","doi-asserted-by":"crossref","first-page":"553","DOI":"10.1002\/hep.20569","article-title":"Evidence of normal thrombin generation in cirrhosis despite abnormal conventional coagulation tests","volume":"41","year":"2005","journal-title":"Hepatology"},{"key":"lt25198-bib-0006-20240115","doi-asserted-by":"crossref","first-page":"355","DOI":"10.1016\/j.jhep.2009.12.001","article-title":"Normal to increased thrombin generation in patients undergoing liver transplantation despite prolonged conventional coagulation tests","volume":"52","year":"2010","journal-title":"J Hepatol"},{"key":"lt25198-bib-0007-20240115","doi-asserted-by":"crossref","first-page":"54","DOI":"10.1016\/j.jcrc.2017.07.053","article-title":"Balanced haemostasis with both hypo\u2010 and hyper\u2010coagulable features in critically ill patients with acute\u2010on\u2010chronic\u2010liver failure","volume":"43","year":"2018","journal-title":"J Crit Care"},{"key":"lt25198-bib-0008-20240115","doi-asserted-by":"crossref","first-page":"265","DOI":"10.1016\/j.jhep.2013.03.036","article-title":"Evidence that low protein C contributes to the procoagulant imbalance in cirrhosis","volume":"59","year":"2013","journal-title":"J Hepatol"},{"key":"lt25198-bib-0009-20240115","doi-asserted-by":"crossref","first-page":"2105","DOI":"10.1053\/j.gastro.2009.08.045","article-title":"An imbalance of pro\u2010 vs anti\u2010coagulation factors in plasma from patients with cirrhosis","volume":"137","year":"2009","journal-title":"Gastroenterology"},{"key":"lt25198-bib-0010-20240115","doi-asserted-by":"crossref","first-page":"484","DOI":"10.1002\/hep.20317","article-title":"Performance standards for therapeutic abdominal paracentesis","volume":"40","year":"2004","journal-title":"Hepatology"},{"key":"lt25198-bib-0011-20240115","doi-asserted-by":"crossref","first-page":"1413","DOI":"10.1111\/j.1537-2995.2005.00546.x","article-title":"Dzik WH; for Transfusion Medicine\/Hemostasis Clinical Trials Network. 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