From the Guidelines
In patients with cirrhosis, an elevated INR should not be corrected unless there is active bleeding or a need for an invasive procedure, as it reflects the underlying liver disease and does not necessarily indicate an increased bleeding risk. The coagulation cascade in cirrhosis is rebalanced, resulting in a relative hypercoagulable state, as evidenced by the increased risk for both portal vein thrombosis (PVT) and venous thromboembolism (VTE) 1. Standard measures of coagulation, such as INR, are poor indicators of bleeding risk in these patients.
When assessing a patient’s pre-procedure bleeding risk, it is essential to consider the necessity of treatment to prevent bleeding, as several procedures (paracentesis, thoracentesis, and diagnostic endoscopy) do not require routine evaluation unless the patient is on therapeutic anticoagulation 1. Additionally, platelet number and fibrinogen level should be adequate. Transfusions carry significant risks, including immunologic consequences and exacerbation of portal hypertension, and are likely overutilized in patients with cirrhosis 1.
Key considerations in managing elevated INR in cirrhosis include:
- Addressing the underlying liver disease
- Avoiding routine correction of INR in non-bleeding patients
- Using vitamin K administration or fresh frozen plasma (FFP) for acute bleeding or pre-procedural correction
- Considering prothrombin complex concentrates for urgent intervention
- Understanding the complex rebalanced hemostatic system in cirrhotic patients, which includes both pro- and anti-coagulant changes 1.
From the Research
INR Increase in Cirrhosis
- The international normalized ratio (INR) is a test used to measure blood clotting, and it can be affected in patients with cirrhosis 2, 3, 4, 5, 6.
- Studies have shown that patients with cirrhosis are at a higher risk for both bleeding and thrombosis-related complications, and the INR can be elevated in these patients 3, 4, 5, 6.
- The use of direct oral anticoagulants (DOACs) in patients with cirrhosis can lead to an increase in INR, which can result in artificial inflation of the model of end-stage liver disease (MELD) score 2.
- Research has also shown that the INR does not correlate with bleeding risk in patients with cirrhosis, and other parameters such as thrombin generation (TG) may be more useful in assessing coagulopathy 5.
- Elevated INR levels have been associated with an increased risk of portal vein thrombosis (PVT) in patients with cirrhosis, suggesting a hypercoagulable state 6.
Factors Affecting INR in Cirrhosis
- The use of DOACs can increase INR in patients with cirrhosis, leading to clinically meaningful increases in MELD points 2.
- The baseline INR value can affect the increase in INR caused by DOACs, with higher baseline INR values resulting in greater increases 2.
- Other factors such as serum albumin, malnutrition, and comorbidities can also affect coagulation status and VTE risk in patients with cirrhosis 4.
Clinical Implications
- Patients with cirrhosis should be monitored closely for signs and symptoms of bleeding and thrombosis while on anticoagulation therapy 3.
- The use of INR to assess bleeding risk in patients with cirrhosis should be avoided, and other parameters such as TG should be explored as clinical markers of coagulopathy 5.
- Elevated INR levels can be a risk factor for PVT in patients with cirrhosis, and clinicians should consider this when making decisions about anti-coagulation therapy 6.