From the Guidelines
Tranexamic acid should not be used in patients with liver failure, particularly those with cirrhosis and active variceal bleeding, due to the lack of beneficial effect and potential increased risk of thrombotic events. The European Association for the Study of the Liver (EASL) clinical practice guidelines on prevention and management of bleeding and thrombosis in patients with cirrhosis strongly recommend against the use of tranexamic acid in patients with cirrhosis and active variceal bleeding 1. This recommendation is based on a large randomized placebo-controlled trial that showed no beneficial effect of tranexamic acid in patients with acute upper gastrointestinal bleeding, including those with suspected variceal bleeding and liver disease comorbidity 1. Additionally, the trial found an increased incidence of venous thromboembolic events in the tranexamic acid group, particularly in patients with comorbid liver disease or suspected variceal bleeding 1.
The use of tranexamic acid in patients with liver failure is further complicated by the potential for coagulation abnormalities and the risk of worsening the balance between clotting and bleeding in these patients. Patients with liver failure often have a fragilely rebalanced fibrinolytic system, with decreases in both pro- and anti-fibrinolytic factors, which can lead to either hyperfibrinolysis or hypofibrinolysis 1. Tranexamic acid's antifibrinolytic properties could potentially worsen this imbalance, leading to thrombotic complications.
In general, the management of bleeding in patients with liver failure should focus on addressing the underlying cause of bleeding, such as portal hypertension, and using targeted therapies to control bleeding. The use of viscoelastic tests, such as thromboelastography, may be helpful in guiding transfusion therapy and reducing blood product use in patients with cirrhosis and active upper gastrointestinal bleeds 1. However, the routine use of antifibrinolytic agents, including tranexamic acid, is not recommended in patients with cirrhosis undergoing invasive procedures or in those with active bleeding from a non-portal hypertensive cause 1.
Key points to consider when managing bleeding in patients with liver failure include:
- Avoiding the use of tranexamic acid in patients with cirrhosis and active variceal bleeding
- Using targeted therapies to control bleeding, such as portal hypertension-lowering measures
- Considering the use of viscoelastic tests to guide transfusion therapy
- Monitoring for thrombotic complications and coagulation abnormalities
- Avoiding the routine use of antifibrinolytic agents in patients with cirrhosis undergoing invasive procedures or in those with active bleeding from a non-portal hypertensive cause.
From the Research
Tranexamic Acid in Liver Failure
- Tranexamic acid has been studied in the context of liver failure, particularly in patients with cirrhosis and upper gastrointestinal bleeding (UGIB) 2.
- A randomized controlled trial found that tranexamic acid significantly reduces the failure to control bleeding by day 5 and failure to prevent rebleeding after day 5 to 6 weeks in patients with advanced liver cirrhosis (Child-Turcotte-Pugh class B or C) presenting with UGIB 2.
- A case report and literature review described the successful management of refractory bleeding in liver failure with tranexamic acid, highlighting its potential use in this setting 3.
- In the context of liver transplantation, tranexamic acid has been shown to reduce blood loss, transfusion requirements, and coagulation factor use in primary orthotopic liver transplantation 4.
- However, a retrospective cohort study found that tranexamic acid administration during liver transplantation was not associated with lower blood loss or reduced utilization of red blood cell transfusion 5.
Mechanism of Action
- Tranexamic acid is an antifibrinolytic agent that works by inhibiting the activation of plasminogen to plasmin, thereby reducing fibrinolysis and promoting clot stability.
- In patients with liver failure, tranexamic acid may help to reduce bleeding by preventing the breakdown of clots and promoting hemostasis.
Clinical Implications
- The use of tranexamic acid in patients with liver failure and UGIB may be beneficial in reducing bleeding and improving outcomes 2.
- However, the use of tranexamic acid in liver transplantation is more controversial, and its benefits and risks should be carefully considered on an individual basis 4, 5.
- Further studies are needed to fully understand the role of tranexamic acid in the management of bleeding in patients with liver failure.