What is the cause of elevated international normalized ratio (INR) in a patient with cirrhosis presenting with spontaneous bruising?

From the Guidelines

In a cirrhosis patient with elevated INR and spontaneous bruising, immediate medical attention is required, and treatment should focus on addressing the underlying coagulopathy, with vitamin K administration being a key component, while the use of fresh frozen plasma (FFP) or prothrombin complex concentrates (PCCs) should be considered with caution due to the risk of thrombosis and other complications, as suggested by recent guidelines 1.

Key Considerations

• The elevated INR in cirrhosis patients reflects impaired liver synthesis of clotting factors, particularly factors II, VII, IX, and X, which are vitamin K-dependent.
• Cirrhosis compromises the liver's ability to synthesize these proteins, leading to prolonged clotting times and increased bleeding risk.
• Patients should avoid NSAIDs and other medications that may worsen bleeding risk.
• Monitoring for signs of gastrointestinal bleeding, which is common in cirrhosis due to portal hypertension and varices, is crucial.

Management Approach

• Vitamin K administration (10 mg IV or subcutaneously daily for 3 days) is recommended to address the coagulopathy.
• The use of FFP or PCCs should be considered on a case-by-case basis, taking into account the risk of thrombosis and other complications, as highlighted in recent studies 1.
• Regular follow-up with hepatology is essential, and patients should be educated about avoiding alcohol and maintaining a low-sodium diet to manage their underlying liver disease.
• The decision to correct haemostasis should be based on individual patient needs and the severity of bleeding, as suggested by guidelines 1.

Risks and Complications

• The use of FFP or PCCs carries risks, including thrombosis, transfusion-related acute lung injury, and transfusion-associated circulatory overload, as noted in recent studies 1.
• Patients with cirrhosis are at increased risk of these complications due to their underlying liver disease and potential for portal hypertension.
• Therefore, a cautious approach to the use of these products is necessary, with careful consideration of the potential benefits and risks, as emphasized in recent guidelines 1.

From the Research

Coagulopathy in Cirrhosis Patients

• Cirrhosis patients are at higher risk for both bleeding and thrombosis-related complications due to the liver's impaired production of procoagulant and anticoagulant factors 2.
• Elevated international normalized ratio (INR) levels are associated with an increased risk of portal vein thrombosis (PVT) in cirrhotic patients, suggesting a hypercoagulable state 3.

Management of Coagulopathy

• Low-molecular-weight heparin (LMWH) is the treatment of choice for preventing and treating deep-vein thrombosis, pulmonary embolism, and portal vein thrombosis in patients with cirrhosis 2.
• Fresh frozen plasma (FFP) transfusion may not be effective in improving coagulation test values in cirrhotic patients and may even worsen them in some cases 4.
• Four-factor prothrombin complex concentrates (PCCs) and recombinant factor VIIa (rFVIIa) may be more effective than FFP in reducing INR and facilitating procedures in critically ill patients with coagulopathy associated with liver impairment 5.

Reversal of Anticoagulation

• Activated 4-factor PCCs, such as FEIBA, may be effective in reversing warfarin-related bleeding in patients with elevated INR levels 6.
• A fixed, low dose of FEIBA may be sufficient to control bleeding in most cases, with minimal risk of thrombosis 6.

Signs and Symptoms

• Spontaneous bruising may be a sign of coagulopathy in cirrhotic patients, and patients on anticoagulation therapy should be monitored closely for signs and symptoms of bleeding and thrombosis 2.