Von Willebrand factor is an independent predictor of short-term mortality in acutely ill patients with cirrhosis

Beyond the Limits of Conventional Coagulation Tests: A Comprehensive Overview of ACLF-Related Coagulopathies

Acute-on-chronic liver failure (ACLF) is a complex and severe condition marked by multiple organ failure and high short-term mortality. Coagulopathy, a key component of ACLF, is characterized by rebalanced hemostasis with both hypo- and hypercoagulable features, increasing the risk of bleeding and thrombosis. Conventional coagulation tests, including prothrombin time (PT) and platelet count, fail to fully capture the complexity of coagulation dysfunction in ACLF. Advanced diagnostic tools, like viscoelastic tests (VETs), offer a more comprehensive assessment, yet they remain limited in evaluating endothelial dysfunction and fail to account for reduced levels of anticoagulant factors. Emerging therapeutic strategies targeting coagulopathies in ACLF hold promise, but their clinical efficacy remains unclear. A more nuanced approach to diagnosing and managing coagulopathy in ACLF is needed, incorporating advanced hemostatic profiling to better inform prognosis and guide treatment decisions.

[Acute management of bleeding complications and coagulation disorders in critically ill patients with liver cirrhosis]

Critically ill patients with liver cirrhosis exhibit complex alterations in coagulation that should be considered in clinical acute management. As routine laboratory tests (e.g., INR, aPTT, platelet count) cannot always adequately reflect the coagulation status of critically ill patients with liver cirrhosis, functional hemostatic tests, such as viscoelastic tests, should also be used to assess coagulation disorders in these patients. If invasive procedures are planned, hemostatic interventions to prevent bleeding and measures to stabilize coagulation disorders should be considered depending on the risk of procedure-associated bleeding, while a prophylactic routine correction of abnormal laboratory coagulation parameters should be avoided. If an acute bleeding complication manifests in critically ill patients with liver cirrhosis, an individualized correction of hemostatic changes is indicated in addition to prompt identification of the source of bleeding. This review article describes the pathophysiological changes underlying the altered hemostatic system in critically ill patients with liver cirrhosis and provides an overview of diagnostic and therapeutic options for hemostatic complications.

Therapeutic Plasma Exchange in Hepatology: Indications, Techniques, and Practical Application

It is sobering that many liver failure patients die in the absence of liver transplantation (LT), and reducing its morbidity and mortality urgently needs more non-transplant treatment options. Among the several artificial liver support devices available, therapeutic plasma exchange (TPE) is the only one that improves survival in acute liver failure (ALF) patients. In many other disorders, data on survival benefits and successful bridging to transplant is encouraging. TPE removes the entire plasma, including damage-associated-molecular patterns, and replaces it with healthy donor fresh frozen plasma. In contrast, other artificial liver support systems (ALSS) correct the blood composition through dialysis techniques. TPE has become increasingly popular due to advances in apheresis techniques and a better understanding of its applicability in treating liver failure's pathophysiology. It provides metabolicdetoxification, and synthetic functions and modulates early innate immunity, fulfilling the role of ALSS. TPE is readily available in intensive care units, dialysis units, or blood banks and has enormous potential to improve survival outcomes. Hepatologists must take advantage of this treatment option by thoroughly understanding its most frequent indications and its rationale and techniques. This primer on TPE for liver clinicians covers its current clinical, technical, and practical applications, addresses the knowledge gaps, and provides future directions.

Artificial intelligence-based evaluation of prognosis in cirrhosis

Cirrhosis represents a significant global health challenge, characterized by high morbidity and mortality rates that severely impact human health. Timely and precise prognostic assessments of liver cirrhosis are crucial for improving patient outcomes and reducing mortality rates as they enable physicians to identify high-risk patients and implement early interventions. This paper features a thorough literature review on the prognostic assessment of liver cirrhosis, aiming to summarize and delineate the present status and constraints associated with the application of traditional prognostic tools in clinical settings. Among these tools, the Child-Pugh and Model for End-Stage Liver Disease (MELD) scoring systems are predominantly utilized. However, their accuracy varies significantly. These systems are generally suitable for broad assessments but lack condition-specific applicability and fail to capture the risks associated with dynamic changes in patient conditions. Future research in this field is poised for deep exploration into the integration of artificial intelligence (AI) with routine clinical and multi-omics data in patients with cirrhosis. The goal is to transition from static, unimodal assessment models to dynamic, multimodal frameworks. Such advancements will not only improve the precision of prognostic tools but also facilitate personalized medicine approaches, potentially revolutionizing clinical outcomes.