The Disseminated Intravascular Coagulation Score With Bleeding Events Associates With 28-day Outcomes In Patients With Acute-on-chronic Liver Disease

BackgroundThe number of chronic liver disease patients is large,and some patients progress to acute-on-chronic liver failure(ACLF),with acute decompensation and high short-dated mortality.In recent decades,chronic liver disease has been considered the epitome of acquired coagulation disorders.Due to a complicated hemostatic status,those who have acute hepatic deterioration on chronic liver disease are more likely to have both clotting and bleeding,which is easily confused with disseminated intravascular coagulation.Ineffective hemostasis represented by prolongation of the prothrombin time and international ratio(INR)is commonly observed in ACLF patients and worsens with increasing disease severity.Severe liver disease also leads to multiple site bleeding due to the reduced synthesis of coagulation factors 10 and thrombocytopenia.However,patients with chronic liver disease are also at a relatively high risk of venous thromboembolism.Unfortunately,commonly used laboratory indicators cannot accurately reflect or predict the occurrence of clinical bleeding or thrombotic events.Over the past years,studies regarding the International Society for Thrombosis and Hemostasis(ISTH)-disseminated intravascular coagulation(DIC)score have focused mainly on patients with sepsis.However,increasing evidence indicates that the disseminated intravascular coagulation score can predict short-term prognosis of other populations,for example,patients who have viral hemorrhagic fever or who have experienced cardiac arrest.Therefore,we aimed to investigate the incidence of DIC events in patients with AD of chronic liver disease using the ISTH-DIC scoring system,and to determine whether the ISTH DIC score be able to predict 28-day prognosis.Aims1)Observe bleeding events in patients with liver disease.2)To evaluate the application of ISTH bleeding scoring criteria in hepatic bleeding events.3)Use a prospective observational cohort to study the DIC events in patients with acute-on chronic liver disease.4)Assess the impact of bleeding events and DIC events on the short-term prognosis in patients with acute-on chronic liver disease.MethodsThis single-center observational research prospectively recruited in patients with chronic liver disease due to acute hepatic deterioration including elevated total bilirubin(>3 mg/dL)or significant flare of alanine aminotransferase(ALT>10 upper limit of normal),from January 2018 to October 2019.The disseminated intravascular coagulation was evaluated applying International Society for Thrombosis and HemostasisResultsWe prospectively screened 395 patients,116 of whom met the exclusion criteria.Of the 269 patients enrolled,the overt hepatic encephalopathy was 8.9%(n=24),bleeding events observed within first 3 days on admission was 48.7%(n=131)and 28-day mortality was 10.8%(n=29).Consistent with ISTH criteria,91(33.8%)patients were categorized as disseminated intravascular coagulation;which experienced more bleeding events(69.2 vs.38.2%,p<0.001)and greater 28-day mortality(22.0 vs.5.1%,p<0.001),respectively than those patients unmet ISTH-DIC definition.Patients with DIC diagnosis and overt bleeding events(n=63)had the greatest 28-day mortality(28.6%),compared with patients without DIC diagnosis nor/or overt bleeding events.DIC diagnosis with bleeding events,infection,and hepatic encephalopathy at admission were independent predictors of 28-day mortality.ConclusionsWe observed an association between the incidence of disseminated intravascular coagulation with or without bleeding events and 28-day mortality.Further,using sensitivity analyses,we showed that the disseminated intravascular coagulation with bleeding events is a powerful tool that can predict mortality which may merit further investigation,and proves the practicability in populations in the absence of any potential diseases,such as sepsis related to disseminated intravascular coagulation.