Hemostasis in cirrhosis: understanding destabilising factors during acute decompensation.

Hospitalised patients with decompensated cirrhosis are in a rebalanced hemostatic state due to a parallel decline in both pro- and anti-hemostatic pathways. However, this rebalanced hemostatic state is highly susceptible to perturbations and may easily tilt towards hypo-coagulability and bleeding. Acute kidney injury (AKI), bacterial infections and sepsis, and progression from acute decompensation to acute-on-chronic liver failure (ACLF) are associated with additional alterations of specific hemostatic pathways and a higher risk of bleeding. Unfortunately, there is no single laboratory method that can accurately stratify the individual patient's bleeding risk and guide pre-procedural prophylaxis. A better understanding of hemostatic alterations during acute illness would lead to a more rational and individualised management of these challenging patients. This review will outline the latest findings on hemostatic alterations driven by AKI, bacterial infections/sepsis, and ACLF in hospitalised patients with decompensated cirrhosis and provide evidence supporting more tailored management of bleeding risk in these patients. TRIAL REGISTRATION NUMBER: Not available.