Acquired Bleeding Disorders

Abstract

Acquired bleeding disorders include disseminated intravascular coagulation (DIC), vitamin K deficiency, massive transfusion, renal and liver disease and hyperfibrinolysis. A history of a bleeding tendency should be followed by appropriate laboratory investigations. DIC is characterised by consumption of platelets and coagulation factors and increased fibrinolytic activity. The treatment of the underlying condition is key to DIC management. In major bleeding, serial coagulation tests should be performed to guide use of blood components. Vitamin K deficiency occurs in neonates and malabsorptive states. Abnormalities in liver disease involve coagulation and fibrinolytic defects and platelet dysfunction, whereas in renal disease, abnormal platelet function and adhesion is the primary abnormality. Hyperfibrinolysis involves excessive fibrinolytic activity causing disproportionately elevated FDPs (fibrinogen degradation products) (D‐dimer levels) and should be considered in patients with liver disease and disseminated cancers. Acquired coagulation inhibitors result from immune‐mediated inhibition of a coagulation factor in patients with inherited bleeding disorder or previously normal haemostasis.

Key Concepts

  • Key to management of DIC is treatment of the underlying condition.

  • Only replace coagulation proteins and platelets in bleeding patient or for planned interventions.

  • Early use of fresh frozen plasma to prevent coagulopathy development is currently recommended.

  • Tranexamic acid should be given in all patients at risk of or with significant bleeding.

  • Vitamin K prophylaxis should be offered to all neonates at birth.

  • Prothrombin complex concentrate is recommended when rapid reversal of vitamin K antagonist therapy is required.

  • Vitamin K given either orally or intravenously will reverse the effects of VKAs in 6 h.

  • In liver disease, asymptomatic patients with abnormal coagulation tests do not routinely require replacement therapy.

  • Abnormalities of platelet function and adhesion are the major causes of bleeding in renal disease.

  • Acquired coagulation inhibitors can occur in patients with congenital coagulation factor deficiencies or in patients with previously normal haemostasis.

Keywords: disseminated intravascular coagulation; vitamin K; massive transfusion; renal disease; liver disease; hyperfibrinolysis

Figure 1. Pathophysiology of disseminated intravascular coagulation.
Figure 2. The multiple potential effects of thrombin.
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Further Reading

Allard S, Green L and Hunt BJ (2014) How we manage the haematological aspects of major obstetric haemorrhage. British Journal of Haematology 164: 177–188. An in‐depth review on current approaches in management of major obstetric haemorrhage.

Collins PW, Chalmers E, Hart D, et al. (2012) Diagnosis and treatment of factor VIII and IX inhibitors in congenital haemophilia: (4th edition). British Journal of Haematology 160: 153–170. UK Haemophilia Centre Doctors Organization (UKCDO) updated guideline on management of inhibitors in patients with congenital haemophilia.

Holcomb JN, del Junco DJ, Fox EE, et al. (2013) The prospective, observational, multicenter, major trauma transfusion (PROMMTT) study: comparative effectiveness of a time‐varying treatment with competing risks. JAMA Surg 148: 127–136. A study comparing the timing of transfusions to the outcome of in‐hospital patient mortality.

Hunt BJ (2014b) Bleeding and coagulopathies in critical care. New England Journal of Medicine 370: 847–859. A detailed state of the art review of acquired bleeding disorders in adults.

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Wada H, Thachil J, Di Nisio M, et al. (2013) Guidance for diagnosis and treatment of disseminated intravascular coagulation from harmonization of the recommendations from three guidelines. Journal of Thrombosis and Haemostasis 11: 761–767. A review which integrates recommendations from three recently published guidelines on management of DIC.

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How to Cite close
O'Sullivan, Jennifer, and Hunt, Beverley J(Jan 2015) Acquired Bleeding Disorders. In: eLS. John Wiley & Sons Ltd, Chichester. http://www.els.net [doi: 10.1002/9780470015902.a0002254.pub2]