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.