Haemostasis Patterns in Patients With Acute-on-chronic Liver Failure and Acute Decompensation of Cirrhosis Including Thromboelastometric Tests With and Without the Addition of Protac: a Pilot Study

Background: Thromboelastometry is considered as the best method to assesses hemostasis in liver disease, diagnostic performance could be improved by adding protein C activators such as thrombomodulin or Protac®. We assess the changes in ROTEM parameters after the addition of Protac® in patients with acute-on-chronic liver failure (ACLF), acute decompensation (AD), and healthy individuals (HI), to define a different hemostasis pattern, considering standard and velocity ROTEM parameters, and to assess whether the Protac® can improve this pattern definition. Methods: : In a pre-test, we investigated whether diluted EXTEM reagent improves the effect of Protac® on clotting time (CT)-ratio with and without Protac®. Ten ACLF, 20 AD patients and 21 HI were included in the main study. Results: : Standard EXTEM was used in the main study. INTEM CFT, INTEM A5 (inverse), and INTEM TPI (inverse) were the best parameters to differentiate liver disease from HI (ROC AUC, 0.921, 0.906, and 0.928, respectively; all P-values < 0.001 ). Combining INTEM CFT with EXTEM LI60-ratio only slightly improved the diagnostic performance (ROC AUC, 0.948; P<0.001 ). EXTEM LI60 and INTEM maxV-t were the best parameters to differentiate between ACLF and AD patients (ROC AUC, 0.743, P=0.033 ; and 0.723, P=0.050 ; respectively). Combining EXTEM LI60 + INTEM maxV-t moderately improved the diagnostic performance, (ROC AUC, 0.81, P<0.001 ). Conclusions: : ROTEM velocity, fibrinolysis parameters and calculated indices improve the diagnostic in combination with standard parameters (e.g., CFT and A5). Ratios calculated with and without Protac (e.g., EXTEM LI60-ratio) only slightly increased the diagnostic performance to discriminate hemostasis patterns.