In patients with acute liver failure (ALF), elevated prothrombin time and thrombocytopenia can fuel a perception of a bleeding tendency. However, the incidence, site, risk factors, and clinical significance of bleeding complications have not been quantified in a large cohort of patients with ALF. We studied 1,770 adult patients enrolled in the ALF Study Group Registry between 1998 and 2016. Bleeding complications and blood component transfusions were collected for 7 days after admission. The relationship of bleeding complications to 21‐day mortality was assessed. Despite a median international normalized ratio of 2.7 and platelet count of 96 × 109/L on admission, bleeding complications were observed in only 187 patients (11%), including 173 spontaneous and 22 postprocedural bleeding episodes. Eighty‐four percent of spontaneous bleeding episodes were from an upper gastrointestinal source and rarely resulted in red blood cell transfusion. Twenty patients experienced an intracranial bleed; half of these occurred spontaneously and half after intracranial pressure monitor placement, and this was the proximate cause of death in 20% and 50%, respectively. Bleeders and patients who received red blood cell transfusions were more acutely ill from extrahepatic organ system failure but not from hepatocellular failure. Consistent with this observation, bleeding complications were associated with lower platelet counts but not higher international normalized ratio. Transfusion of any blood component was associated with nearly 2‐fold increased death or need for liver transplantation at day 21, but bleeding complications were the proximate cause of death in only 5% of cases. Conclusions. Despite a perceived bleeding diathesis, clinically significant bleeding is uncommon in patients with ALF; bleeding complications in patients with ALF are markers of severe systemic inflammation rather than of coagulopathy and so portend a poor prognosis. (Hepatology 2018;67:1931‐1942)

中文翻译：

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急性肝功能衰竭的出血并发症

在急性肝功能衰竭 (ALF) 患者中，凝血酶原时间延长和血小板减少症会加剧对出血倾向的感知。然而，尚未在大量 ALF 患者中量化出血并发症的发生率、部位、危险因素和临床意义。我们研究了 1998 年至 2016 年间参加 ALF 研究组注册的 1,770 名成年患者。 入院后 7 天收集出血并发症和血液成分输血。评估了出血并发症与 21 天死亡率的关系。尽管入院时国际标准化比率中位数为 2.7，血小板计数为 96 × 109/L，但仅在 187 名患者（11%）中观察到出血并发症，包括 173 次自发性出血和 22 次手术后出血。84% 的自发性出血发作来自上消化道，很少导致红细胞输注。20 名患者出现颅内出血；其中一半是自发发生的，一半是在放置颅内压监测器后发生的，这分别是 20% 和 50% 的直接死亡原因。出血者和接受红细胞输注的患者因肝外器官系统衰竭而病情加重，但肝细胞衰竭则不然。与这一观察结果一致，出血并发症与较低的血小板计数有关，但与较高的国际标准化比率无关。在第 21 天，任何血液成分的输注都与死亡或肝移植需求增加近 2 倍有关，但出血并发症是仅 5% 病例的近因。结论。尽管有出血素质，但 ALF 患者临床上显着的出血并不常见。ALF 患者的出血并发症是严重全身炎症而不是凝血病的标志，因此预示着预后不良。（肝病学 2018；67：1931-1942）