A point-of-care ROTEM predicts bleeding in cirrhosis


By Mardi Chapman

16 Sep 2023

Rotational thromboelastometry (ROTEM) predicts future bleeding events in patients with cirrhosis, according to Melbourne-based research.

In one of the top-ranked posters of merit at Australian Gastroenterology Week 2023, gastroenterologist Dr Natasha Janko from Alfred Health presented results from a prospective study of 162 patients who underwent ROTEM analysis and were followed for any bleeding or thrombotic events.

The study reported that 19 patients experienced a bleeding event within one year of ROTEM.

A univariate analysis found maximum clot firmness using both the EXTEM and INTEM tests was significantly reduced in patients who had a bleeding event compared to those who did not (p<0.01 for both).

As well, clotting time in the INTEM test was prolonged in the group of patients with a bleeding event (p=0.01).

However on multivariate analysis, only maximum clot firmness using EXTEM remained a significant predictor of a bleeding event.

Dr Janko told the limbic that ROTEM was routinely used in active bleeding situations such as postpartum haemorrhage,  trauma surgery, cardiac surgery and liver transplant surgery.

“It’s a global haemostatic assay that can be performed at point-of-care really quickly. It allows you to identify which part of the haemostatic pathway is not working and then the treatment for it. How we’re using it is quite different from that. We’re using it in people who aren’t actively bleeding to try and predict bleeding.”

“In liver disease, you get a number of alternations in the haemostatic system and the blood tests we use routinely such as platelet count, INR and fibrinogen only measure one component of the pathway.”

“Why we like ROTEM is that it gives you a more global picture because most people with liver disease get reductions in procoagulant and anticoagulant factors. So even though those standard tests look abnormal, they often have compensatory mechanisms in place so their overall clot formation should be, in a lot of them, normal.”

Dr Janko is currently recruiting for a RCT [link here] which will compare ROTEM-guided prophylactic blood component administration to standard of care in patients with cirrhosis and coagulopathy undergoing invasive procedures.

“We are hoping to show that you can safely reduce the number of products we give to these patients without impacting bleeding outcomes.”

In a separate poster, Dr Janko also presented results showing that ROTEM predicted transplant-free survival in the cohort of patients with liver cirrhosis.

It found maximum clot firmness using EXTEM was a significant predictor of survival on multivariate analysis. The optimal cut-off threshold to predict survival was 58 mm (HR 0.40; p=0.02).

“We hypothesised that ROTEM is a better test of coagulopathy in patients with liver disease so it could be used to predict outcomes like bleeding and survival. And it looks like in the preliminary analyses that it potentially can.”

“These are very novel findings and need to be validated. We need to know what cut-offs we should use, how frequently we should be doing the test in order to best predict outcomes, etc.”

The RCT investigators include haematologist Professor Harshal Nandurkar from Alfred Health.

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