Our study was retrospectively done on 60 patients of chronic liver disease who presented in Department of Gastroenterology of SS hospital, Benaras Hindu University. Patients who were referred from outside over a period of one and half years (Jan 2014 to Jun 2015) were also included. Patients were divided into two groups. First group (n=30) included serologically diagnosed cases of chronic hepatitis. All the patients in this group had undergone liver biopsy and showed mild to moderate fibrosis (Ishak fibrosis score 0-3). Second group (n=30) consisted of histologically (Ishak fibrosis score 4 and 5), radiologically or clinically established cases of liver cirrhosis with or without oesophageal varices or ascites. Informed consent was taken from every patient included in the study.

Control group comprised of 30 age and sex matched healthy subjects recruited randomly from blood donors, academic staff and volunteers from the general public. General exclusion criteria included history of bleeding or thrombotic disorder, history of renal disease, diabetes mellitus, ongoing or recent pregnancy, recent history of transfusion of blood products, current anticoagulation therapy. After getting informed consent detailed history was taken.

For coagulation studies blood was collected in blue top (containing 3.2% sodium citrate) vacutainers in a ratio of 9 volume blood to 1 volume of anticoagulant. Platelet Poor Plasma (PPP) was made by centrifugation at 2000 g for 10 minutes. Coagulation tests were done immediately or PPP were stored in cuvettes at temperature of -20 to -40 degree celcius for later dates. Almost 2 ml blood was collected in EDTA vial for complete blood count by Beckman Coulter Haematology Fully Automated Autoanalyser LH750. The coagulation screening tests; PT (STA-Neoplastine RCl), activated partial thromboplastin time (CK PRESTR) and thrombin time (STA-THROMBIN) were performed by the conventional methods and the clotting times were registered by an optical coagulation system (STartR4; Diagnostica Stago). Plasma fibrinogen was measured by the turbidometric method of Clauss (FIBRI-PRESTR). Assessment of Protein C levels was done by kit provided by Diagnostic Stago (Staclot Protein C). D-Dimer test was performed using D-DI latex kit (Diagnostica Stago, France).

Statistical analysis was done using SPSS 16.0 Comparisons between two group frequencies were made using Chi-square test. For the comparison of group means, Student’s t-test was applied.

The age of chronic liver disease patients (n=60) ranged between 26-67 years and mean age was 46.62 years. There were 47 male and 13 female patients with M:F ratio of 3.6:1. Mean age for CH, cirrhosis and control group were 42.13, 51.10 and 40.8 years respectively. Fatigue was most common clinical symptom present in all 60 cases (100%) of patient group. The aetiology of chronic liver disease of the overall study group is summarized in [Table/Fig-1].

In our study mean platelet count was 197000±44277/mm³ and 91400±41692/mm³ in chronic hepatitis and cirrhosis group respectively and significantly lower than that of control group (292130+72824/ mm³) (p-value<0.001). Platelet count was significantly lower in cirrhosis group in comparison to chronic hepatitis group. In our study 33 (55%) out 60 cases of Chronic Liver Disease (CLD) had thrombocytopenia (platelet count <150x103/μl). Thrombocytopenia were found in five cases (16.7%), 25 cases (93.3%) and 0% cases of chronic hepatitis, cirrhosis and control respectively.

PT, aPTT and TT in cirrhosis group were significantly higher when compared to CH and control group (p-value <0.001). There were no significant difference in PT, aPTT and TT of CH group compared to control [Table/Fig-2].

Fibrinogen level in cirrhosis group was significantly lower than that of control and CH group (p-value <0.001). There was no significant difference in CH group compared to control.

Cirrhosis group had significantly lower protein C value compared to CH and control group (p<0.001). Though chronic hepatitis group had mean protein C level within normal limit, compared to control group it was significantly reduced (p=0.030) [Table/Fig-2].

In the present study, cirrhosis group had 21 cases out of 30 (70%) with increased D-Dimer level (>0.5ug/ml-FEU). When compared with chronic hepatitis and control group, cirrhosis group had significant number of cases with increased D Dimer level. Chronic hepatitis had two cases (6.67%) with increased D-Dimer level which was not significant when compared with control group [Table/Fig-3].

In present study, 33 out of 60 cases (55%) had thrombocytopenia (platelet count <150x103/μl). Afdhal N et al., found that thrombocytopenia (platelet counts <150,000/dL) was a common complication in patients with CLD, reported in as many as 76% of cirrhotic patients [11]. Various factors can lead to thrombocytopenia like splenic platelet sequestration, bone marrow suppression by chronic hepatitis C infection, and antiviral treatment with interferon-based therapy [11]. Reduced level or activity of the Thrombopoietin (TPO) may also play a role [11]. Similar to our study, Papatheodoridis GV et al., found mean platelet count in chronic hepatitis to be within normal limit (208X 103/mm³) and Zocco MA et al., found mean platelet count in cirrhosis to be reduced (96 X 103/ mm³) [12,13].

Findings of PT and aPTT in our study are in concordance with study done by Saray A et al., and Saja MF et al., and confirmed that prolongation of conventional coagulation screening tests appears in advanced liver disease and are not sensitive markers of liver damage [14,15]. Furthermore, recent studies have shown that these global tests are not predictive of bleeding in patients with cirrhosis however PT has kept its place as one of the parameters of common prognostic indices in advanced liver disease [16].

Al-Ghumlas AK et al., documented TT as a measurement of the final step of the coagulation cascade, viz., the conversion of fibrinogen to fibrin. Prolongation of the TT reflects quantitative as well as qualitative fibrinogen abnormalities (Dysfibrinogenemia). Our findings of TT were in agreement with Saja et al., [15,17].

Our findings of serum fibrinogen level were in line with similar study done by Saray A et al., [14]. Al-Ghumlas et al., found that plasma fibrinogen as an acute-phase reactant remains normal or increases in chronic liver disease [17]. Fibrinogen is synthesized almost exclusively in the liver and low levels in cirrhotics are generally attributed to decreased liver synthetic capacity, consumption during Disseminating Intravascular Coagulation (DIC), destruction by abnormal plasma fibrinolytic activity or accelerated catabolism [18].

Our finding of protein C was in concordance with Saja MF et al., and Saray A et al., who also found significantly low protein C value in both chronic hepatitis and cirrhosis group when compared with control group [14,15]. This was a sign of reduced hepatocyte synthetic capacity in chronic hepatitis. Zocco MA et al., showed that in CLD reduction in plasma levels of PC correlate with a higher Model For End-Stage Liver Disease (MELD) score [13]. Abdo AA et al., documented PC as a potential predictor of hepatic fibrosis in chronic liver disease [19].

These findings, including the present one, confirm that levels of PC are sensitive markers [19]. Study done by Ahmadhameed SN et al., also found 49 patients out of 50 of chronic liver disease had FDP (D-dimer) levels above normal (> 250 ng/ml) [20]. Our findings of fibrinolytic activity in CLD were compatible with other studies done by Cioni G et al., and Takahashi H et al., [21,22]. The underlying mechanism for increased fibrinolysis is increased conversion of plasminogen to plasmin, increased tissue plasminogen activators and impaired clearance of circulating plasminogen activators. It may also be due to defect of the antiplasmin and other inhibitory factors. The major inhibitor of plasmin i.e., α-2 antiplasmin is reduced in cirrhotic patients with resultant increased fibrinolysis. Moronglu F et al., stated that fibrinolysis may also be secondary to disseminated intravascular coagulation [23].

Due to some technical issue we could not include other markers of thrombosis and bleeding tendencies like protein S, Von Willebrand factor, thromboelastography and platelet function tests which would have helped in better understanding as well as enhancing the quality of our study.

Thus it was observed in our study that in cirrhosis patients severe derangement in both anti and procoagulant factors occurs. Haemostatic profile in chronic hepatitis patient remains within normal limits.

Since clinically there was neither any bleeding complication nor any evidence of thrombotic manifestations, our study therefore supported the concept of rebalanced haemostasis in liver diseases. As these balance appeared to be very precarious, patients should be kept under close watch for any of the two complications.

Longstanding dogma that patients with liver disease have a haemostasis related bleeding tendency is not supported by data collected in our study. Routine haemostasis tests such as the platelet count, PT and aPTT did not reflect the increased bleeding complication in the patients of chronic liver disease.

We also found that patients with chronic hepatitis exhibited significant reduction in protein C levels in comparison with healthy controls. All other haemostatic assays did not show any significant fluctuation in this patient group. Thus it supported use of protein C as one of the sensitive markers for hepatic dysfunction.