Spectrum of Liver Diseases and Associated Coagulation Abnormalities: A Comprehensive Review

Abstract

The liver is central to hemostasis, orchestrating the synthesis of coagulation factors, natural anticoagulants, fibrinolytic regulators, and thrombopoietin, while also clearing activated clotting proteins. Liver diseases disrupt these pathways, causing dynamic and often paradoxical hemostatic alterations. Traditionally considered hemorrhagic disorders due to prolonged prothrombin time (PT), international normalized ratio (INR), and thrombocytopenia, liver diseases are now recognized to induce a fragile equilibrium known as rebalanced hemostasis, which explains the simultaneous risk of bleeding and thrombosis. This comprehensive review examines coagulation abnormalities across the spectrum of liver disorders, including acute liver failure (ALF), chronic hepatitis, cirrhosis, metabolic dysfunction–associated steatotic liver disease (MASLD), cholestatic liver diseases, and vascular liver disorders. It discusses underlying pathophysiology, laboratory assessment using conventional and global hemostatic assays, clinical implications, and evidence-based management strategies. The review emphasizes individualized risk assessment, judicious transfusion, selective anticoagulation, and the integration of viscoelastic and thrombin generation testing into clinical practice. Finally, future research directions focusing on novel biomarkers, therapeutic targets, and outcome-based studies are highlighted.