THE PAST AS PROLOGUE — CIRRHOSIS AS THE EPITOME OF THE HEMORRHAGIC DISEASES ?

Th e state of the clinical art regarding coagulation issues in liver disease patients in 1999 was generally diff erent from the concepts that have slowly taken hold since that time when J.H. Joist, writing in this journal, introduced the term “AICF” (accelerated intravascular coagulation and fi brinolysis) and asserted that the complex coagulopathy of liver disease may also involve a “hypercoagulable state” ( 1 ). Since that time, a great deal of work has slowly, but surely, carried this fi eld forward. Although the advances are broad and much more translational work is needed in many areas, the single most notable clinical change is rejection of the prothrombin time (PT)-based international normalized ratio (INR) as an isolated measure of bleeding risk in cirrhosis, and the use of arbitrary cutoff values to guide administration of procoagulants— most notably fresh frozen plasma (FFP). As presaged by Joist’s editorial ( 1 ) and confi rmed in subsequent laboratory study, the pathophysiology involved in cirrhotic coagulopathy is much more nuanced than previously appreciated and requires a more sophisticated approach to discern dominant pathways. Below, we examine the interesting history of how these conceptual changes came about over the past 17 years since Joist’s prescient editorial ( 1 ).