Podcast 647: INR and Liver Failure


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Contributor: Erik Verzemnieks, MD

Educational Pearls:

  • INR measures the clotting cascade including factors II, VII, IX, and X
  • Coumadin most commonly elevates the INR, and it is used to monitor the anticoagulant’s effectiveness
  • Liver failure can cause a similar elevation in the INR due to lack of synthesis of factors II, VII, IX, X
  • An elevated INR in liver failure does not mean that the patient is anticoagulated, at increased risk for bleeding, or is at less risk of forming a clot
  • There is more commonly an increased risk of clot formation due to lack of production of protein C and S, which are natural anticoagulants
  • Lack of production of proteins C and S have a larger effect and lead to typically a net clotting risk
  • Levels of these can be indirectly measured through albumin
  • Portal venous thrombosis is one of the most common examples of this phenomenon


Harrison MF. The Misunderstood Coagulopathy of Liver Disease: A Review for the Acute Setting. West J Emerg Med. 2018;19(5):863-871. doi:10.5811/westjem.2018.7.37893

Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

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