Splanchnic vein thrombosis in candidates for liver transplantation: usefulness of screening and anticoagulation

Direct oral anticoagulants in patients with liver cirrhosis: A systematic review

INTRODUCTION

Anticoagulant treatment in patients with liver cirrhosis is challenging. The aim of this systematic review was to evaluate clinical outcomes of direct oral anticoagulant (DOAC) therapy in cirrhosis patients.

MATERIALS AND METHODS

A systematic search was performed in MEDLINE, Embase, and conference proceedings up to November 7th, 2017, for studies that evaluated the efficacy and safety of DOACs in cirrhosis patients with venous thromboembolism (VTE), splanchnic vein thrombosis (SVT), or atrial fibrillation (AF). Two authors independently screened titles, abstracts, and full-text articles, and assessed risk of bias. A meta-analysis could not be performed due to heterogeneity of the included studies.

RESULTS

Of the 2927 articles assessed, five retrospective cohort studies were included (n = 239, including 20 patients overlap). All studies had fair methodological quality. Two studies evaluated DOAC treatment only, and three also evaluated vitamin K antagonists (VKAs) or low-molecular-weight heparins (LMWHs). Recurrent VTE (DOAC n = 12, LMWH/VKA n = 8) or ischemic stroke (DOAC n = 37, LMWH/VKA n = 9) occurred in none of the patients. Progression of VTE was 8% with DOACs (n = 12) and 13% with VKAs and LWWH (n = 8). Recurrent SVT occurred in 0 to 4% with DOACs (n = 31). Progression of SVT was 0 to 5% with DOACs (n = 24) and 0 to 47% with VKAs and LMWH (n = 33). Major bleeding risk ranged from 4 to 15% with DOACs (n = 172) and from 7 to 28% with VKAs and LMWH (n = 67). All-cause mortality risk was 6% with DOACs (n = 36).

CONCLUSIONS

There is paucity of data on the efficacy and safety of DOACs in patients with cirrhosis. This analysis suggests that DOACs may be effective and safe for treatment of VTE, SVT, and AF in these patients.

Long-Term Outcome of Splanchnic Vein Thrombosis in Cirrhosis

Introduction

Little is known about the long-term outcome of cirrhotic patients with splanchnic vein thrombosis (SVT). This prospective cohort study aimed to describe the clinical presentation, bleeding incidence, thrombotic events, and mortality in patients with SVT associated with cirrhosis.

Methods

Among 604 consecutive patients with SVT enrolled over 2 years, 149 had cirrhosis. Major bleeding, thrombotic events, and all-cause mortality were recorded during a 2-year follow-up. In a subgroup, the degree of recanalization with or without anticoagulation therapy, and the correlation between clinical events and liver disease severity were also investigated.

Results

The most common thrombosis sites were the portal (88%) and mesenteric veins (34%). At presentation, 50% of patients were asymptomatic. Anticoagulation was administered to 92/149 patients for a median of 6.5 months. Vessel recanalization was documented in 47/98 patients with a radiological follow-up. Anticoagulation was associated with a 3.33-fold higher of recanalization rate, and a lower recurrent thrombosis rate, while patients with and without anticoagulation experienced a similar rate of major bleeding episodes. Mortality rates were 6.8 per 100 patient-years for patients with thrombosis completely or partially resolving during the follow-up, and 15.4 per 100 patient-years for those with stable or progressing thrombosis. An impact of SVT on survival was only apparent in patients with more advanced liver disease (Child–Pugh B-C).

Conclusions

Patients with SVT and cirrhosis have a substantial long-term risk of recurrent thrombotic events, which is reduced by anticoagulation therapy without any increase in bleeding risk. Anticoagulation can improve the likelihood of vessel recanalization, and is associated with a lower risk of death for decompensated patients.

Nontumorous Portal Vein Thrombosis in Liver Cirrhosis: Possible Role of β-Blockers

OBJECTIVE

Nonselective β-blockers (NSBB) are used in liver cirrhosis (LC) to prevent variceal bleeding because they decrease portal pressure. A main risk factor for the development of portal vein thrombosis (PVT) in LC is decreased portal vein inflow velocity. The aim of our study was to examine retrospectively the incidence of PVT and its correlation with the use of β-blockers in a cohort of LC patients.

SUBJECTS AND METHODS

Data from 230 LC patients (90% Child-Pugh class A), who had been followed up for at least 5 years, were reviewed. The diagnosis of PVT was made by ultrasound. The presence of PVT was evaluated with multiple logistic regression analysis where the independent variables were those significant in the univariate analysis.

RESULTS

The prevalence of PVT at baseline was 4.5%, and the incidence was 4.3% at 5 years; among the subjects taking β blockers, 46.4% were taking NSBB. A total of 19 PVT cases were found. Grade of esophageal varices (p < 0.01), PLT (p < 0.003), INR (p < 0.03), spleen diameter (p < 0.001) and PLT/spleen ratio (p < 0.0005) were significantly associated with PVT. The use of NSBB indicated a higher risk of PVT compared to selective β-blockers (SBB) (p < 0.05). In logistic regression analysis only the grade of esophageal varices was significant (p < 0.02). Univariate analysis of patients taking β-blockers showed an association of PVT with grade of esophageal varices (p < 0.01), CP class (p < 0.02), AST (p < 0.03), ALT and albumin (p < 0.02), PLT count and PLT/LD (p < 0.03), longitudinal diameter of the spleen (p < 0.005), ascites (p < 0.05), portal vein (p < 0.0001) and NSBB (OR 8.1; 95% CI 1.7-38.8).

CONCLUSION

NSBB seem to play a role in PV thrombogenesis. Further studies are needed, especially in decompensated LC patients.

Intensive Care Therapy for Patients with Advanced Liver Diseases

Decompensated cirrhosis is characterized by high hospitalization rates and costs, frequent readmissions, and poor short-term survival. Patients admitted to the hospital with acute variceal bleeding and/or hepatic encephalopathy and/or renal dysfunction are at serious risk for developing infection and/or sepsis; in turn, this renders them highly susceptible to the development of multi-system organ failure. The lack of standardized intensive care unit management protocols in patients with cirrhosis along with only few data reports from longitudinal clinical trials makes it difficult for hepatologists and critical care specialists to provide uniform evidence for clinical practice that could safely consolidate favorable outcomes such as lower hospitalization rates and/or mortality. Based on a rigorous online search of the scientific literature as well as a longtime clinical experience of the authors in the field of hepatology and critical care medicine, this work represents a focused effort to elucidate the specific bio-morbidity of advanced liver diseases in relation to the aforementioned challenges in clinical management. Further meta-analyses and/or systematic reviews are needed to enable clinicians to develop more effective strategies to bridge patients with decompensated liver disease to recompensation or liver transplantation.

Efficacy and safety of anticoagulation in non-malignant portal vein thrombosis in patients with liver cirrhosis

BACKGROUND AND AIM

Treatment for portal vein thrombosis (PVT) is not well established. Nevertheless, anticoagulation therapy can seemingly be used as first-line therapy. However, there are limited data on the role of this treatment in patients with PVT and cirrhosis. We sought to assess the safety and efficacy of anticoagulation therapy in a series of patients with non-malignant PVT and liver cirrhosis.

METHODS

We analyzed the data of 32 patients with cirrhosis and PVT between March 2009 and September 2015. All patients received anticoagulation treatment. PVT was diagnosed within the context of biannual hepatocellular carcinoma screening in these patients.

RESULTS

Recanalisation was achieved in 23 patients: complete in 17 patients (53.1%) and partial in 6 patients (18.7%). The median time for achieving a complete response was 7 months (95% CI: 6-8). We did not discover any risk factors associated with repermeation (partial or complete). None of the patients presented with thrombosis progression while receiving anticoagulation. Nine patients who achieved complete recanalisation and stopped anticoagulation therapy suffered rethrombosis (52%). There were no differences between the patients who achieved complete or partial recanalisation (35%) and those who did not (33%) in relation to the onset of hepatic events during follow-up. Three patients (9%) presented with bleeding complications: two variceal bleeding episodes and one brain hemorrhage.

CONCLUSIONS

In cirrhotic patients with non-malignant PVT, anticoagulation therapy led to partial or complete recanalisation in 70% of patients, with a broad safety profile. Due to the existing rethrombosis rate, long-term anticoagulation should be considered.

Utility of Oral Anticoagulants as Prophylaxis of Recurrent Portal Thrombosis after Liver Transplantation

INTRODUCTION

Portal vein thrombosis (PVT) is a relatively common finding in patients undergoing liver transplantation. Although the recommendation to prevent its recurrence is anticoagulation for a duration of 3 to 6 months, this is controversial.

AIM

The aim of our study was to determine the efficacy of oral anticoagulants (OAC) as prophylaxis for recurrent PVT after liver transplantation.

MATERIALS AND METHODS

Our study included 215 liver transplant patients who underwent surgery in our center from January 2012 to August 2017. We selected all patients diagnosed with PVT either pre-transplantation (using Doppler echography or Angio-CT) or during transplant surgery. All patients with PVT were initially anticoagulated with low-molecular-weight heparin in the postoperative period; at discharge they received OAC for a duration of six months. Control Doppler ultrasound was performed at 3, 6, and 12 months post-transplantation.

RESULTS

PVT was identified in 37 out of 215 patients (17.2%). PVT was diagnosed with a pre-transplant vascular study in 17 out of 37 cases (45.9%). All patients were anticoagulated with OAC (warfarin) for at least 6 months. There were no cases of recurrent thrombosis and no complications associated with anticoagulant treatment throughout the follow-up period.

CONCLUSIONS

The prevalence of portal thrombosis in liver transplant patients in our study was fairly high, at 17.2%. PVT was identified in nearly 50% of patients using high-quality vascular studies prior to transplant surgery. Anticoagulation with OAC for 6 months was effective in preventing a recurrence of thrombosis and there were no associated complications.

Harmful and Beneficial Effects of Anticoagulants in Patients With Cirrhosis and Portal Vein Thrombosis

BACKGROUND & AIMS

Vitamin K antagonists (VKAs) promote recanalization of portal vein thrombosis (PVT) in patients with cirrhosis. However, the benefit of PVT recanalization might be offset by major and minor bleeding associated with use of anticoagulants. We evaluated harmful and beneficial effects of VKA in patients with PVT and cirrhosis.

METHODS

We performed a retrospective study of 63 consecutive patients with cirrhosis given anticoagulants for the first detection of non-neoplastic PVT from 2003 to 2015 in Italy. We collected data on bleeding events in these patients and compared them with those from patients without cirrhosis with venous thromboembolism (VTE) (n = 160) for up to 4 years. Time in the therapeutic range, based on the international normalized ratio, was used to determine the quality of anticoagulation. We also collected data from 139 patients with cirrhosis who did not receive VKAs (controls), to analyze portal hypertension-related events. We performed survival analyses to determine the effects of VKA in patients with PVT vs controls.

RESULTS

The group with VTE and the group with PVT were comparable in age, sex, and time in the therapeutic range, but patients with VTE received VKAs for a longer time period (31.1 ± 16.9 mo vs 23.3 ± 16.2 mo; P = .002). The incidence of major or minor bleeding was higher in patients with PVT than patients with VTE (major, 24% vs 7%; P = .012; minor, 29% vs 19%; P = .024). Patients with PVT had a higher rate of major bleeding from the upper-gastrointestinal tract than patients with VTE (P = .019), but there were no significant differences in other types of major bleeding (P = .376). Patients with PVT and controls had the same rate of upper-gastrointestinal bleeding. Complete recanalization in patients with PVT receiving VKA (n = 31) was independently associated with increased portal hypertension-related event-free and transplantation-free survival times.

CONCLUSIONS

In a retrospective analysis of 63 patients with cirrhosis given anticoagulants for PVT, we found VKA use to increase risk of minor bleeding, compared with patients without cirrhosis given VKA. However, this risk is offset by the ability of VKA to increase portal hypertension-related, event-free, and transplantation-free survival of patients with PVT recanalization. Portal hypertension, rather than anticoagulants, could account for the difference in risk of major bleeding between patients with PVT vs patients with VTE.

Anticoagulation in non-malignant portal vein thrombosis is safe and improves hepatic function

Background

Non-malignant portal vein thrombosis (PVT) is common in patients with advanced liver disease. Anticoagulation (AC) increases the chances of recanalization and may improve liver function in patients with cirrhosis.

Aim

We retrospectively assessed the course of non-malignant PVT in patients receiving AC.

Methods

Parameters related to hepatic injury (aspartate aminotransferase [AST]/alanine aminotransferase [ALT]), severity of disease (ascites) and synthesis function (albumin) as well as AC, rates of PVT regression/progression and AC-associated complications were documented.

Results

Among 122 patients with PVT, 51 patients with non-malignant PVT (27 incomplete, 24 complete) were included, 12 patients (25%) received long-term AC therapy (≥9 months) as compared to 36 patients without long-term AC. We observed a trend towards higher regression rates with long-term AC of 58% (vs. 28% without AC; p = 0.08) and lower progression rates of 25% (vs. 42% without AC; p = 0.15). In the subgroup of patients with decompensation prior to PVT diagnosis (n = 39), long-term AC (n = 10, 25.6%) resulted in a significantly higher rate of PVT regression/resolution (70% vs. 24%, p = 0.031). Interestingly, AST/ALT tended to decrease (−19%/−16%) and the proportion of patients with ascites became lower (−33%) with long-term AC (without AC: ±0%). Furthermore, there was a significant improvement in albumin levels (+9%/+3.6 g/dl) when compared to patients without long-term AC (−2%/−0.8 g/dl; p = 0.04). Additionally, 10 patients were treated with direct oral anticoagulants (DOACs) for splanchnic vein thrombosis. Importantly, there were no AC-associated bleeding events in patients with conventional AC and one bleeding event in patients with DOAC treatment (10%).

Conclusion

Our findings support anticoagulation in patients with non-malignant PVT, since AC seems safe and associated with superior PVT regression rates and might also decrease hepatic injury and improve liver synthesis.

Newer Oral Anticoagulants in the Treatment of Acute Portal Vein Thrombosis in Patients with and without Cirrhosis

BACKGROUND

Newer oral anticoagulants (NOACs) are being utilized increasingly for the treatment of venous thromboembolism (VTE). NOAC use is the standard of care for stroke prophylaxis in nonvalvular atrial fibrillation and treatment of acute VTE involving extremities and pulmonary embolism. In contrast, most guidelines in the literature support the treatment of acute portal vein thrombosis (PVT) with low molecular weight heparin (LMWH) and vitamin K antagonists (VKA). Literature evaluating NOAC use in the treatment of acute portal vein thrombosis is sparse. This review focuses on the safety and efficacy of the use of NOACs in the treatment of acute PVT in patients, with or without concomitant cirrhosis, based on the most recent data available in the current literature.

METHODS

A systematic review was conducted through a series of advanced searches in the following medical databases: PubMed, BioMed Central, Cochrane, and Google Scholar. Keywords utilized were as follows: NOAC, DOAC (direct oral anticoagulants), portal vein thrombosis, rivaroxaban, apixaban, dabigatran, and edoxaban. Articles related to newer anticoagulant use in patients with portal vein thrombosis were included.

RESULTS

The adverse events, including bleeding events (major and minor) and the failure of anticoagulation (propagation of thrombus or recurrence of PVT), are similar between the NOACs and traditional anticoagulants for the treatment of acute PVT, irrespective of the presence of cirrhosis.

CONCLUSIONS

Newer oral anticoagulants are safe and efficacious alternatives to traditional anticoagulation with low molecular weight heparin and vitamin K antagonists in the treatment of acute portal vein thrombosis with or without cirrhosis.

Transient portal vein thrombosis in liver cirrhosis

In real-world clinical practice, the acceptance of anticoagulation therapy in the management of portal vein thrombosis (PVT) in patients with cirrhosis is limited by the fear of an increased bleeding risk. Additionally, accumulating evidence indicates that spontaneous recanalization of PVT may occur in the absence of antithrombotic treatment. Therefore, risk stratification based on outcomes in such patients is crucial for determining a therapeutic strategy. In this paper, we draw attention to the distinct clinical entity, "transient PVT" by introducing two cases with PVT that spontaneously recanalized in the absence of antithrombotic treatment. We reviewed the available data regarding the probability of and predictors for spontaneous recanalization of PVT. Available data suggest singling out transient thrombosis in the natural history of PVT in patients with cirrhosis because of its prognostic and management implications.

Transjugular intrahepatic portosystemic shunt creation for cirrhotic portal hypertension is well tolerated among patients with portal vein thrombosis

BACKGROUND

Portal vein thrombosis (PVT) develops in cirrhotic patients because of stagnation of blood flow. Transjugular intrahepatic portosystemic shunt (TIPS) creates a low-resistance conduit that restores portal venous patency and blood flow.

AIM

The effect of PVT on transplant-free survival in cirrhotic patients undergoing TIPS creation was evaluated.

PATIENTS AND METHODS

A multicenter, retrospective cohort study of patients who underwent TIPS creation for cirrhotic portal hypertension was carried out. A Cox model with propensity score adjustment was developed to evaluate the effect of PVT on 90-day and 3-year transplant-free survival. A subgroup analysis examining mortality of those with superior and inferior PVT was also carried out.

RESULTS

A total of 252 consecutive TIPS creations were assessed, including 65 in patients with PVT. Survival of patients with high Model for End-stage Liver Disease scores (≥18) and PVT was not statistically different compared with patients with low Model for End-stage Liver Disease scores (<18) and no PVT at 90 days (P=0.46) and 3 years (P=0.42). Those with superior PVT had improved 90-day and 3-year survival both compared with patients with a inferior PVT and those without a PVT (P<0.01, all cases).

CONCLUSION

The presence of PVT does not impair the prognosis of patients following TIPS creation, particularly in patients with superior portal occlusion.

Non-neoplastic Portal Vein Thrombosis in HCV Cirrhosis Patients: Is it an Immuno-Inflammatory Disorder?

BACKGROUND AND AIMS

Portal vein thrombosis (PVT) is a critical complication in cirrhotic patients. We explored the role of the activated factor VII-antithrombin (FVIIa-AT) complex and enhanced monocytic tissue factor (TF) expression in the development and prediction of non-neoplastic PVT in cirrhotic patients.

MATERIAL AND METHODS

A total of 30 HCV-cirrhosis patients were included in our study. They were compared to 35 cirrhotic patients without PVT, 15 non-cirrhotic patients with PVT, and 15 healthy controls. The plasma level of the FVIIa-AT complexes was analyzed by ELISA. MIF CD142, CD86, and HLA-DR on monocytes (CD14) were determined by flow cytometry.

RESULTS

Compared with cirrhotic patients without PVT, cirrhotic patients with PVT had comparable plasma values of FVIIa, AT, and the FVIIa-AT complex. However, they had significantly lower values compared to non-cirrhotic patients with PVT and healthy controls. Cirrhotic patients with PVT had increased monocytic TF expression (MIF CD142) compared to non-PVT cirrhotic patients and healthy controls [86.5 (93.5) vs. 18 (32.0) and 11.0 (6.0), respectively; p < 0.001 for each]. However, cirrhosis PVT could not be distinguished from non-cirrhosis PVT. The area under the ROC curve of MIF CD142 was 0.759 (0.641- 0.876; p = 0.000) at an optimal cut-off value of 45, which yielded a sensitivity of 60% and a specificity of 77.1%, as well as a PPV and NPV of 69.2% for each.

CONCLUSION

Enhanced expression of monocytic TF may have a role in the development and prediction of non-neoplastic PVT in HCV-cirrhosis patients. Large multicenter studies are necessary to validate our results.

Portal Vein Thrombosis in Patients With Cirrhosis Undergoing Elective Transjugular Intrahepatic Portosystemic Shunt: Risk Factors, Warfarin Efficacy, and Clinical Outcomes

Portal vein thrombosis (PVT) is a common complication in cirrhosis. The aim of this study was to determine risk factors for PVT, assess the efficacy of anticoagulant therapy, and evaluate the effects of PVT on patients with cirrhosis undergoing elective transjugular intrahepatic portosystemic shunt (TIPSS). A total of 101 patients with cirrhosis undergoing elective TIPSS were prospectively studied. After TIPSS, all patients received preventive therapy for PVT and were followed up at 3, 6, 12, and 24 months. Clinical outcomes were compared between patients who developed PVT after TIPSS and those who did not. Multivariate analysis showed that white blood cell count (relative risk [RR]: 0.377; 95% confidence interval [CI]: 0.132-0.579; P = .001), Child-Turcotte-Pugh score (RR: 1.547; 95% CI: 1.029-2.365; P = .032), and ascites (RR: 1.264; 95% CI: 1.019-1.742; P = .040) were independent predictors for PVT. Warfarin treatment within 12 months achieved significantly higher rates of complete recanalization than aspirin or clopidogrel in patients with PVT (54.5% vs 31.3%; P = .013), although adverse events were similar between the 2 groups ( P > .05). Patients without PVT had significantly lower 2-year cumulative rates of variceal rebleeding (15.9% vs 36.6%; P = .023), shunt dysfunction (27.0% vs 46.8%; P = .039), hepatic encephalopathy (24.1% vs 42.6%; P = .045), and hepatocellular carcinoma (11.4% vs 31.2%; P = .024) and markedly higher 2-year cumulative survival rates (89.8% vs 72.9%; P = .041) than those with PVT. The PVT is associated with poorer clinical outcomes in TIPSS-treated patients, and warfarin is both safe and more effective in recanalizing PVT than aspirin or clopidogrel.

Portal vein thrombosis in cirrhosis: diagnosis, natural history, and therapeutic challenges

Portal vein thrombosis (PVT) is a frequent complication in cirrhosis and its prevalence increases with disease severity. Several factors are involved in the development and progression of PVT. The challenge for the management of PVT is the precise evaluation of the bleeding risk as opposed to life-threatening extension of thrombosis. Nevertheless, the impact on the progression and outcome of liver disease is unclear. A critical evaluation of the available data discloses that treating PVT in cirrhotics is safe and effective. However, there are open issues, such as which anticoagulant could represent a safer therapeutic option, and when and for how long this treatment should be administered to cirrhotic patients with PVT.

Antithrombin III for portal vein thrombosis in patients with liver disease: A randomized, double-blind, controlled trial

AIM

Portal vein thrombosis (PVT) is one of the most critical disorders in liver disease patients. These patients have the imbalance of coagulation and coagulation inhibition resulting from decreased levels of coagulation inhibitory factors, such as protein C, protein S, and antithrombin III (AT-III). We designed this randomized, double-blind, placebo-controlled trial comparing the safety and efficacy of AT-III for PVT in liver disease patients with those who received no treatment.

METHODS

Eligible patients were diagnosed with the association of thrombus, without tumor thrombus, and thrombus in more than 50% of the cross-sectional lumen of the portal vein. Patients with 70% or less serum level of AT-III were included. The study drug was given up to three times in a 5-day consecutive infusion interval if the thrombus decreased in size. Efficacy was evaluated by contrast enhanced computed tomography using a five-grade scale (complete response, partial response, slight response, no response, and progression). From October 2014 through to March 2016, 36 patients were randomly assigned to the AT-III group and 37 patients to the placebo group.

RESULTS

The proportion of patients with complete response or partial response of PVT was significantly higher in the AT-III group (55.6%; 20/36 patients; 95% confidence interval, 38.1-72.1) than in the placebo group (19.4%; 7/36 patients, 95% confidence interval, 8.2-36.0) (P = 0.003). The overall incidence of adverse events and adverse drug reactions did not differ significantly between the two groups.

CONCLUSION

Antithrombin III is one of the essential therapies for patients with PVT in cases with lower concentration levels of AT-III.

The use of nonselective beta blockers is a risk factor for portal vein thrombosis in cirrhotic patients

BACKGROUND/AIM

A reduction in portal vein inflow velocity seems to predispose to the emergence of portal vein thrombosis (PVT). Nonselective β-blockers (NSBBs), used to prevent variceal bleeding, may increase the development of PVT by reducing portal vein inflow velocity. In this retrospective case-control study, we evaluated the risk factors and clinical features of a first event of PVT in 130 cirrhotics, 19 (15%) with (PVT group) and 111 (85%) without PVT (non-PVT group).

PATIENTS AND METHODS

Patient evaluation and NNBB treatment were carried out according to the AASLD guidelines.

RESULTS

PVT was prevalently partial (84%) and asymptomatic (84%). Patients with PVT were treated with different regimens, and resolution of thrombosis was observed in about 50% of the cases. In both groups, HCV was the most frequent cause of cirrhosis and Child-Pugh score A was prevalent. Ascites and esophageal varices were more frequent in the PVT group (P = 0.05 and <0.000, respectively). Treatment with NSBBs was significantly more frequent in the PVT group than in the non-PVT group (P < 0.000). PVT was associated with higher prevalence of chronic renal disease (P = 0.002), higher PT impairment (P = 0.003) and lower AST and ALT (P = 0.000). At multivariate logistic regression analysis, history of esophageal varices (P = 0.007) and NSBB treatment (P = 0.0003) were independent risk factors significantly associated with PVT.

CONCLUSIONS

Esophageal varices and NSBB treatment were independent risk factors of PVT. Larger studies should evaluate the risk between variceal bleeding and portal vein thrombosis of using NSBBs, particularly in the prevention of first bleeding in nonadvanced liver cirrhosis.

Obesity is not associated with an increased risk of portal vein thrombosis in cirrhotic patients

AIM

To determine the impact of obesity on development of portal vein thrombosis in cirrhotic patients.

BACKGROUND

Cirrhosis is a known risk factor for portal vein thrombosis (PVT). Evidence also points to obesity as being a risk factor for venous thromboembolism. Limited information is available on how obesity impacts the development of PVT in cirrhotic patients.

METHODS

This was a retrospective cohort study using the 2013 National Inpatient Sample. Patients older than 18 years with an ICD-9 CM code for any diagnosis of liver cirrhosis were included. There was no exclusion criteria. The primary outcome was the impact of obesity on development of PVT. Obesity was also sub-classified according to body-mass index (BMI). Secondary outcomes were in-hospital mortality, ICU admission, shock, TPN use, and resource utilization. Odds ratios (OR) and means were adjusted for age, gender, and ethnicity.

RESULTS

We included 69,934 obese cirrhotics of which, 1,125 developed PVT (mean age 59 years, 35% female). Overall in-hospital mortality rates were 9% (11% with PVT vs 5% without PVT). On multivariate analysis, obesity was not associated with a significantly different adjusted OR for development of PVT compared to non-obese. When stratifying by obesity subtype, class 1 obesity was associated with increased odds of PVT (OR: 1.45, 95%CI: 1.06-1.96, p=0.02), while class 3 obesity was associated with a decreased odds of PVT (OR: 0.72, 95%CI: 0.58-0.88, p<0.01) compared to non-obese.

CONCLUSION

Obesity is not associated with increased odds of PVT.

Decreased portal vein velocity is predictive of the development of portal vein thrombosis: A matched case-control study

BACKGROUND & AIMS

Portal vein thrombosis (PVT) in cirrhosis may lead to hepatic decompensation and increased mortality. We aimed to investigate if decreased portal vein (PV) velocity is associated with future PVT.

METHODS

Data on adult patients with cirrhosis and PVT between January 1, 2005 and July 30, 2015 were obtained. Cases with PVT were matched by age, gender and Model for End-stage Liver Disease (MELD) score to corresponding controls without PVT. Cox proportional hazards models, receiver operator curves and Kaplan Meier curves were constructed.

RESULTS

One hundred subjects (50 matched pairs) with mean age 53.8±13.1 y and MELD score 14.9±5.5 were included in our analysis. Sixty-four percent were male and 76% were Child-Turcotte-Pugh Class A or B. Baseline characteristics (prior to development of PVT) were similar, except for baseline PV velocity (16.9 cm/s, 95% CI 13.9-20.0 PVT vs 25.0, 95% CI 21.8-28.8 no PVT, P<.001). 30 PVT subjects had PV velocity <15 cm/s compared to five without PVT (P<.001). On adjusted multivariable analysis, PV velocity was the strongest independent risk factor predicting PVT development (HR 0.86, 95% CI 0.80-0.93). The predictive value for PVT development was greatest for flow <15 cm/s (c-statistic 0.77). PV velocity <15 cm/s had a highly significant association with future PVT (HR 6.00, 95% CI 2.20-16.40, P=<.001).

CONCLUSIONS

Decreased PV velocity is associated with increased risk of future PVT. Patients with cirrhosis and decreased PV velocity are a high-risk subgroup that warrants further investigation with prospective study.

[Anticoagulation in Patients with Liver Cirrhosis]

Cirrhotic patients have bleeding tendencies due to the lack of coagulation factors and thrombocytopenia. However, decreased levels of procoagulants are also accompanied by decreased levels of natural anticoagulants. However, there have been contrasting reports. It has been reported that patients with cirrhosis are at risk for thrombotic complications, including portal vein thrombosis and venous thromboembolism. Physicians consider active anticoagulation for prophylaxis and treatment of portal vein thrombosis and/or venous thromboembolism in cirrhotic patients with high risk of thrombosis. Concurrently, there are safety concerns regarding the risk of bleeding from anticoagulants in people with advanced liver disease. Further prospective studies are required to determine not only if cirrhotic patients benefit from receiving anticoagulation therapy for preventing thrombotic complications, but also to determine which prophylactic regimen is most appropriate.

The disseminated intravascular coagulation score is a novel predictor for portal vein thrombosis in cirrhotic patients with hepatitis B

BACKGROUND

The development of portal vein thrombosis (PVT) in cirrhotic patients has not been fully elucidated. The disseminated intravascular coagulation (DIC) score, which is based on readily available and relatively inexpensive coagulation parameters, including platelet count, fibrin-related markers, prothrombin time and fibrinogen, has not been reported regarding PVT development in cirrhotic patients to date. We aimed to evaluate the prognostic value of the DIC score in predicting PVT development in cirrhotic patients with hepatitis B.

MATERIAL AND METHODS

A total of 109 cirrhotic patients with hepatitis B were included. Clinical data, laboratory tests and imaging were collected from the patients at baseline and every three months after enrollment. All patients were followed until the study endpoint (either occurrence of PVT or 12months after baseline). We measured routine laboratory parameters and conducted imaging examinations in cirrhotic patients and evaluated the prognostic value of the DIC score as a novel predictor for PVT in patients with cirrhosis. We also compared the effectiveness of the DIC score with other common coagulation and hemodynamic parameters.

RESULTS

Among the 109 patients, 14 (12.8%) developed PVT. At the study endpoint, significant increases in D-dimer, Child-Pugh score and DIC score (all P<0.001) and significantly reduced portal flow velocity (P<0.001) were noted in the PVT group. Among the selected factors, the DIC score had the largest area under the curve (AUC) (0.845), followed by the Child-Pugh score (0.778), D-dimer (0.732), and portal vein velocity (0.709).

CONCLUSION

Among the selected factors, the DIC score showed non-significantly higher diagnostic performance in predicting the PVT development in cirrhotic patients compared with other factors. A validation cohort of the study is needed in the near future.

Critical care management of the patient with cirrhosis awaiting liver transplant in the intensive care unit

Patients with cirrhosis who are awaiting liver transplantation (LT) are at high risk for developing critical illnesses. Current liver allocation policies that dictate a "sickest first" approach coupled with a mismatch between need and availability of organs result in longer wait times, and thus, patients are becoming increasingly ill while awaiting organ transplantation. Even patients with well-compensated cirrhosis may suffer acute deterioration; the syndrome of acute-on-chronic liver failure (ACLF) results in multisystem organ dysfunction and a marked increase in associated short-term morbidity and mortality. For patients on transplant waiting lists, the development of multisystem organ failure may eliminate candidacy for transplant by virtue of being "too sick" to safely undergo transplantation surgery. The goals of intensive care management of patients suffering ACLF are to rapidly recognize and treat inciting events (eg, infection and bleeding) and to aggressively support failing organ systems to ensure that patients may successfully undergo LT. Management of the critically ill ACLF patient awaiting transplantation is best accomplished by multidisciplinary teams with expertise in critical care and transplant medicine. Such teams are well suited to address the needs of this unique patient population and to identify patients who may be too ill to proceed to transplantation surgery. The focus of this review is to identify the common complications of ACLF and to describe our approach management in critically ill patients awaiting LT in our centers. Liver Transplantation 23 1465-1476 2017 AASLD.

Portal vein thrombosis before and after transjugular intrahepatic portosystemic shunt placement: An observational study (STROBE compliant)

Portal vein thrombosis (PVT) is common in patients with cirrhosis undergoing transjugular intrahepatic portosystemic shunt (TIPS). This study had 3-fold aims: to assess risk factors for PVT; to determine the efficacy of anticoagulant therapy; to investigate the impact of PVT on clinical outcomes in TIPS-treated cirrhosis.Between June 2012 and February 2016, 126 TIPS-treated patients with cirrhosis were enrolled and studied prospectively. Enrolled patients were screened for PVT before TIPS and at 3, 6, 12, and 24 months post-TIPS. All patients received warfarin (1.5-3.0 mg/day) or aspirin (100 mg/day) or clopidogrel (75 mg/day) post-TIPS. Results of patients with and without PVT (baseline and de novo) were compared.White blood cell (WBC) counts (odds ratio (OR): 0.430, 95% confidence interval (CI): 0.251-0.739, P = .002) and Child-Turcotte-Pugh (CTP) score (OR: 2.377, 95% CI: 1.045-5.409, P = .039) were significant baseline predictors for PVT in TIPS-treated patients with cirrhosis. Warfarin resulted in markedly greater rates of complete recanalization than aspirin or clopidogrel (P < .05) in patients with PVT. Patients with PVT had markedly higher 2-year cumulative rates of variceal rebleeding, shunt dysfunction, hepatic encephalopathy, and hepatocellular carcinoma, and prominently lower overall survival than those without PVT (P < .05).In TIPS-treated patients with cirrhosis, lower WBC count and higher CTP score were independent baseline predictors for PVT; patients with PVT had worse clinical outcomes than those without; warfarin may be more effective in recanalizing PVT than aspirin or clopidogrel.

Portal vein thrombosis in liver cirrhosis: incidence, management, and outcome

Background

Portal vein thrombosis (PVT) is a serious complication in liver cirrhosis with portal hypertension. We examined the treatment, recurrence and prognosis of PVT in cirrhotic patients.

Methods

The study subjects were all 90 cirrhotic patients with PVT treated with danaparoid sodium (DS) at our department between July 2007 and September 2016. The mean age was 68 years and mean Child-Pugh score was 7. All patients received 2500 U/day of DS for 2 weeks, and repeated in those who developed PVT recurrence after the initial therapy.

Results

Complete response was noted in 49% (n = 44), partial response (shrinkage ≥70%) in 33% (n = 30), and no change (shrinkage <70%) in 18% (n = 16) of the patients after the initial course of treatment. DS treatment neither caused adverse events, particularly bleeding or thrombocytopenia, nor induced significant changes in serum albumin, total bilirubin, prothrombin time, and residual liver function. Re-treatment was required in 44 patients who showed PVT recurrence and 61% of these responded to the treatment. The cumulative recurrence rates at 1 and 2 posttreatment years were 26 and 30%, respectively. The recurrence rates were significantly lower in patients with acute type, compared to the chronic type (p = 0.0141). The cumulative survival rates at 1 and 3 years after treatment (including maintenance therapy with warfarin) were 83 and 60%, respectively, and were significantly higher in patients with acute type than chronic type (p = 0.0053).

Conclusion

We can expect prognostic improvement of liver cirrhosis by warfarin following two-week DS therapy for the treatment of PVT in patients with liver cirrhosis safety and effectiveness. An early diagnosis of PVT along with the evaluation of the volume of PVT on CT and an early intervention would contribute to the higher efficacy of the treatment.

Austrian consensus guidelines on the management and treatment of portal hypertension (Billroth III)

The Billroth III guidelines were developed during a consensus meeting of the Austrian Society of Gastroenterology and Hepatology (ÖGGH) and the Austrian Society of Interventional Radiology (ÖGIR) held on 18 February 2017 in Vienna. Based on international guidelines and considering recent landmark studies, the Billroth III recommendations aim to help physicians in guiding diagnostic and therapeutic strategies in patients with portal hypertension.

Techniques and long-term effects of transjugular intrahepatic portosystemic shunt on liver cirrhosis-related thrombotic total occlusion of main portal vein

Portal vein hypertension (PVH) in liver cirrhosis complicated with portal venous thrombosis (PVT) has been mainly treated with transjugular intrahepatic portosystemic shunt (TIPS). The clinical effects of TIPS have been confirmed, however, no large-scale studies have been focused on technical analyses and a long-term follow-up, especially on thrombotic total occlusion of main portal vein (MPV). To demonstrate critical techniques and clinical outcome of TIPS on liver cirrhosis-related thrombotic total occlusion of MPV, 98 patients diagnosed with liver cirrhosis related thrombotic total occlusion of MPV and treated with TIPS from January 2000 to January 2010 were retrospectively analyzed. Twenty-three (23.5%) patients had MPV (single site) thrombosis, 55 (56.1%) had multiple site-thrombosis (MPV and other), 17 (17.3%) had cavernous transformation of portal vein, and 3 (3.1%) had post-transplant thrombosis. The successful rate of TIPS was 90.7%, without any procedure-related deaths or severe complications. Mean portal pressure was dropped from 33.08 ± 1.38 mmHg preoperatively to 20.18 ± 0.83 mmHg postoperatively (p < 0.001). Collectively, TIPS is safe and effective in treating liver cirrhosis-related thrombotic total occlusion of MPV. This complex procedure requires combination of indirect portography and percutaneous transhepatic portal techniques to increase the rate of success.

Effects of Anticoagulants in Patients With Cirrhosis and Portal Vein Thrombosis: A Systematic Review and Meta-analysis

BACKGROUND & AIMS

Liver cirrhosis is complicated by bleeding from portal hypertension but also by portal vein thrombosis (PVT). PVT occurs in approximately 20% to 50% of patients with cirrhosis, and is a warning sign for poor outcome. It is a challenge to treat patients with cirrhosis using anticoagulants, because of the perception that the coexistent coagulopathy could promote bleeding. We performed a systematic review and meta-analysis to determine the effects of anticoagulant therapy in patients with cirrhosis and PVT.

METHODS

We searched the PubMed, ISI Web of Science, SCOPUS, and Cochrane databases through February 14, 2017, for studies that assessed the effect of anticoagulant therapy vs no treatment in patients with cirrhosis and PVT. We performed a meta-analysis to estimate the effect of anticoagulant treatment vs no therapy on recanalization and progression of PVT in patients with cirrhosis. We also assessed variceal and nonvariceal bleeding.

RESULTS

We analyzed data from 8 studies, comprising 353 patients, that assessed the effects of anticoagulant therapy (low-weight heparin or warfarin vs no therapy) in patients with cirrhosis and PVT; these studies reported rates of complete and partial recanalization. A significantly higher proportion of patients treated with anticoagulants underwent PVT recanalization than patients who did not receive anticoagulants (71% vs 42%, respectively; P < .0001). From 6 studies (comprising 217 patients), 53% of patients treated with anticoagulants vs 33% of patients who did not receive anticoagulants had complete PVT recanalization (P = .002). From 6 studies (comprising 225 patients), PVT progressed in 9% of patients treated with anticoagulants vs 33% of patients who did not receive these drugs (P < .0001). Six studies (257 patients) reported rates of any bleeding; there was no difference in the proportions of patients with major or minor bleeding between groups that did vs did not receive anticoagulants (11% for both groups). Four studies (comprising 158 patients) reported rates of spontaneous variceal bleeding, which occurred in a significantly lower proportion of patients who received anticoagulants vs those who did not (P = .04).

CONCLUSIONS

Based on a systematic review and meta-analysis, patients with cirrhosis and PVT who receive anticoagulant therapy have increased recanalization and reduced progression of thrombosis, compared with patients who do not receive anticoagulants, with no excess of major and minor bleedings and less incidence of variceal bleeding.

Hematological Issues in Liver Disease

Acute and chronic liver failure are associated with numerous alterations in different features of the coagulation system. Consequently, there is widespread confusion regarding the potential for both bleeding and thrombosis in patients with liver disease. The risk of bleeding is related to the hemodynamic changes in portal pressures and venous congestion whereas the thrombotic risk stems from changes in the coagulation system. Antithrombotic prophylaxis and treatment of patients with hemorrhage and thrombosis requires careful assessment, interpretation of laboratory workup, and attention to coexistent morbidities. A framework for the management of these conditions is presented for clinicians.

Clinical Impact and Risk Factors of Portal Vein Thrombosis for Patients on Wait List for Liver Transplant

OBJECTIVES

The effect of portal vein thrombosis on the progression of liver disease is controversial, with no consensus on optimal treatment. We aimed to assess how portal vein thrombosis affects wait list outcomes, identify risk factors associated with its development while on a wait list, and assess its effects on patient and graft survival.

MATERIALS AND METHODS

This US-based retrospective cohort study analyzed 134 109 adult patients on wait lists for or undergoing primary orthotopic liver transplant between January 2002 and June 2014. Rate of portal vein thrombosis development, time from entry on wait list to transplant, comparisons of wait list drop-off rates between patients with versus those without portal vein thrombosis, risk factors associated with its development while on a wait list, and its effects on patient and graft survival were analyzed.

RESULTS

We found that the rate of portal vein thrombosis at listing increased. Patients with the disease at listing were more likely to be removed from wait lists because of being too sick. Portal vein thrombosis at listing was an independent risk factor for being removed from a wait list. Of 63 265 patients who underwent primary orthotopic liver transplant, those with the disease were more likely to have higher Model for End-Stage Liver Disease scores and incidence of nonalcoholic steatohepatitis and diabetes mellitus. Portal vein thrombosis had a negative effect on patient and graft survival. Nonalcoholic steatohepatitis, body mass index, diabetes, and hepatocellular carcinoma were identified as risk factors for its development.

CONCLUSIONS

Portal vein thrombosis represents an increasing management and outcome burden in liver transplant. Having this disease at listing and/or at time of transplant is associated with worse patient and graft survival. Nonalcoholic steatohepatitis and hepatocellular carcinoma are among the biggest risk factors for its development while on a wait list.

The early prevention and treatment of PVST after laparoscopic splenectomy: A prospective cohort study of 130 patients

BACKGROUND

After laparoscopic splenectomy (LS) in patients with cirrhotic and hypersplenism, there is highly risk of suffering from portal vein system thrombosis (PVST) complication. This study is aimed to investigate the risk factors of PVST and study the anticoagulation effect on the prevention of PVST after LS.

MATERIALS AND METHODS

We retrospectively observed 130 patients who performed LS from February 2009 to December 2016. Patients were classified into the anticoagulation group (73 patients) and the non-anticoagulation group (57 patients). At the same time, the non-PVST and PVST groups were used to analyze the factors of thrombosis.

RESULTS

We analyzed the risk factors of PVST, the mean platelet volume (MPV), platelet count (PLT), plasma d-dimer, thickness of spleen and portal vein diameter were statistically significant (P < 0.05) between PVST group and non-PVST group. Compared with the non-anticoagulant group, anticoagulant group had a lower incidence of PVST (P = 0.044), a significant lower PLT (P = 0.001), a notable lower mean platelet volume (P = 0.006), and an obvious lower d-dimer (P = 0.001) after LS. And prothrombin time (PT) and international normalized ratio (INR) were significant increase after treated with anticoagulant drugs. Multiple logistic regression analysis reported that PLT, d-dimer, portal vein diameter and thickness of spleen were the risk factors of PVST, however the anticoagulant drug was an independent protective factor for PVST (P = 0.001).

CONCLUSIONS

Anticoagulant drug significantly decreased the incidence rate of PVST in patients with cirrhotic and portal hypertension after LS.

Anticoagulation in chronic liver disease

In this Grand Round presentation, the case of a man with decompensated liver disease is described. He subsequently developed a fatal pulmonary embolism, which may not have occurred if he had been prescribed prophylactic anticoagulation to prevent venous thromboembolic disease. The burden of thrombotic disease in those with chronic liver disease is discussed, before a more detailed analysis of the current evidence, safety data, and clinical dilemmas regarding the use of anticoagulation in patients with chronic liver disease. Finally, the future directions within this field are explored.

Coagulopathy Before and After Liver Transplantation: From the Hepatic to the Systemic Circulatory Systems

The hemostatic environment in patients with cirrhosis is a delicate balance between prohemostatic and antihemostatic factors. There is a lack of effective laboratory measures of the hemostatic system in patients with cirrhosis. Many are predisposed to pulmonary embolus, deep vein thrombosis, and portal vein thrombosis in the pretransplantation setting. This pretransplantation hypercoagulable milieu seems to extend for at least several months post-transplantation. Patients with nonalcoholic fatty liver disease, inherited thrombophilia, portal hypertension in the absence of cirrhosis, and hepatocellular carcinoma often require individualized approach to anticoagulation. Early reports suggest a potential role for low-molecular-weight heparins and direct-acting anticoagulants.

Portal vein thrombosis in patients with cirrhosis

Portal vein thrombosis (PVT) is frequent in patients with liver cirrhosis and possible severe complications such as mesenteric ischemia are rare, but can be life-threatening. However, different aspects of clinical relevance, diagnosis and management of PVT are still areas of uncertainty and investigation in international guidelines. In this article, we elaborate on PVT classification, geographical differences in clinical presentation and standards of diagnosis, and briefly on the current pathophysiological understanding and risk factors. This review considers and highlights the pitfalls of the various treatment approaches and prophylactic treatments. Finally, we review the controversial issue of clinical impact of PVT on prognosis, especially considering liver transplantation and future perspectives.

Serum omentin and vaspin levels in cirrhotic patients with and without portal vein thrombosis

AIM

To investigate serum omentin and vaspin levels in cirrhotic patients; and to assess the relationship of these levels with hemostatic parameters, metabolic abnormalities, cirrhosis severity and etiology.

METHODS

Fifty-one cirrhotic patients (17 with portal vein thrombosis) were analyzed. Serum omentin and vaspin levels were measured with commercially available direct enzyme-linked immunosorbent assays (ELISAs). To assess platelet activity, the following tests were performed using a MULTIPLATE^®PLATELET FUNCTION ANALYZER: (1) an ADP-induced platelet activation test; (2) a cyclooxygenase dependent aggregation test (ASPI test); (3) a von Willebrand factor and glycoprotein Ib-dependent aggregation (using ristocetin) test (RISTO test); and (4) a test for thrombin receptor-activating peptide-6 induced activation of the thrombin receptor, which is sensitive to IIb/IIIa receptor antagonists.

RESULTS

Omentin, but not vaspin, serum concentrations were significantly decreased in patients with portal vein thrombosis (PVT) (P = 0.01). Prothrombin levels were significantly increased in patients with PVT (P = 0.01). The thrombin receptor activating peptide (TRAP) test results were significantly lower in the PVT group (P = 0.03). No significant differences in adipokines serum levels were found regarding the etiology or severity of liver cirrhosis assessed according to the Child-Pugh or Model of End-Stage Liver Disease (MELD) scores. There was a significant increase in the TRAP (P = 0.03), ASPI (P = 0.001) and RISTO high-test (P = 0.02) results in patients with lower MELD scores. Serum omentin and vaspin levels were significantly down-regulated in patients without insulin resistance (P = 0.03, P = 0.02, respectively). A positive relationship between omentin and vaspin levels were found both when all of the patients were analyzed (r = 0.41, P = 0.01) and among those with PVT (r = 0.94, P < 0.001).

CONCLUSION

Serum omentin levels are increased in patients without PVT. Cirrhosis origin and grade do not affect omentin and vaspin levels. The analyzed adipokines do not influence platelet activity.

2D Shear Wave Elastography of Liver in Patients with Primary Extrahepatic Portal Vein Obstruction

AIMS

To evaluate liver stiffness (LS) in patients of primary extrahepatic portal vein obstruction (EHPVO) using 2D shear wave elastography (SWE) and compare it with healthy volunteers.

METHODS

Fifty patients (mean age: 22.4 years) of EHPVO and 25 healthy volunteers were included in the study. Liver function tests and viral markers were done in both groups and endoscopy in EHPVO group, followed by ultrasonography and SWE of liver. Liver elastography was done with patients/volunteers in supine position through right intercostal space. The LS for right lobe of liver was recorded in kilopascals. Three such measurements were taken and the mean of both groups were compared. The variables were also correlated with mean LS using Pearson's correlation coefficient in EHPVO group.

RESULTS

There was no significant difference in the mean LS in patients of EHPVO (5.96 kPa) and healthy volunteers (5.47 kPa) (P = 0.093). There was no significant correlation between LS with duration of symptoms, hematemesis, esophageal varices, total bilirubin, serum alkaline phosphatase and aspartate aminotranferase levels in EHPVO group.

CONCLUSION

SWE of liver may be used as a simple additional tool in the diagnosis of patients of EHPVO who show LS values similar to normal liver.

Practical Considerations of Real Life of Hepatocellular Carcinoma in a Tertiary Center of Brazil

BACKGROUND

Hepatocellular carcinoma (HCC) is the most common malignancy that develops in cirrhotic livers. Its clinical and epidemiological characteristics and mortality rates vary according to geographical region. The objective of this study was to evaluate the clinical profile, epidemiological characteristics, laboratory parameters, treatment and survival of patients with HCC.

MATERIAL AND METHODS

Patients with HCC seen between 2000 and 2012 were studied. The Kaplan-Meier method was used for survival analysis according to variables in question.

RESULTS

The study included 247 patients with a mean age of 60 ± 10 years. There was a predominance of males (74%). The main etiologies of HCC were HCV infection (55%), excessive alcohol consumption (12%), and HBV infection (8%). Liver cirrhosis was present in 92% of cases. The mean tumor number and diameter were 2 and 5 cm, respectively. Patients meeting the Milan criteria corresponded to 43% of the sample. Liver transplantation was performed in 22.4% of patients of the Milan subset and in 10% of the whole sample. The overall mean survival was 60 months, with a 1-, 3- and 5-year survival probability of 74%, 40% and 29%, respectively. Lower survival was observed among patients with alcoholic etiology. Survival was higher among patients submitted to liver transplantation (P &lt; 0.001), TACE (P &lt; 0.001), or any kind of treatment (P &lt; 0.001). However, no difference was found for surgical resection (P = 0.1) or sorafenib (P = 0.1).

CONCLUSION

Patients with HCC were mainly older men diagnosed at an advanced stage. Treatment was associated with better overall survival, but few patients survived to be treated.

Anticoagulation in cirrhosis: a new paradigm?

The liver plays a crucial role in coagulation cascade. Global hemostatic process is profoundly influenced by the presence of liver disease and its complications. Patients with cirrhosis have impaired synthesis of most of the factors involved in coagulation and fibrinolysis process due to a reduced liver function and altered platelet count secondary to portal hypertension. Altered routine tests and thrombocytopenia were considered in the past as associated with increased risk of bleeding. These concepts explain both the routine use of plasma and/or platelets transfusion in patients with liver cirrhosis, especially before invasive procedures, and why these patients were considered "auto-anticoagulated". New recent evidences show that patients with liver cirrhosis have a more complex hemostatic alteration. Despite the presence of altered levels of factors involved in primary hemostasis, coagulation and fibrinolysis, patients with stable cirrhosis have a rebalanced hemostatic, which however can easily be altered by decompensation or infection, both in hemorrhagic or thrombotic direction. Patients with cirrhosis have an increased risk of venous thrombotic events (namely portal vein thrombosis) while bleeding seems to be related to the grade of portal hypertension rather than to a hemostatic imbalance. The use of anticoagulants both as treatment or prophylaxis is safe, reduces the rate of portal vein thrombosis and decompensation, and improves survival. Standard laboratory coagulation tests are unable to predict bleeding and are inadequate for the assessment of hemostatic status in these patients, hence more comprehensive tests are required to guide the management of thrombotic and bleeding complications.