Incidence, predictive factors and clinical significance of development of portal vein thrombosis in cirrhosis: A prospective study

Development and validation of an integrated model for the diagnosis of liver cirrhosis with portal vein thrombosis combined with endoscopic characters and blood biochemistry data: a retrospective propensity score matching (PSM) cohort study

BACKGROUND

Liver cirrhosis complicated by portal vein thrombosis (PVT) is a fatal complication with no specific manifestations but often misdiagnosed, it crucially increases the mortality worldwide. This study aimed to identify risk factors and establish a predictive model for diagnosis of venous thrombosis clinical by routine blood tests and endoscopic characteristics.

METHODS

Patients from Gansu Provincial Hospital from October 2019 to December 2023 were enrolled. The retrospective modelling cohort was screened by propensity score matching (PSM) at a 1:1 ratio from the baseline characteristics before endoscopic diagnosis. Variables were collected from blood test and endoscopic signs using machine learning method (ML). Logistic regression determined risk factors. The predictive performance was evaluated by receiver operation curve (ROC), calibration curve, clinical decision analysis (DCA) and influence curve (CIC). Furthermore, external cohort was used for validation, an online nomogram was established.

RESULTS

A total of 1,058 patients were enrolled, and 470 patients were included after PSM 1: 1. The model identified 7 factors, including splenectomy, blood urea nitrogen (BUN), serum sodium, activated partial thromboplastin time (APTT), thrombin time (TT), D-dimer, and degree of oesophageal varices. The area under the curve (AUC) was 0.907 (95% CI, 0.877-0.931). The calibration curve, decision and clinical impact curves showed the model demonstrated a good predictive accuracy and clinical benefits. The validation got an AUC of 0.890 (95% CI, 0.831-0.934), A nomogram tool was finally established for application.

CONCLUSION

Blood test combined endoscopic characters could preliminarily predict the liver cirrhosis with portal vein thrombosis for cirrhotic patients undergoing endoscopic examination.

The risk factors of liver cirrhosis complicated with portal vein thrombosis and the efficacy and safety of anticoagulant therapy: a meta analysis

OBJECTIVE

To evaluate the risk factors of liver cirrhosis complicated with portal vein thrombosis and the efficacy and safety of anticoagulant therapy.

METHODS

Relevant literature was searched through PubMed, Cochrane library, Embase, Web of Science, Wanfang Medical Network and CNKI databases, and eligible literature was included. QUADS scale was used to evaluate the quality of the included literatures, and Stata15.1 software was used for meta-analysis and statistical processing.

RESULTS

For risk factors analysis for cirrhosis with Portal vein thrombosis, 19 literatures were included, including 1563 patients with cirrhosis with portal vein thrombosis and 2579 patients with cirrhosis without portal vein thrombosis, all of which were not treated with anticoagulation. The results of meta-analysis showed that compared with the PVT group, there was no significant difference in creatinine(Scr,MD = 0.09,95%CI: -0.03-0.22,P = 0.132)and total bilirubin(TBIL,MD = -0.00, 95%CI: -0.10 ~ 0.09,P = 0.948).There was significant difference in albumin(ALB,MD = -0.32, 95%CI:-0.43-0.21,P = 0.000)and PLT(PLT, MD = 0.15, 95%CI: 0.05-0.26, P = 0.004).And there was also no difference in hypertension history (OR = 0.78,95%CI:0.59 ~ 1.03,P = 0.079). In the study on the anticoagulant effect and safety of liver cirrhosis complicated with portal vein thrombosis, a total of 9 literatures were included. Among them,497 patients with liver cirrhosis complicated by portal vein thrombosis are treated with Anticoagulation treatment, and 633 patients with cirrhosis complicated by portal vein thrombosis without anticoagulation treatment. The analysis results showed that the thrombus recanalization situation of liver cirrhosis complicated with portal vein thrombosis after anticoagulation treatment was better than that of patients without anticoagulation (OR = 4.052,95%CI: 2.737-6.000,P = 0.000),and there was no significant difference in the occurrence of bleeding events between patients with anticoagulation and those without anticoagulation (OR = 1.017, 95%CI:0.735-1.407,P = 0.920). The Stata15.1Egger test showed no significant publication bias for all the results(P > 0.05).

CONCLUSIONS

Patients with liver cirrhosis complicated with low platelet and low albumin are more likely to develop PVT. Anticoagulation is helpful and safe for thrombolysis in patients with liver cirrhosis complicated with PVT.

The impact of bacterial infection on the risk of portal vein thrombosis development in patients with cirrhosis: A post-hoc analysis

BACKGROUND

Portal vein thrombosis (PVT) is a common complication in liver cirrhosis. Bacterial infections (BIs) may increase PVT risk through bacterial translocation, systemic inflammation, and coagulation dysfunction, but evidence is limited.

AIMS

This study investigates the 6-month risk of onset of PVT in patients hospitalized with BIs.

METHODS

This post-hoc analysis included 563 cirrhotic patients hospitalized between 2011 and 2021, with or without BIs diagnosis, and followed for 6 months post-discharge. Patients with HCC outside of Milan criteria were excluded. The main endpoint was the onset of PVT, diagnosed via abdominal ultrasound or CT/MRI.

RESULTS

BI was diagnosed in 146 patients (26 %). Forty-seven patients (8.5 %) experienced PVT events within 6 months, including 15 (10 %) with BIs and 32 (7.8 %) without (p = 0.4). Logistic regression showed no significant effect of BI on PVT occurrence (OR 1.35, 95 % CI 0.69-2.54), even after adjusting for confounding factors. However, urinary tract infections were independently associated with higher PVT risk (OR 3.17, 95 % CI 1.05-10.8, p = 0.048). Other infection sites (pneumonia, spontaneous bacterial peritonitis-SBP, spontaneous bacteremia) and isolated microbial strains (n = 77) were not associated with increased PVT risk. When analyzing the population excluding patients with HCC, the risk of developing PVT was significantly higher in patients with previous BI, regardless of the severity of liver disease (OR 2.92, 95 % CI 1.06-8.16).

CONCLUSIONS

In this large cohort, BIs did not significantly increase PVT risk within 6 months post-hospitalization in cirrhotic patients. However, when the cohort was reduced to patients without HCC, the risk of PVT appears to be significant.

Establish and validate an artificial neural networks model used for predicting portal vein thrombosis risk in hepatitis B-related cirrhosis patients

BACKGROUND

The portal vein thrombosis (PVT) can exacerbate portal hypertension and lead to complications, increasing the risk of mortality.

AIM

To evaluate the predictive capacity of artificial neural networks (ANNs) in quantifying the likelihood of developing PVT in individuals afflicted with hepatitis B-induced cirrhosis.

METHODS

A retrospective study was conducted at Beijing Ditan Hospital, affiliated with Capital Medical University, including 986 hospitalized patients. Patients admitted between January 2011 and December 2014 were assigned to the training set (685 cases), while those hospitalized from January 2015 to December 2016 were divided into the validation cohort (301 cases). Independent risk factors for PVT were identified using COX univariate analysis and used to construct an ANN model. Model performance was evaluated through metrics such as the area under the receiver operating characteristic curve (AUC) and concordance index.

RESULTS

In the training set, PVT occurred in 19.0% of patients within three years and 23.7% within five years. In the validation cohort, PVT developed in 16.7% of patients within three years and 24.0% within five years. The ANN model incorporated nine independent risk factors: Age, ascites, hepatic encephalopathy, gastrointestinal varices with bleeding, Child-Pugh classification, alanine aminotransferase levels, albumin levels, neutrophil-to-lymphocyte ratio, and platelet. The model achieved an AUC of 0.967 (95%CI: 0.960-0.974) at three years and 0.975 (95%CI: 0.955-0.992) at five years, significantly outperforming existing models such as model for end-stage liver disease and Child-Pugh-Turcotte (all P < 0.001).

CONCLUSION

The ANN model demonstrated effective stratification of patients into high- and low-risk groups for PVT development over three and five years. Validation in an independent cohort confirmed the model's predictive accuracy.

Chinese expert consensus on clinical management of hepatopathy-related thrombocytopenia (2023 edition)

Hepatopathy-related thrombocytopenia refers to a reduction in platelet count caused by liver disease or its treatment. The incidence of this condition is correlated with the duration and severity of liver disease. The direct impact of thrombocytopenia on the clinical outcome of patients with liver disease is an increased risk of bleeding. In addition, the indirect effect involves delays or discontinuation of treatment due to the potential risk of bleeding. The pathophysiological mechanisms of hepatopathy-related thrombocytopenia include reduced platelet production, abnormal distribution, increased destruction or consumption, and so on. Current treatment strategies targeting different mechanisms include thrombopoietic agents, surgery, immunosuppressants, and platelet transfusion. However, their clinical application lacks standardization. The National Clinical Research Center for Infectious Diseases organized experts to discuss and develop this consensus to enhance the clinical management level of hepatopathy-related thrombocytopenia in China. The experts focused on aspects of diagnosis, classification, and choosing the best treatment plans based on the most recent research in the field.

Activation of the Contact System and Intrinsic Pathway in Peripheral and Portal Venous Circulations in Liver Cirrhosis

BACKGROUND

 Portal vein system-specific risk factors contributing to portal vein thrombosis in cirrhosis are poorly investigated.

AIM

 This study aimed to quantify contact system and intrinsic pathway activation in the peripheral compared to portal venous blood in patients with decompensated cirrhosis.

METHODS

 Adult patients with cirrhosis undergoing transjugular intrahepatic portosystemic shunt underwent simultaneous blood sampling from a peripheral vein and the portal vein. Complexes of serine proteases with their respective inhibitors were measured by ELISA to quantify contact system (PKa:C1-INH [plasma kallikrein:C1-esterase inhibitor] and FXIIa:C1-INH) and intrinsic pathway activation (FXIa:C1-INH, FXIa:α1at [α-1 antitrypsin], FXIa:AT [antithrombin], and FIXa:AT).

RESULTS

 Twenty patients with cirrhosis (mean age 55 ± 7 years, M = 58%, Child-Pugh A/B/C 6/11/3) and 25 healthy controls (mean age 45 ± 12 years, M = 60%) were enrolled. The etiology of cirrhosis was primarily alcohol abuse, followed by chronic viral infection. Log-transformed peripheral levels of all the complexes were significantly higher in patients compared with controls. While levels of PKa:C1-INH, FXIIa:C1-INH, FXIa:C1-INH and FXIa:α1at were similar in peripheral and portal venous blood in cirrhotic patients, FXIa:AT and FIXa:AT levels were significantly higher in portal blood (p = 0.013 and 0.011, respectively). FXIa:C1-INH significantly correlated with both contact system complexes (FXIIa:C1-INH and PKa:C1-INH) and with FIX:AT.

CONCLUSION

 Markers of contact system and intrinsic pathway activation in the systemic circulation were significantly higher in cirrhosis versus controls. Complexes of FXIa and FIXa with AT were significantly higher in the portal than in peripheral plasma in cirrhosis, possibly indicating a unique heparin-like effect in portal venous blood.

Administration of anticoagulation strategies for portal vein thrombosis in cirrhosis: network meta-analysis

Objectives

Evidences for anticoagulation strategies in cirrhotic with portal vein thrombosis (PVT) are still insufficient. This study aims to comprehensively compare the therapeutic effects of different therapeutic therapeutic measures in individuals suffering from cirrhosis with PVT, with the ultimate goal of providing evidence-based recommendations for thrombolytic therapy in this population.

Methods

Starting from 20 October 2023, a comprehensive search about therapeutic strategies for portal vein thrombosis in cirrhosis was conducted on PubMed, EMBASE, and Cochrane Library.

Results

19 studies were eventually incorporated into this study. Comparison with control in network meta-analysis, direct oral anticoagulants (DOACs) (RR = 2.15, 95%CI: 1.33, 3.48), LMWH (RR = 1.41, 95%CI: 1.01, 1.99), TIPS (RR = 5.68, 95%CI: 2.63, 12.24), warfarin (RR = 2.16, 95%CI: 1.46, 3.21), EBL plus propranolol (RR = 2.80, 95%CI: 1.18, 6.60), LMWH-DOACs sequential (RR = 7.92, 95%CI: 2.85, 21.99) and LMWH-warfarin sequential (RR = 2.26, 95%CI: 1.16, 4.42) significantly improved the incidence of complete recanalization. The anticoagulation drugs were ranked based on their SUCRA values, with the LMWH-DOACs sequential (92.7%), TIPS plus warfarin (91.3%), and TIPS (80.3%) emerging as the top three effective treatments.

Conclusion

In this study, active anticoagulants were recommended for cirrhosis with PVT. The TIPS plus warfarin, LMWH-DOACs sequential, and TIPS improved the complete recanalization rate most effectively, and the EBL plus propranolol, heparin plus DOACs plus warfarin, and DOACs were highly recommended for increasing the incidence of partial recanalization. Warfarin and TIPS were recommended for reducing the frequency of bleeding events, while LMWH plus warfarin and DOACs proved to be most effective in decreasing the rate of major bleeding events. Warfarin, heparin plus DOACs plus warfarin, and DOACs demonstrated the most significant reduction in mortality rates, highlighting its potential as an effective intervention. TIPS plus warfarin, LMWH-DOACs sequential, and TIPS were recommended for reducing the occurrence of PVT expansion. Heparin plus DOACs plus warfarin was recommended for reducing the occurrence of hepatic encephalopathy, and protocols that involve TIPS were generally associated with a higher risk of hepatic encephalopathy. However, a longer follow-up period is necessary to comprehensively evaluate the efficacy of active anticoagulants therapy in patients with PVT in cirrhosis.

Predictive value of hepatic venous pressure gradient in cirrhotic portal vein thrombosis development

BACKGROUND & AIMS

There are lots of risk factors reported for cirrhotic portal vein thrombosis (PVT) development, however, the relationship between hepatic venous pressure gradient (HVPG) and PVT development remains unclear.

METHODS

The clinical outcomes of cirrhotic patients who had no PVT and underwent HVPG measurement at baseline between March 2018 and March 2022 were analyzed retrospectively. Screening for non-tumoral PVT development was implemented by contrast-enhanced computed tomography and/or magnetic resonance imaging every 6-12 months.

RESULTS

Eighty-two cirrhotic patients were evaluated over a follow-up period. Of these, 12 patients (14.6%) experienced the development of PVT. The occurrence of non-tumoral PVT at one, two, and three years were 6.6%, 11.7%, and 22.2% respectively. HVPG (p=0.038;HR 1.07;95%CI 1.00-1.14) and alcohol liver disease (ALD) (p=0.019;HR 4.20;95%CI 1.27-13.89) were independently associated with a high PVT risk. The cutoff value of HVPG was 17.52 mmHg. The cumulative incidence of PVT differed significantly among groups stratified by HVPG thresholds of 16mmHg (P=0.011). The sensitivity and specificity of HVPG≥16mmHg in predicting PVT development were 100.0% and 35.7%.

CONCLUSIONS

In patients with liver cirrhosis, the value of HVPG was the independent predictive factor of PVT development. Screening for PVT was recommended during follow-up in patients with HVPG≥16 mmHg.

Comparing clinical outcomes of vitamin K antagonists vs non-vitamin K antagonists in anticoagulant therapy for mesenteric venous thrombosis

OBJECTIVE

Non-vitamin K antagonist oral anticoagulants have shown similar efficacy and lower bleeding rates than vitamin K antagonists for venous thromboembolism. However, this has not been proven in mesenteric vein thrombosis. This study aimed to compare the clinical outcomes of vitamin K antagonists and non-vitamin K antagonist oral anticoagulants.

METHODS

Between January 2014 and July 2022, mesenteric vein thrombosis was diagnosed on computed tomography in 225 patients in a tertiary hospital. Among them, a total of 44 patients who underwent long-term anticoagulation therapy over 3 months were enrolled in this study. Patients were divided into two groups based on the anticoagulant used: vitamin K antagonists (Group 1, n = 21) and non-vitamin K antagonist oral anticoagulants (Group 2, n = 23). The efficacy outcomes were symptom recurrence and thrombus resolution on follow-up computed tomography, and the safety outcome was bleeding complications.

RESULTS

The median age of the patients was 56 years (range, 46-68 years), and 52% were men. The most common risk factors were unprovoked intra-abdominal infections (30%). The median duration of anticoagulation therapy was 13 months (20 months in Group 1 vs 6 months in Group 2; P = .076). Of the 44 patients, 17 (39%) received the standard treatment. The median follow-up period was longer in Group 1 than in Group 2 (57 vs 28 months; P = .048). No recurrence of mesenteric vein thrombosis-related symptoms were observed in either group. The median duration of follow-up computed tomography was 31 months (42 months in Group 1 vs 18 months in Group 2; P = .064). Computed tomography revealed complete thrombus resolution, partial resolution, and no changes in 71%, 19%, and 10%, respectively (P = .075). Regarding bleeding complications, varix bleeding and melena developed in two patients in Group 2, and anticoagulation treatment thereafter ceased.

CONCLUSIONS

Despite the short follow-up duration in the non-vitamin K antagonist oral anticoagulants group, there was no clinically significant difference in the thrombus resolution rate or bleeding complications when compared with the vitamin K antagonists group. Although research on the long-term effects of non-vitamin K antagonist oral anticoagulants in patients is limited, non-vitamin K antagonist oral anticoagulants can be considered an alternative to conventional treatments.

Anticoagulation for stroke prevention in atrial fibrillation and treatment of venous thromboembolism and portal vein thrombosis in cirrhosis: guidance from the SSC of the ISTH

While advanced liver disease was previously considered to be an acquired bleeding disorder, there is increasing recognition of an associated prothrombotic state with patients being at higher risk of atrial fibrillation (AF) and stroke and venous thromboembolism (VTE) including portal vein thrombosis (PVT). We review the available literature on epidemiology, pathophysiology, and risk factors and provide guidance on anticoagulant management of these conditions in adults with cirrhosis. In patients with Child-Pugh A or B cirrhosis and AF, we recommend anticoagulation with standard-dose direct oral anticoagulants (DOACs) in accordance with cardiology guideline recommendations for patients without liver disease. In those with Child-Pugh C cirrhosis, there is inadequate evidence with respect to the benefit and risk of anticoagulation for stroke prevention in AF. In patients with cirrhosis and acute deep vein thrombosis or pulmonary embolism, we recommend anticoagulation and suggest use of either a DOAC or low-molecular-weight heparin (LMWH)/vitamin K antagonist (VKA) in Child-Pugh A or B cirrhosis and LMWH alone (or as a bridge to VKA in patients with a normal baseline international normalized ratio) in Child-Pugh C cirrhosis. We recommend anticoagulation for patients with cirrhosis and symptomatic PVT. We suggest anticoagulation for those with asymptomatic, progressing PVT and recommend continuing extended anticoagulation for liver transplant candidates with PVT.

Metabolic dysfunction-associated steatotic liver disease related cirrhosis and incidence of portal vein thrombosis

BACKGROUND

There is heterogeneous data on whether metabolic-associated steatohepatitis is an independent risk factor for portal vein thrombosis (PVT). We aim to compare the incidence of PVT in patients with cirrhosis with and without metabolic dysfunction-associated steatotic liver disease (MASLD).

METHODS

This is a single-center retrospective study of patients with cirrhosis seen between 1 January 2016 and 31 January 2021. Patients with a history of hepatocellular cancer, liver transplant, Budd-Chiari syndrome, and intra-abdominal malignancies were excluded. Patients with cirrhosis were followed from their first hepatology visit for 180 days to determine the incidence of PVT. Cox proportional hazard regression was used to determine the relationship between MASLD with PVT.

RESULTS

We analyzed data from 2785 patients with cirrhosis who met inclusion and exclusion criteria [mean age: 61.0 ± 12.3 years, 44.3% female, 63.8% Whites and mean model for end-stage liver disease-sodium (MELD-Na) score: 11.7 ± 6.1]. MASLD was present in 21.7% of patients. A total of 89 patients developed PVT during the follow-up, which was fewer in patients with MASLD [2.0% vs. 3.5%, P  = 0.04, unadjusted heart rate (HR): 0.60, 95% confidence interval (CI): 0.27-0.96, P  = 0.04]. After adjusting for the demographics, MASLD-related comorbid conditions and MELD-Na score, MASLD was associated with a lower incidence of PVT as compared to non-MASLD cirrhosis (HR: 0.44, 95% CI: 0.21-0.92, P  = 0.03). After adjusting for the indicators of Child-Pugh Turcotte score, the risk of PVT in patients with MASLD compared to non-MASLD was not statistically significant (HR: 0.50, 95% CI: 0.22-1.13, P  = 0.096).

CONCLUSION

PVT incidence was lower in patients with MASLD cirrhosis as compared to non-MASLD cirrhosis. However, the difference was not significantly different after adjusting for liver decompensation.

Portal Vein Thrombosis in Liver Cirrhosis. Part 1: Epidemiology, Pathogenesis, Clinic, Diag-nosis, Impact on Prognosis

   Portal vein thrombosis is the most common thrombotic complication in patients with liver cirrhosis, especially in cases of severe forms. The pathogenesis is multifactorial in nature, it determined by a change in the balance between the coagulation and anticoagulation systems. Thrombosis is often asymptomatic and is accidentally detected, although it can be complicated by varicose bleeding, intestinal ischemia, and portal biliopathy. Ultrasound Doppler examination is a screening method, as an alternative, computed tomography and magnetic resonance imaging are used. The review highlights data on epidemiology, risk factors, clinical features, and diagnosis of portal vein thrombosis in patients with liver cirrhosis. The data on the effect of portal vein thrombosis on the progression of liver cirrhosis and the survival of patients, including after liver transplantation, are presented.

Statin use in cirrhosis and its association with incidence of portal vein thrombosis

BACKGROUND AND AIM

Statin use has shown a reduction in hepatic decompensation and portal hypertension. Its association with portal vein thrombosis (PVT) incidence is unknown. We aim to compare the incidence of PVT in patients with and without statin use.

METHODS

We excluded patients with a history of hepatocellular cancer, liver transplants, Budd-Chiari syndrome, and intra-abdominal malignancies. Patients with cirrhosis were followed from their first hepatologist clinical encounter (January 1, 2016, to January 31, 2021) for 180 days to determine PVT incidence. We tested the association of statin use with PVT using 1:1 propensity score (PS) matching and Cox proportional hazard regression.

RESULTS

We analyzed 2785 patients with cirrhosis (mean age:61.0 ± 12.3 years, 44.3% female, 63.8% White, mean MELD-Na score:11.7 ± 6.1, and statin use:23.1%). A total of 89 patients developed PVT during the follow-up, which was lower in patients with statin use as compared to no statin use (1.3% vs 3.8%, P = 0.001, unadjusted HR:0.28, 95% CI: 0.13-0.62, P = 0.001). After matching for demographics, comorbidities, and hepatic decompensation events, patients with statin use had a lower risk of developing PVT in 180-day follow-up as compared to those without statin use (HR:0.24, 95% CI: 0.10-0.55, P = 0.001). Subgroup analysis showed that statin use was associated with lower PVT incidence in non-NASH (HR: 0.20, 95% CI: 0.07-0.54, P = 0.002) and decompensated cirrhosis (HR: 0.12, 95% CI:0.03-0.53, P = 0.005) than no statin use.

CONCLUSION

PVT incidence was lower in decompensated cirrhosis patients with statin use than in those with no statin use. However, this finding needs to be further tested in randomized control trials.

Predictive model for non-malignant portal vein thrombosis associated with cirrhosis based on inflammatory biomarkers

BACKGROUND

Portal vein thrombosis (PVT), a complication of liver cirrhosis, is a major public health concern. PVT prediction is the most effective method for PVT diagnosis and treatment.

AIM

To develop and validate a nomogram and network calculator based on clinical indicators to predict PVT in patients with cirrhosis.

METHODS

Patients with cirrhosis hospitalized between January 2016 and December 2021 at the First Hospital of Lanzhou University were screened and 643 patients with cirrhosis who met the eligibility criteria were retrieved. Following a 1:1 propensity score matching 572 patients with cirrhosis were screened, and relevant clinical data were collected. PVT risk factors were identified using the least absolute shrinkage and selection operator (LASSO) and multivariate logistic regression analysis. Variance inflation factors and correlation matrix plots were used to analyze multicollinearity among the variables. A nomogram was constructed to predict the probability of PVT based on independent risk factors for PVT, and its predictive performance was verified using a receiver operating characteristic curve (ROC), calibration curves, and decision curve analysis (DCA). Finally, a network calculator was constructed based on the nomograms.

RESULTS

This study enrolled 286 cirrhosis patients with PVT and 286 without PVT. LASSO analysis revealed 13 variables as strongly associated with PVT occurrence. Multivariate logistic regression analysis revealed nine indicators as independent PVT risk factors, including etiology, ascites, gastroesophageal varices, platelet count, D-dimer, portal vein diameter, portal vein velocity, aspartate transaminase to neutrophil ratio index, and platelet-to-lymphocyte ratio. LASSO and correlation matrix plot results revealed no significant multicollinearity or correlation among the variables. A nomogram was constructed based on the screened independent risk factors. The nomogram had excellent predictive performance, with an area under the ROC curve of 0.821 and 0.829 in the training and testing groups, respectively. Calibration curves and DCA revealed its good clinical performance. Finally, the optimal cutoff value for the total nomogram score was 0.513. The sensitivity and specificity of the optimal cutoff values were 0.822 and 0.706, respectively.

CONCLUSION

A nomogram for predicting PVT occurrence was successfully developed and validated, and a network calculator was constructed. This can enable clinicians to rapidly and easily identify high PVT risk groups.

Management of Nonmalignant Portal Vein Thrombosis in Cirrhosis

Nonmalignant portal vein thrombosis (PVT) is a common complication of cirrhosis especially at the stage of decompensations. The diagnosis of PVT in cirrhosis is often incidental and it may be detected during routine semestral abdominal ultrasound with Doppler during screening for hepatocellular carcinoma or during hospitalization for decompensated cirrhosis. After detection of PVT on abdominal ultrasound, it is important to evaluate patients with cross-sectional imaging to determine the age of thrombus, whether acute or chronic, the extent and degree of luminal occlusion of the portal vein, and to rule out hepatocellular carcinoma or other underlying malignancy. Factors influencing management include the degree and extent of luminal occlusion of PVT, potential listing for liver transplantation, and portal hypertension (PHT) complications such as variceal hemorrhage and refractory ascites, severity of thrombocytopenia, and other comorbidities including chronic kidney disease. Anticoagulation is the most common therapeutic option and it is specially indicated in patients who are candidates for liver transplantation. Interventional procedures including transjugular intrahepatic portosystemic shunt (TIPS) placement and mechanical thrombectomy may be used on a case-by-case basis in patients with contraindications or adverse events related to anticoagulation, who develop worsening PVT while on anticoagulant therapy, or have chronic PVT and PHT complications that are not manageable medically or endoscopically.

Bacterial infections as a risk factor for non-neoplastic portal vein thrombosis development in cirrhotic patients

BACKGROUND

Portal vein thrombosis (PVT) and sepsis are common complications in patients with liver cirrhosis. Factors that lead to PVT are not completely understood. This study aimed to investigate the possible association between bacterial infections and the development of PVT in cirrhotic patients.

PATIENTS AND METHODS

202 consecutive cirrhotic patients without previous infections, followed at the Liver Unit in Verona Hospital, were enrolled from 2017 to 2021 (median follow-up 3.3 years). During the follow-up period, PVT was diagnosed by ultrasound, CT and/or MRI, and episodes of bacterial infections requiring hospitalization were recorded. Malignant PVT was an exclusion criterion.

RESULTS

Of the 202 patients enrolled (68.3 % males, mean age 63.8 ± 11 years), 22 (10.8 %) developed PVT during the follow up. In patients with PVT, the prevalence of previous bacterial infections was significantly higher compared to patients without PVT (63.6% vs 31.1 %; p = 0.02). Cox regression analysis revealed that a history of bacterial infection was the only variable that demonstrated a significant association with the risk of de novo PVT occurrence (HR 4.04, 95 % CI: 1.68-9.65).

CONCLUSION

in patients with liver cirrhosis bacterial infections are a predisposing factor for the following development of PVT. Further studies are needed to confirm this evidence.

Predictors of portal vein thrombosis after splenectomy in patients with cirrhosis

BACKGROUND

Portal vein thrombosis (PVT) is a commonthsn complication after splenectomy in patients with cirrhosis. However, the predictors of postoperative PVT are not known.

AIM

To investigate the predictors of PVT after splenectomy in patient with cirrhosis.

METHODS

A total of 45 patients with cirrhosis who underwent splenectomy were consecutively enrolled from January 2017 to December 2018. The incidence of PVT at 1 months, 3 months, and 12 months after splenectomy in patients with cirrhosis was observed. The hematological indicators, biochemical and coagulation parameters, and imaging features were recorded at baseline and at each observation point. The univariable, multivariable, receiver operating characteristic curve and time-dependent curve analyses were performed.

RESULTS

The cumulative incidence of PVT was 40.0%, 46.6%, and 48.9% at 1 months, 3 months, and 12 months after splenectomy. Multivariable analysis showed that portal vein diameter (PVD) ≥ 14.5 mm and monthsdel‎ end-stage liver disease (MELD) score > 10 were independent predictors of PVT at 1 months, 3 months, and 12 months after splenectomy (P < 0.05). Time-dependent curve showed that the cumulative incidence of PVT was significantly different between patients with MELD score ≤ 10 and > 10 (P < 0.05). In addition, the cumulative incidence of PVT in the PVD ≥ 14.5 mm group was significantly higher than that in the PVD < 14.5 mm group (P < 0.05).

CONCLUSION

Wider PVD and MELD score > 10 were independent predictors of PVT at 1 months, 3 months, and 12 months after splenectomy in patient with cirrhosis.

Role of nonneoplastic PVT in the natural history of patients with cirrhosis and first diagnosis of HCC

BACKGROUND AND AIMS

HCC can increase the risk of nonneoplastic PVT in cirrhosis. However, the natural history of PVT and its prognostic role in HCC patients are unknown.

APPROACH AND RESULTS

Consecutive HCC patients with cirrhosis undergoing laparoscopic ablation were retrospectively evaluated and followed up to 36 months. HCC and PVT characteristics and evolution were reviewed. PVT was categorized according to lumen occupancy (≤50%, >50% <100%, and = 100%) and extension to other veins. The evolution of thrombosis was considered at 1 year from diagnosis. Variables associated with the presence of PVT and evolution patterns were analyzed, as well as their impact on survival. In all, 750 patients were included, 88 of whom had PVT. On multivariate analysis, the occurrence of PVT at HCC diagnosis was associated with pretreatment total tumor volume ( p < 0.001) and clinically significant portal hypertension ( p = 0.005). During the follow-up, 46 de novo PVT occurred, 27/46 (58.7%) in the presence of a viable tumor. Among 115 PVT diagnosed in the presence of HCC, 83 had available radiological follow-up, and 22 were anticoagulated. The "complete/progressive" evolution pattern was associated with nonresponse to HCC treatment in non-anticoagulated patients. The presence of PVT was independently associated with lower overall survival, particularly when progressive or occlusive ( p < 0.001). A higher competing risk of death emerged for "complete and progressive" PVT, both for HCC-related ( p < 0.001) and non-HCC-related ( p = 0.002) death.

CONCLUSIONS

HCC represents an independent risk factor for the occurrence and progression of PVT in cirrhosis. Since progressive and occlusive PVT seems to be an independent factor associated with mortality, screening and prompt treatment of this complication should be considered.

The Early Initiation of Perioperative Anticoagulation Therapy in Cirrhotic Patients with Portal Hypertension After Laparoscopic Splenectomy Plus Esophagogastric Devascularization: A 10-Year Single-Center Experience

Background: Portal veinous system thrombosis (PVST) is a common complication after laparoscopic splenectomy plus esophagogastric devascularization (LSED). Anticoagulation therapy was still in debate in LSED perioperation. This study aimed to determine the postoperative risk factors of PVST, the efficacy and safety of the anticoagulation therapy after LSED procedure, and the potential impact of anticoagulation on patients' liver function and overall survival (OS). Methods: Three hundred patients who underwent LSED were retrospectively enrolled and analyzed in the study. The characteristics of patients, perioperative parameters, risk of PVST, and long-term follow-up data were recorded and analyzed. Results: One hundred eighty six of 300 patients received perioperative anticoagulation therapy (p-AT) postoperation, while 114 patients did not receive p-AT (non-p-AT). The non-p-AT group had more intraoperative blood loss, PVST, longer abdominal drain days, and postoperative hospital stays separately compared with the p-AT group. No significant difference of postoperative complications was found between the two groups. In the 1-year follow-up postoperation, both groups had great improvement in hypersplenism and the portal vein hemodynamics. During the 10-year follow-up period, the incidence of PVST was significantly higher in the non-p-AT group than in the p-AT group. Anticoagulation therapy, sex, variceal hemorrhage history, portal vein diameter, and portal vein velocity were the independent prognostic factors determined by the Cox regression analysis for PVST. The thrombosis-free survival rate (P = .002), recurrent hemorrhage-free survival rate (P < .01), and the OS rate (P < .01) were significantly lower in the non-p-AT group than in the p-AT group. Conclusions: The initiate use of anticoagulation therapy in postoperation of LSED is effective and safe in cirrhotic patients. The anticoagulation therapy after LSED will help decrease portal vein thrombosis, the rebleeding rate, and extend the OS of the patients, especially among women, with variceal hemorrhage history, high portal vein diameter, and low portal vein velocity.

Association of nonmalignant portal vein thrombosis and clinical outcomes in patients with cirrhosis and acute variceal bleeding: a multicenter observational study

BACKGROUND AND AIM

Baveno VII workshop recommends management of acute variceal bleeding (AVB) in cirrhotic patients with nonmalignant portal vein thrombosis (PVT) should be performed according to the guidelines for patients without PVT. Nevertheless, whether PVT affects the outcome of patients with cirrhosis and AVB remains unclear. The aim of this study was to assess the clinical impact of PVT on the outcomes in the pre-emptive TIPSS eligible patients with cirrhosis and AVB.

METHODS

From December 2010 to June 2016, 1219 consecutive cirrhotic patients admitted due to AVB with (n = 151; 12.4%) or without PVT (n = 1068; 87.6%), who received drug plus endoscopic treatment (a combination of vasoactive drugs, antibiotics, and endoscopic ligation for AVB, followed by beta-blockers plus variceal ligation for prevention of rebleeding) were retrospectively included. Fine and Gray competing risk regression models were taken to evaluate the impact of PVT on clinical outcomes after adjusting for potential confounders.

RESULTS

During follow-up, 211 patients (17.3%) died, 490 (40.2%) experienced further bleeding, and 78 (6.4%) experienced new or worsening ascites within 1 year. Compared with those without PVT, patients with PVT had a similar risk of mortality (PVT vs no-PVT: 19.9% vs 16.7% at 1 year; adjusted HR 0.88, 95%CI 0.51-1.52, p = 0.653), further bleeding (47.0% vs 39.2% at 1 year, adjusted HR 1.19, 95% CI 0.92-1.53, p = 183), and new or worsening ascites (7.9% vs 9.6%, adjusted HR 0.70, 95% CI 0.39-1.28, p = 0.253) after adjusting for confounders in multivariable models. These findings were consistent across different relevant subgroups and confirmed by propensity score matching analysis.

CONCLUSIONS

Our study showed no evidence that the PVT was associated with an improved or worsened outcome among cirrhotic patients with AVB who received standard treatment.

Approach to different thrombolysis techniques and timing of thrombolysis in the management of portal vein thrombosis in cirrhotic patients

Thrombolysis is not currently recommended in cirrhotic patients with acute portal vein thrombosis (PVT) in most guidelines, because of the exceedingly limited data and the perceived high risk of bleeding adverse events. However, in the few studies including patients with cirrhosis, the rate of success was high and that of adverse events was similar in patients with or without cirrhosis. Hence, thrombolysis might be a rescue therapeutic option in patients with cirrhosis and acute, symptomatic thrombosis of the portal venous system, unresponsive to anticoagulation, provided a suitable timing is kept, less than 30 days and, if possible, less than 14 days from the acute onset of portal vein thrombosis. In this review perspective article, I discuss the several potential approaches of thrombolysis, either local or systemic, alone or combined with mechanical procedures for thrombus removal, or as a complement to Transjugular Intrahepatic Portosystemic Shunt placement, with a focus on the more suitable timing of thrombolysis. However, the very limited available data preclude from performing firm recommendations, and decision to carry out thrombolysis must take into account both the occurrence of major contraindications and the current critical clinical setting. In the next future, large high-quality multicentre studies will hopefully be able to settle more firm indications and preferable techniques.

Anticoagulation improves survival in patients with cirrhosis and portal vein thrombosis: The IMPORTAL competing-risk meta-analysis

BACKGROUND & AIMS

Previous meta-analyses demonstrated the safety and efficacy of anticoagulation in the recanalization of portal vein thrombosis in patients with cirrhosis. Whether this benefit translates into improved survival is unknown. We conducted an individual patient data (IPD) meta-analysis to assess the effect of anticoagulation on all-cause mortality in patients with cirrhosis and portal vein thrombosis.

METHODS

In this IPD meta-analysis, we selected studies comparing anticoagulation vs. no treatment in patients with cirrhosis and portal vein thrombosis from PubMed, Embase, and Cochrane databases (until June 2020) (PROSPERO no.: CRD42020140026). IPD were subsequently requested from authors. The primary outcome - the effect of anticoagulation on all-cause mortality - was assessed by a one-step meta-analysis based on a competing-risk model with liver transplantation as the competing event. The model was adjusted for clinically relevant confounders. A multilevel mixed-effects logistic regression model was used to determine the effect of anticoagulation on recanalization.

RESULTS

Individual data on 500 patients from five studies were included; 205 (41%) received anticoagulation and 295 did not. Anticoagulation reduced all-cause mortality (adjusted subdistribution hazard ratio 0.59; 95% CI 0.49-0.70), independently of thrombosis severity and recanalization. The effect of anticoagulation on all-cause mortality was consistent with a reduction in liver-related mortality. The recanalization rate was higher in the anticoagulation arm (adjusted odds ratio 3.45; 95% CI 2.22-5.36). The non-portal-hypertension-related bleeding rate was significantly greater in the anticoagulation group.

CONCLUSIONS

Anticoagulation reduces all-cause mortality in patients with cirrhosis and portal vein thrombosis independently of recanalization, but at the expense of increasing non-portal hypertension-related bleeding.

PROSPERO REGISTRATION NUMBER

CRD42020140026.

IMPACT AND IMPLICATIONS

Anticoagulation is effective in promoting recanalization of portal vein thrombosis in patients with cirrhosis, but whether this benefit translates into improved survival is controversial. Our individual patient data meta-analysis based on a competing-risk model with liver transplantation as the competing event shows that anticoagulation reduces all-cause mortality in patients with cirrhosis and portal vein thrombosis independently of recanalization. According to our findings, portal vein thrombosis may identify a group of patients with cirrhosis that benefit from long-term anticoagulation.

Portal vein thrombosis in liver cirrhosis: An updated overview

Portal vein thrombosis (PVT) is a frequent and severe complication in patients with cirrhosis; however, the pathophysiology of PVT needs to be better clarified. There are few significant predictive factors in clinical practice, and the impact of PVT on cirrhosis progression and its complications, such as gastrointestinal bleeding, hepatic encephalopathy, and hepatorenal syndrome, remains uncertain. In recent years, the understanding of the mechanisms of PVT has become more profound with the publication of related literature. Therefore, in this review, we aim to summarize the advanced progress in the epidemiology, hazards, risk factors, diagnosis and classification, and treatment of PVT to provide insight into clinical management.

Treatment of portal vein thrombosis in cirrhosis: a multicenter real life cοhort study

BACKGROUND

Portal vein thrombosis (PVT) is a common complication of cirrhosis and can be a cause or consequence of liver disease progression. It is unclear whether PVT treatment is affecting clinical outcomes in cirrhotics.

METHODS

This is a multicenter study of cirrhotics with PVT, initially retrospectively and thereafter prospectively registered in a data base. We studied the impact of PVT treatment on this population for efficacy, safety and the impact on survival. In survival analysis Mantel-Cox and Wilcoxon-Breslow-Gehan tests were used. A P value of <0.05, was considered significant. For statistical computations the STATA 12.1 was used.

RESULTS

Seventy-six patients were included (76% decompensated, median MELD score 12 and Child-Pugh score 7), 47% with concomitant HCC. Fifty-one patients with PVT were treated with Vitamin-K antagonists or Low-Molecular-Weight Heparin. Patients were followed up for at least 6 months after PVT diagnosis, or until death or transplantation. PV patency after 6 months was not statistically different between patients receiving or not anticoagulation (complete-partial recanalization 27.4% of treated vs. 20% of untreated, P=0.21). Median survival was statistically worse between patients treated with anticoagulation than those untreated (10 vs. 15 months, P=0.036). Less portal hypertensive bleeding and less decompensation rates were found in treated cirrhotics vs. untreated (45.8% vs. 54.2%, P=0.003 and 78% vs. 80.9%, P=0.78, respectively). Patients with HCC had worse survival when treated vs. untreated (P=0.047).

CONCLUSIONS

In our cohort of cirrhotics with PVT, treatment was feasible with acceptable side effects, but without meaningful clinical benefits.

Evaluation of Low-Molecular-Weight Heparin for Treatment of Portal Vein Thrombosis in Liver Cirrhosis Patients

Background and Objectives: Even though low-molecular-weight heparin (LMWH), including dalteparin, has a critical role in portal vein thrombosis (PVT) treatment in liver cirrhosis (LC) patients, the predictive factors and the proper dose of dalteparin for PVT treatment and relapse have not yet been investigated. Materials and Methods: This retrospective study evaluated the records of LC patients receiving dalteparin from July 2013 to June 2019. The odds ratio (OR) and adjusted OR were calculated from univariate and multivariable analyses, respectively. Results: Among data from 121 patients, the overall recanalization rate of all patients was 66.1% (80 patients). No history of variceal bleeding (OR 4.6, 95% CI: 1.88-11.43) and the case of newly developed thrombus before dalteparin treatment (OR 3.2, 95% CI: 1.24-8.08) were predictive factors associated with increased treatment response. Relapse of PVT occurred in 32 out of 80 patients (40%) who showed a recanalization. The risk of relapse was 3.1-3.9 times higher in those who took more than three months or more than six months from the diagnosis of PVT to dalteparin treatment compared to those who took less than these durations, respectively. In the dosing regimen, patients with the kg-based dosing regimen showed 2.6 times better response than those with the fixed dosing regimen. However, no difference in bleeding complications was observed. Conclusion: In the dosing regimen, the kg-based regimen that was the same as the venous thromboembolism regimen was a better option for the efficacy and safety of dalteparin therapy. Additionally, when treating PVT in LC patients, careful monitoring is recommended for patients with predictive factors for treatment response and relapse of PVT.

Incidence and outcomes of thromboembolic and bleeding events in patients with liver cirrhosis in the USA

BACKGROUND & AIMS

Understanding the epidemiology of bleeding and thromboembolism (clotting) in liver cirrhosis provides important data for future studies and policymaking; however, head-to-head comparisons of bleeding and clotting remain limited.

METHODS

This is a populational retrospective cohort study using the US National Readmission Database of 2018 to compare the incidence and outcomes of bleeding and clotting events in patients with liver cirrhosis. The primary outcomes were the 11-month incidence proportion of bleeding and clotting events.

RESULTS

Of 1 304 815 participants, 26 569 had liver cirrhosis (45.0% women, mean age 57.2 [SD, 12.7] years). During the 11-month follow-up, in patients with cirrhosis, for bleeding and clotting events, the incidence proportions was 15.3% and 6.6%; the risk-standardized all-cause mortality rates were 2.4% and 1.0%; the rates of intensive care intervention were 4.1% and 1.9%; the rates of rehabilitation transfer were .2% and .2%; the cumulative length of stays were 45 100 and 23 566 days; total hospital costs were 147 and 84 million US dollars; total hospital charges were 620 and 365 million US dollars. Compared to non-cirrhosis, liver cirrhosis was associated with higher rates of bleeding (adjusted hazard ratio, 3.02 [95% CI, 2.85-3.20]) and portal vein thrombosis (PVT) (18.46 [14.86-22.92]), and slightly lower risks of other non-PVT venous thromboembolic events (.82 [.75-.89]).

CONCLUSIONS

Bleeding is more common than thromboembolism in patients with liver cirrhosis, causes higher morbidity, mortality and resource utilization. Liver cirrhosis is an independent risk factor for bleeding and PVT, but not non-PVT thromboembolism including venous thromboembolism, acute myocardial infarction and ischemic stroke.

Analysis of related factors of portal vein thrombosis in liver cirrhosis

BACKGROUND AND AIMS

To investigate the usefulness of interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), protein C (PC), and thromboelastography (TEG) to serve as a predictor of portal vein thrombosis (PVT) in patients with liver cirrhosis. Additionally, we examined the clinical significance of the above indicators in terms of disease progression.

METHODS

A total of 123 patients with liver cirrhosis were recruited from May 2021 to December 2021, according to the imaging findings. They were divided into the PVT group (n = 52) and the non-PVT group (n = 71). Furthermore, patients with PVT were divided into plasma transfusion groups (n = 13) and non-plasma transfusion groups (n = 39). The basic general information, past medical history, laboratory, and imaging examination data were collected and analyzed.

RESULTS

In univariate analysis, there was no significant difference between the two groups in IL-6, PC, reaction time (R), alpha angle (Angle), maximum amplitude, or coagulation index (CI) (P > 0.05). TNF-α in the PVT group was significantly lower than that in the non-PVT group (P = 0.001). K-time (K) in the PVT group was significantly higher than that in the non-PVT group (P = 0.031). There was no significant difference in IL-6, TNF-α, PC, or TEG between different Child-Pugh classification groups (P > 0.05). There were no significant differences in TEG between the plasma transfusion group and the non-plasma transfusion group. In Binary logistic regression analysis, TNF-α (OR = 0.9881, 95%CI = 0.971, 0.990, P < 0.001), K(OR = 1.28, 95% = 1.053, 1.569, P = 0.014), activate partial thromboplastin time (APTT) (OR = 0.753, 95%CI = 0.656, 0.865, P < 0.001), portal vein diameter (OR = 1.310, 95%CI = 1.108, 1.549, P = 0.002)and the history of splenectomy or embolism (OR = 7.565, 95%CI = 1.514, 37.799, P = 0.014)were related to the formation of PVT.

CONCLUSIONS

TNF-α, K, APTT, portal vein diameter, and splenectomy or embolism history were associated with PVT formation, but IL-6 was not.

Establishment and verification a nomogram for predicting portal vein thrombosis presence among admitted cirrhotic patients

Background

Portal vein thrombosis (PVT) is an increasingly recognized complication of cirrhosis and possibly associated with mortality. This study aims to evaluate provoking factors for PVT, then establish a concise and efficient nomogram for predicting PVT presence among admitted cirrhotic patients.

Materials and methods

All cirrhotic patients admitted in Hunan Provincial People's Hospital between January 2010 and September 2020 were retrospectively reviewed, the clinical and laboratory data were collected. Multivariate logistic regression analysis and the least absolute shrinkage and selection operator regression method were used for screening the independent predictors and constructing the nomogram. The calibration curve was plotted to evaluate the consistent degree between observed outcomes and predicted probabilities. The area under the receiver operating characteristics curve was used to assess the discriminant performance. The decision curve analysis (DCA) was carried out to evaluate the benefits of nomogram.

Results

A total of 4,479 patients with cirrhosis were enrolled and 281 patients were identified with PVT. Smoking history, splenomegaly, esophagogastric varices, surgical history, red blood cell transfusion, and D-dimer were independent risk factors for PVT in cirrhosis. A nomogram was established with a good discrimination capacity and predictive efficiency with an the area under the curve (AUC) of 0.704 (95% CI: 0.664-0.745) in the training set and 0.685 (95% CI: 0.615-0.754) in the validation set. DCA suggested the net benefit of nomogram had a superior risk threshold probability.

Conclusion

A concise and efficient nomogram was established with good performance, which may aid clinical decision making and guide best treatment measures.

Diagnostic and Therapeutic Challenges of Chronic Portal Vein Thrombosis Secondary to Myeloproliferative Neoplasm in Sub-Saharan Region: A Series of Cases and Literature Review

Myeloproliferative neoplasms (MPN) are the commonest causes of non-cirrhotic abdominal vein thrombosis. MPN was observed in 30-40% with Budd Chiari Syndrome (BCS) and portal vein thrombosis (PVT), whereas this is the cause in only a minority of other types of venous thrombosis. Herein, we report 10 cases of chronic PVT secondary to Janus Kinase 2 gene (JAk 2) positive myeloproliferative neoplasm (MPN). The median age was 35 years with M:F 1:1. Portal hypertension was present at presentation in all of them. Nine patients have esophageal varices, of which 6 have bleeding at presentation. Classical MPN phenotype on complete blood count (CBC) was not present in 6 of them. Management of patients with anticoagulation was difficult with 4 patients experiencing bleeding during anticoagulation, and bleeding occurring despite the target international normalized ratio (INR) in 2 of them. Portal hypertension leading to hypersplenism and hemodilution may mask erythrocytosis and thrombocytosis, which are the main criteria used to diagnose MPN. The resulting absence of a typical MPN phenotype in routine laboratory studies alongside accessibility issues, and the need for a multidisciplinary treatment approach imparts a diagnostic as well as a therapeutic challenge for chronic PVT associated with Jak 2 positive MPN in sub-Saharan patients.

Nomogram for Predicting Portal Vein Thrombosis in Cirrhotic Patients: A Retrospective Cohort Study

AIM

Portal vein thrombosis (PVT) is a common complication in cirrhotic patients and will aggravate portal hypertension, thus leading to a series of severe complications. The aim of this study was to develop a nomogram based on a simple and effective model to predict PVT in cirrhotic patients.

METHODS

Clinical data of 656 cirrhotic patients with or without PVT in the First Affiliated Hospital of Soochow University and The Third Affiliated Hospital of Nantong University from January 2017 to March 2022 were retrospectively collected, and all patients were divided into training, internal and external validation cohorts. SPSS and R software were used to identify the independent risk factors and construct a predictive model. We evaluated the predictive value of the model by receiver operating characteristic (ROC) curve, calibration curve, and decision curve analyses. The feasibility of the model was further validated in the internal and external cohorts. All enrolled patients were followed up to construct the survival curves and calculate the incidence of complications.

RESULTS

The predictors of PVT included serum albumin, D-dimer, portal vein diameter, splenectomy, and esophageal and gastric varices. Based on the clinical and imaging findings, the final model served as a potential tool for predicting PVT in cirrhotic patients, with an AUC of 0.806 (0.766 in the internal validation cohort and 0.845 in the external validation cohort). The decision curve analysis revealed that the model had a high level of concordance between different medical centers. There was a significant difference between the PVT and non-PVT groups in survival analyses, with p values of 0.0477 and 0.0319 in the training and internal validation groups, respectively, along with p value of 0.0002 in the external validation group according to log-rank test; meanwhile, the median survival times of the PVT group were 54, 43, and 40 months, respectively. The incidence of recurrent esophageal and gastric variceal bleeding (EGVB) during the follow-up showed significant differences among the three cohorts (p = 0.009, 0.048, and 0.001 in the training, internal validation, and external validation cohorts, respectively).

CONCLUSION

The nomogram based on our model provides a simple and convenient method for predicting PVT in cirrhotic patients. Cirrhotic patients with PVT had a shorter survival time and were prone to recurrent EGVB compared with those in the non-PVT group.

Transjugular intrahepatic portosystemic shunt for portal hypertension: 30 years experience from China

Liver diseases are a major cause of illness and death worldwide. In China, liver diseases, primarily viral hepatitis, affect approximately 300 million people, thus having a major impact on the global burden of liver diseases. Portal hypertension is the most severe complication of chronic liver diseases, including ascites, hepatic encephalopathy and bleeding from gastroesophageal varices. Transjugular intrahepatic portosystemic shunt (TIPS) represents a very effective treatment of these complications. Since its introduction 30 years ago in China, the use of TIPS has evolved and has played an increasingly important role in the management of the complications of portal hypertension. This review will focus on the history, current application and management of complications of TIPS in China.

Review article: the safety of anticoagulants and antiplatelet agents in patients with cirrhosis

Patients with cirrhosis were long thought to be coagulopathic. However, this paradigm has changed in recent years and currently, cirrhosis is recognised as a prothrombotic state. Due to the increasing incidence of cirrhosis from nonalcoholic steatohepatitis which is closely associated with cardiac disease, patients with cirrhosis increasingly require therapy with anticoagulants and antiplatelet agents. However, their potential for causing catastrophic and life-threatening bleeding in patients with cirrhosis leads to hesitancy about their use in patients with cirrhosis. Overall, traditional anticoagulation is safe for all Child-Pugh classes while newer direct oral anticoagulants (DOACs) are mostly safe in Child-Pugh class A/B and contraindicated in severe hepatic impairment. For different indications, published data to date suggest that anticoagulation is overall safe for patients with cirrhosis who have venous thromboembolism, atrial fibrillation and portal vein thrombosis, and does not increase the risk of variceal bleeding. Moreover, DOACs appear to have similar safety profiles as traditional anticoagulants. Finally, most studies suggest that antiplatelet agents are also safe to use in patients with cirrhosis although they are mostly contraindicated in severe hepatic impairment. For both anticoagulants and antiplatelet agents, severe thrombocytopaenia presents a relative contraindication to their use. More prospective trials and large cohort studies are needed to advance our understanding of the safety and nuances of DOACs and antiplatelet agents in patients with advanced cirrhosis.

Impact of Asymptomatic Superior Mesenteric Vein Thrombosis on the Outcomes of Patients with Liver Cirrhosis

BACKGROUND

 The impact of asymptomatic superior mesenteric vein (SMV) thrombosis on the outcomes of cirrhotic patients remains uncertain.

METHODS

 Nonmalignant cirrhotic patients who were consecutively admitted between December 2014 and September 2021 and underwent contrast-enhanced computed tomography/magnetic resonance imaging scans were screened. Portal venous system thrombosis (PVST) was identified. Death and hepatic decompensation were the outcomes of interest. Nelson-Aalen cumulative risk curve analysis and competing risk regression analysis were performed to evaluate the impact of asymptomatic SMV thrombosis and portal vein thrombosis (PVT) on the outcomes.

RESULTS

 Overall, 475 patients were included, of whom 67 (14.1%) had asymptomatic SMV thrombosis, 95 (20%) had PVT, and 344 (72.4%) did not have any PVST. Nelson-Aalen cumulative risk curve analyses showed that the cumulative incidences of death (p = 0.653) and hepatic decompensation (p = 0.630) were not significantly different between patients with asymptomatic SMV thrombosis and those without PVST, but the cumulative incidences of death (p = 0.021) and hepatic decompensation (p = 0.004) were significantly higher in patients with PVT than those without PVST. Competing risk regression analyses demonstrated that asymptomatic SMV thrombosis was not a significant risk factor for death (subdistribution hazard ratio [sHR] = 0.89, p = 0.65) or hepatic decompensation (sHR = 1.09, p = 0.63), but PVT was a significant risk factor for death (sHR = 1.56, p = 0.02) and hepatic decompensation (sHR = 1.50, p = 0.006). These statistical results remained in competing risk regression analyses after adjusting for age, sex, and Child-Pugh score.

CONCLUSION

 Asymptomatic SMV thrombosis may not influence the outcomes of cirrhotic patients. The timing of intervention for asymptomatic SMV thrombosis in liver cirrhosis should be further explored.

Preprocedural prophylaxis with blood products in patients with cirrhosis: Results from a survey of the Italian Association for the Study of the Liver (AISF)

INTRODUCTION

The concept of rebalanced hemostasis in cirrhosis challenges the policy of transfusing plasma or platelets before invasive procedures in patients with prolonged PT or severe thrombocytopenia. Recent guidelines recommend against plasma transfusion and suggest avoiding/minimizing platelet transfusions.

AIM

We assessed how hepato-gastroenterologists manage prolonged PT/INR or severe thrombocytopenia before invasive procedures.

METHODS

On May 2021, AISF members were sent a questionnaire addressing the PT/INR and platelet thresholds required before invasive procedures, the use of other markers of bleeding risk or other hemostatic treatments and the burden of pre-emptive plasma and platelet transfusions.

RESULTS

Of 62 respondents, 94% and 100% use PT/INR and platelet count to assess bleeding risk, respectively. Only 37% and 32% require less conservative PT/INR or platelet counts thresholds for low-risk procedures, respectively. As for those applying single thresholds, 68% require PT/INR <1,5 and 86% require platelet counts ≥50 × 10⁹/L. Half respondents use additional indicators of bleeding risk and 63% other hemostatic treatments. Low-risk procedures account for 70% of procedures, and for 50% and 59% of plasma and platelets units transfused, respectively.

CONCLUSIONS

the survey indicates lack of compliance with guidelines that advise against plasma and platelet transfusions before invasive procedures and the need for prospective studies and inter-society consensus workshops.

Portal Vein Thrombosis in the Setting of Cirrhosis: A Comprehensive Review

Portal vein thrombosis constitutes the most common thrombotic event in patients with cirrhosis, with increased rates in the setting of advanced liver disease. Despite being a well-known complication of cirrhosis, the contribution of portal vein thrombosis to hepatic decompensation and overall mortality is still a matter of debate. The incorporation of direct oral anticoagulants and new radiological techniques for portal vein recanalization have expanded our therapeutic arsenal. However, the lack of large prospective observational studies and randomized trials explain the heterogenous diagnostic and therapeutic recommendations of current guidelines. This article seeks to make a comprehensive review of the pathophysiology, clinical features, diagnosis, and treatment of portal vein thrombosis in patients with cirrhosis.

Portal vein thrombosis associates with high platelet-fibrin clot strength and platelet activation in decompensated cirrhosis: A retrospective study

BACKGROUND AND AIMS

Alteration of platelet status associates with decompensation and death in cirrhosis, while its effect on portal vein thrombosis (PVT) remains unclear. We aimed to retrospectively investigate whether PVT associates with platelet-fibrin clot strength and platelet activation in decompensated cirrhosis.

METHODS

Platelet-fibrin clot strength (G) was measured by thromboelastography (TEG). Platelet activation was reflected by plasma concentrations of soluble p-selectin (sPs) and a platelet aggregation test adjusted for platelet counts.

RESULTS

Among 166 patients, 45 had PVT. The platelet count was significantly lower in PVT. While the G value was positively correlated with platelet count (ρ = 0.74, P < 0.01), increased G was associated with PVT after adjusting for platelet count in the logistic regression (P = 0.04). The normalized G value according to the linear relation with platelet count was calculated as follows: G_platelet = [(G - 2622)/platelet count]. This coefficient had no correlation with platelet count and was an independent risk factor of PVT (OR = 1.03, CI_95%: 1.01-1.05, P = 0.012). In two subanalyses, the collagen-induced platelet aggregation (n = 37, P = 0.029) and plasma concentration of sPs (n = 56, P = 0.001) adjusted for platelet count were significantly higher in PVT.

CONCLUSION

This study showed a positive correlation of high platelet-fibrin clot strength detected via TEG and platelet activation with PVT in decompensated cirrhosis.

Epidemiology of portal vein thrombosis in liver cirrhosis: A systematic review and meta-analysis

BACKGROUND

Portal vein thrombosis (PVT) may be associated with negative outcomes in patients with liver cirrhosis. However, the prevalence and incidence of PVT in liver cirrhosis are heterogeneous among studies and have not been sufficiently determined yet.

METHODS

The PubMed, EMBASE, and Cochrane Library databases were searched. Eligible studies would explore the prevalence and/or incidence of PVT in liver cirrhosis without hepatocellular carcinoma or abdominal surgery. Pooled proportion with 95% confidence interval (CI) was calculated using a random-effect model. Factors associated with the presence/occurrence of PVT were also extracted.

RESULTS

Among the 8549 papers initially identified, 74 were included. Fifty-four studies explored the prevalence of PVT in liver cirrhosis with a pooled prevalence of 13.92% (95%CI=11.18-16.91%). Based on cross-sectional data, Child-Pugh class B/C, higher D-dimer, ascites, and use of non-selective beta-blockers (NSBBs) were associated with the presence of PVT in liver cirrhosis. Twenty-three studies explored the incidence of PVT in liver cirrhosis with a pooled incidence of 10.42% (95%CI=8.16-12.92%). Based on cohort data, Child-Pugh class B/C, higher model of end-stage liver disease score, higher D-dimer, lower platelets count, decreased portal flow velocity, ascites, use of NSBBs, and moderate or high-risk esophageal varices could predict the occurrence of PVT in liver cirrhosis.

CONCLUSION

Approximately one seventh of cirrhotic patients have PVT, and one tenth will develop PVT. Progression of liver cirrhosis and portal hypertension seems to be in parallel with the risk of PVT. Prospective studies with detailed information about classification and extension of PVT in liver cirrhosis are needed.

Portal Interventions in the Setting of Venous Thrombosis or Occlusion

Portal vein thrombosis most commonly occurs as a complication of liver cirrhosis and can result in worsening symptoms of portal hypertension, which often can be challenging to treat with conventional decompression therapies. In addition, because complete portal vein thrombosis is associated with higher posttransplant morbidity and mortality, it is regarded as a relative contraindication to liver transplant. Often, the diagnosis of portal vein thrombosis is incidental; hence, imaging remains the mainstay for diagnosing this complication and is used to guide subsequent treatment. Although anticoagulation is the initial approach used to treat acute portal vein thrombosis, endovascular and/or surgical interventions may be necessary when there is concern for impending bowel ischemia. Treatment of chronic portal vein thrombosis is primarily aimed at alleviating the symptoms of portal hypertension and improving the chance of candidacy for liver transplant. Awareness of the portal venous anatomy to differentiate it from the periportal collaterals is key during recanalization of a chronically occluded portal vein. The authors provide an overview of the pathophysiology, acute and chronic imaging findings, and management of portal vein thrombosis, with a specific focus on endovascular management, as well as a summary of the current related literature. An invited commentary by Lopera and Yamaguchi is available online. ©RSNA, 2022.

Increased platelet aggregation in patients with decompensated cirrhosis indicates higher risk of further decompensation and death

BACKGROUND & AIMS

Studies on platelet aggregation in cirrhosis are controversial because interpretation of platelet function is challenged by thrombocytopenia. We conducted a prospective study to investigate whole blood platelet aggregation in cirrhosis and its association with liver-related outcomes.

METHODS

Platelet aggregation was assessed by whole blood aggregometry (Multiplate®). To overcome the influence of platelet count and compare cirrhosis with thrombocytopenia vs. controls with normal platelet count, we calculated a ratio between platelet aggregation and platelet count (PLT ratio). Then, we prospectively followed patients with cirrhosis and ascertained predictors of decompensation, transplantation, and death.

RESULTS

Two-hundred and three patients with cirrhosis were prospectively recruited (77% decompensated). PLT ratio was significantly higher in cirrhosis than in those with chronic hepatitis and healthy individuals (0.44 vs. 0.25 and 0.26, respectively; p <0.0001). In cirrhosis, the ratio increased with disease severity (Child-Pugh class C>B>A) and was particularly elevated in decompensated patients with severe thrombocytopenia. Among decompensated patients, 65 had further decompensation, underwent transplantation, or died during a 6-month follow-up. On multivariate analysis, PLT ratio (odds ratio 1.87; 95% CI 1.23-2.84; p = 0.003) and MELD score (odds ratio 1.05; 95% CI 1.01-1.08; p = 0.01) were independently associated with outcome. The relative risk of events was 7.5-fold higher in patients with PLT ratio >0.75 vs. patients with PLT ratio <0.25 (95% CI 2.5-21.9; p = 0.003). The increased PLT ratio, its discriminative ability for composite outcome, and the prognostic value of PLT ratio >0.75 were confirmed in an independent cohort of hospitalized patients with decompensated cirrhosis (n = 41).

CONCLUSIONS

Patients with cirrhosis, particularly when decompensated, exhibit significantly increased whole blood platelet aggregation. Decompensated patients with a PLT ratio >0.75 have a >80% probability of further decompensation, transplantation, or liver-related death within 6 months.

LAY SUMMARY

In patients with cirrhosis, previous studies have suggested that platelets (i.e. circulating blood cells that help form clots to stop bleeding) are dysfunctional. In particular, these studies suggested that platelet aggregation (the process by which platelets adhere to each other to form clots) is reduced. Since platelet aggregation is important for clot formation, it has been hypothesized that alterations of platelet aggregation may be responsible for the increased risk of bleeding observed in patients with cirrhosis. Our study demonstrates: i) that platelet aggregation in patients with cirrhosis is higher than in healthy individuals; ii) that platelet aggregation in patients with decompensated cirrhosis (i.e. those who have already experienced some complications of cirrhosis) is particularly elevated and associated with risk of further complications and death.

Nonmalignant portal vein thrombi in patients with cirrhosis consist of intimal fibrosis with or without a fibrin-rich thrombus

BACKGROUND AND AIM

Portal vein thrombosis (PVT) is a common complication of cirrhosis. The exact pathophysiology remains largely unknown, and treatment with anticoagulants does not lead to recanalization of the portal vein in all patients. A better insight into the structure and composition of portal vein thrombi may assist in developing strategies for the prevention and treatment of PVT.

APPROACH AND RESULTS

Sixteen prospectively and 63 retrospectively collected nonmalignant portal vein thrombi from patients with cirrhosis who underwent liver transplantation were included. Histology, immunohistochemistry, and scanning electron microscopy were used to assess structure and composition of the thrombi. Most recent CT scans were reanalyzed for thrombus characteristics. Clinical characteristics were related to histological and radiological findings. All samples showed a thickened, fibrotic tunica intima. Fibrin-rich thrombi were present on top of the fibrotic intima in 9/16 prospective cases and in 21/63 retrospective cases. A minority of the fibrotic areas stained focally positive for fibrin/fibrinogen (16% of cases), von Willebrand factor (VWF; 10%), and CD61 (platelets, 21%), while most of the fibrin-rich areas stained positive for those markers (fibrin/fibrinogen, 100%; VWF, 77%; CD61, 100%). No associations were found between clinical characteristics including estimated thrombus age and use of anticoagulants and presence of fibrin-rich thrombi.

CONCLUSION

We demonstrate that PVT in patients with cirrhosis consists of intimal fibrosis with an additional fibrin-rich thrombus in only one-third of cases. We hypothesize that our observations may explain why not all portal vein thrombi in patients with cirrhosis recanalize by anticoagulant therapy.

Liver status and outcomes in patients without previous known liver disease receiving anticoagulant therapy for venous thromboembolism

The association between elevated liver enzymes or FIB-4 (fibrosis index 4) and outcome in patients with venous thromboembolism (VTE) has not been evaluated. Data from patients in RIETE (Registro Informatizado Enfermedad TromboEmbólica) were used to assess the association between elevated liver enzymes or FIB-4 levels and the rates of major bleeding or death in apparent liver disease-free patients with acute VTE under anticoagulation therapy. A total of 6206 patients with acute VTE and without liver disease were included. Of them, 92 patients had major bleeding and 168 died under anticoagulation therapy. On multivariable analysis, patients with elevated liver enzymes were at increased mortality risk (HR: 1.58; 95% CI: 1.10-2.28), while those with FIB-4 levels > 2.67 points were at increased risk for major bleeding (HR: 1.69; 95% CI: 1.04-2.74). Evaluation of liver enzymes and FIB-4 index at baseline in liver disease-free patients with VTE may provide additional information on the risk for major bleeding or death during anticoagulation.

Antithrombotic Therapy After Venous Interventions: AJR Expert Panel Narrative Review

Interventions for thrombotic and nonthrombotic venous disorders have increased with technical advances and more trained venous specialists. Antithrombotic therapy is essential to clinical and procedural success; however, post-procedural therapeutic regimens exhibit significant heterogeneity due to limited prospective randomized data as well as incomplete mechanistic understanding of the critical factors driving long-term patency. Post-interventional antithrombotic therapy for thrombotic venous disorders should adhere to existing venous thromboembolism management guidelines, which include 3-6 months of therapeutic anticoagulation at minimum and consideration of extended therapy in patients with higher risk of thrombosis due to procedural or patient factors. The additive benefit of antiplatelet agents in the acute and intermediate period is unknown, having shown improved long-term stent patency in some retrospective studies. Dual and/or triple agent therapy should be limited based on individual risks of thrombosis and bleeding. The treatment of non-thrombotic disorders is more heterogeneous, though patients with limited flow, extensive stent material, or underlying prothrombotic states such as malignancy or chronic inflammation may benefit from single- or multi-agent antithrombotic therapy. However, the agent, dose, and duration of therapy remain indeterminate. Future prospective studies are warranted to improve patient risk stratification and standardize post-procedural antithrombotic therapy in patients receiving venous interventions.

The Pathophysiology of Portal Vein Thrombosis in Cirrhosis: Getting Deeper into Virchow's Triad

Portal vein thrombosis (PVT) is a common complication among patients with cirrhosis. However, its pathophysiology is not well established and there are currently very few predictive factors, none of which are actually useful, from a clinical perspective. The contribution of each of the vertices of Virchow’s triad, e.g., blood hypercoagulability, blood flow, and portal vein endothelial damage in the development of PVT is not clear. In this review, we aim to recapitulate the latest studies on the field of PVT development in order to understand its mechanisms and discuss some of the future directions in the study of this important complication of cirrhosis.

Rebalanced hemostasis in liver disease: a misunderstood coagulopathy

The combination of frequently abnormal hemostatic markers and catastrophic bleeding as seen with variceal hemorrhage has contributed to the longstanding misperception that chronic liver disease (CLD) constitutes a bleeding diathesis. Laboratory studies of hemostasis in liver disease consistently challenge this with global coagulation assays incorporating activation of the protein C pathway demonstrating rebalanced hemostasis. It is now recognized that bleeding in CLD is predominantly secondary to portal hypertension (rather than a coagulopathy) and additionally that these patients are at increased risk of venous thrombosis, particularly in the portal venous system. This narrative review describes the current understanding of hemostasis in liver disease, as well as the periprocedural management of hemostasis and anticoagulation for management of venous thromboembolism in patients with CLD.

Nomogram for predicting the risk of gastroesophageal varices after primary endoscopic prophylaxis for variceal hemorrhage in patients with cirrhosis

BACKGROUND AND AIMS

The aim of this study was to identify predictors of non-high-risk gastroesophageal varices and evaluate the probability of the residual high-risk varices in cirrhosis patients after the primary endoscopic treatment.

PATIENTS AND METHODS

Medical records of the patients with cirrhosis admitted for primary endoscopic prophylaxis gastroesophageal varices hemorrhage were retrospectively analyzed. The patients were divided into high-risk varices and non-high-risk varices groups according to the endoscopy. A nomogram was developed based on the results of multivariate Cox analyses. Accuracy of this model was validated by the concordance index (Harrell's c-index) and calibration curve.

RESULTS

Altogether 117 patients were enrolled between March 2014 and April 2018. The multivariate Cox analyses identified spleen length <140 mm [odds ratio (OR) = 2.715; P = 0.037), small or medium size of esophageal varices (OR = 4.412; P = 0.017), unaccompanied with gastric varices (OR = 7.025; P = 0.003) and frequency of endoscopic variceal ligation ≥one time per 4 months (OR = 3.834; P = 0.034) as independent factors of non-high-risk varices. All significant predictors were incorporated into a nomogram to predict the residual high-risk varices, which showed a notable accuracy with the concordance index (0.833).

CONCLUSION

The nomogram-based prediction of residual high-risk varices can be used for risk stratification in cirrhosis patients with gastroesophageal varices.

Natural history and predictors associated with the evolution of portal venous system thrombosis in liver cirrhosis

BACKGROUND

Portal venous system thrombosis (PVST) will progress in some cases, indicating worse outcome and the necessity of antithrombotic treatment, but will spontaneously improve in others. It is crucial to understand the natural history of PVST in liver cirrhosis. However, the knowledge regarding how to predict the evolution of PVST in cirrhotic patients is very scant.

METHODS

Sixty-nine cirrhotic patients without malignancy, who had undergone repeated contrast-enhanced computed tomography or MRI to evaluate the severity of PVST at the first and last admissions, were included. Logistic regression analysis was performed to identify the risk factors for the evolution of PVST in liver cirrhosis. Odds ratios (ORs) were calculated.

RESULTS

Among 42 patients without PVST at the first admission, 10 (23.8%) developed PVST at the last admission. Serum albumin level (OR = 0.873), prothrombin time (OR = 1.619), activated partial thromboplastin time (OR = 1.169), Child-Pugh score (OR = 1.560) and model for end-stage liver disease (MELD) score (OR = 1.292) at the last admission were significant risk factors associated with the development of PVST. Among 27 patients with PVST at the first admission, 11 (40.7%), 4 (14.8%) and 12 (44.4%) had improvement, stabilization and progression of PVST at the last admission, respectively. ΔMELD score (OR = 0.714) was the only significant risk factor associated with the improvement of PVST; additionally, serum albumin level at the first admission (OR = 1.236) was the only significant risk factor associated with the progression of PVST.

CONCLUSION

Aggravation and amelioration of liver dysfunction may predict the development and improvement of PVST in liver cirrhosis, respectively.