Venous thromboembolism with chronic liver disease

Cerebral venous thrombosis presented with symmetrical crescent-shaped intracranial hemorrhage in alcoholic liver disease: Case reports

RATIONALE

Cerebral venous thrombosis (CVT) is a relatively uncommon but fatal disease. It can be caused by a variety of hereditary or acquired thrombotic diseases. Initial presentation with intracranial hemorrhage (ICH) in CVT is rare but can further complicate the therapeutic measures and prognosis. Cases of CVT presented with ICH in patients with alcoholic liver disease (ALD) have not been described in the literature, and it might be related with hemostatic abnormalities in ALD patients.

PATIENT CONCERNS

We report 2 cases of men admitted to our hospital who were diagnosed with CVT but initially presented with symmetrical crescent-shaped ICH; both of them were ALD patients.

DIAGNOSES

Cerebral imaging revealed extended CVT in both cases. The first case was a 64-year-old man with ALD deteriorated with unconsciousness and convulsions; computed tomography showed symmetrical crescent-shaped ICH in the right temporal lobe, and magnetic resonance venography revealed CVT. Another 50-year-old man with ALD complained about dizziness and weakness of his right limbs; computed tomography revealed symmetrical crescent-shaped ICH in bilateral parietal and occipital lobes, and magnetic resonance venography revealed CVT.

INTERVENTIONS

The first patient was referred to the endovascular thrombectomy. Both of them were treated with anticoagulation treatment.

OUTCOMES

Favorable outcomes were observed in both patients.

LESSONS

Symmetrical or multiple crescent-shaped ICH requires a high suspicion in the diagnosis of CVT; even with hemorrhage, it is still important to initiate anticoagulation therapy promptly. The crescent-shaped ICH might be a new sign for CVT, and further studies are needed in the underlying mechanisms of ALD and potential thrombophilia.

Incidence and prevalence of venous thromboembolism in chronic liver disease: A systematic review and meta-analysis

BACKGROUND AND AIMS

Historically, bleeding was thought to be a frequent and fatal complication of liver disease. However, thrombosis due to coagulation disorders in cirrhosis remains a real risk. We aim to systematically analyse published articles to evaluate epidemiology of venous thromboembolism (VTE) in chronic liver disease (CLD).

METHOD

Electronic search was conducted on Ovid Medline, EMBASE and Scopus from inception to November 2021 to identify studies presenting epidemiology VTE (deep vein thrombosis and pulmonary embolism) in CLD in inpatients and/or community settings. Random-effects meta-analysis was performed to determine pooled per-year cumulative incidence, incidence rate and prevalence. Heterogeneity was measured by I² test, and, potential sources of heterogeneity by meta-regression and sensitivity analysis. PROSPERO registration-CRD42021239117.

RESULTS

Twenty-nine studies comprising 19,157,018 participants were included, of which 15,2049 (0.79%) had VTE. None of the included studies were done in the community. In hospitalised patients with CLD: pooled cumulative incidence of VTE was 1.07% (95% CI 0.80,1.38) per-year, incidence rate was 157.15 (95% CI 14.74,445.29) per 10,000 person-years, and period prevalence was 1.10% (95% CI 0.85,1.38) per year. There was significant heterogeneity and publication bias. Pooled relative risk (RR) of studies reporting incidence rate was 2.11 (95% CI 1.35,3.31). CLD patients (n = 1644), who did not receive pharmacological prophylaxis were at 2.78 times (95% CI 1.11, 6.98) increased risk of VTE compared to those receiving prophylaxis.

CONCLUSION

Hospitalised patients with CLD may be at an increased risk of VTE. For every 1000 hospitalised patients with CLD ten have new, and eleven have pre-existing diagnoses of VTE per-year.

The short-term outcomes of patients with chronic liver disease hospitalized with COVID-19

Background and aims

Patients with chronic liver disease (CLD) might have aggravated course upon acquisition of coronavirus disease 2019 (COVID‐19). We aimed to analyse the outcomes of patients with CLD who were hospitalized due to COVID‐19.

Methods

Medical records of 4014 patients hospitalized due to COVID‐19 in a regional referral hospital over a 12‐month period were analysed. Patients with CLD were identified based on discharge diagnoses according to ICD‐10 classification. Patients were followed for 30 days from admission, and their outcomes (intensive care unit (ICU) admission, mechanical ventilation (MV) or death) were analysed.

Results

Of the 4014 patients, 110 (2.7%) had CLD and 49 (1.2%) had cirrhosis. Median age of CLD patients was 67.5 years, 79 (71.8%) were males, 224 (23.5%) obese, 56 (50.9%) reported alcohol abuse, 24 (21.8%) had non‐alcoholic fatty liver disease, 11 (10%) viral hepatitis and 98 (89.1%) had pneumonia. Median length of hospitalization was 12 days, 32 (29.1%) patients required ICU admission and 23 (20.9%) MV, while 43 (39.1%) died. In univariate analysis, patients with cirrhosis (45% vs 73%, HR=2.95; P<0.001), but not those with non‐cirrhotic CLD (74% vs 73%, P>0.05), experienced worse 30‐days survival when compared to age, sex and COVID‐19 duration matched cohorts. In a logistic regression analysis conducted on the overall and matched cohorts, liver cirrhosis, but not CLD, predicted inferior survival independently of age, comorbidities and severity of COVID‐19, with a fourfold higher adjusted risk of 30‐day mortality.

Conclusion

Cirrhosis is independently associated with higher 30‐day mortality of hospitalized patients with COVID‐19.

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Standard coagulation tests are superior to thromboelastometry in predicting outcome of patients with liver cirrhosis

Background and aims

Thromboelastometry (TEM) is superior to standard coagulation tests in the management of bleedings / invasive procedures in patients with liver cirrhosis. In contrast, the role of TEM as a prognostic parameter in liver cirrhosis is not well established. We therefore aimed to assess the role of TEM in predicting survival of outpatients with liver cirrhosis.

Methods

TEM was performed in consecutive outpatients with liver cirrhosis admitted in 2018 and 2019 to the University Hospital Essen. Associations with transplant-free survival were assessed in regression models.

Results

A number of 145 outpatients with liver cirrhosis were included, of whom 27 received a liver transplant (N = 7) or died (N = 20) within 6 months of follow-up. None of the TEM values was associated with transplant-free survival in this cohort. However, as expected, the classical coagulation tests INR (OR = 8.69 (95% CI 1.63–46.48), P = 0.01), PTT (OR = 1.15 (95% CI 1.04–1.27), P<0.01), as well as antithrombin (OR = 0.96 (95% CI 0.94–0.99), P<0.01), and protein C (OR = 0.96 (95% CI 0.92–0.99), P<0.01) were significantly associated with transplant-free survival.

Conclusion

In contrast to the superiority of TEM over classical coagulation tests to guide transfusion of blood products in patients with liver cirrhosis, TEM has no relevance in predicting mortality in outpatients with liver cirrhosis.

Effectiveness of venous thromboembolism prophylaxis in patients with liver disease

BACKGROUND

Patients with liver disease are concomitantly at increased risk of venous thromboembolism (VTE) and bleeding events due to changes in the balance of pro- and anti-hemostatic substances. As such, recommendations for the use of pharmacological VTE prophylaxis are lacking. Recent studies have found no difference in rates of VTE in those receiving and not receiving pharmacological VTE prophylaxis, though most studies have been small. Thus, our study sought to establish if pharmacological VTE prophylaxis is effective and safe in patients with liver disease.

AIM

To determine if there is net clinical benefit to providing pharmacological VTE prophylaxis to cirrhotic patients.

METHODS

In this retrospective study, 1806 patients were propensity matched to assess if pharmacological VTE prophylaxis is effective and safe in patients with cirrhosis. Patients were divided and evaluated based on receipt of pharmacological VTE prophylaxis.

RESULTS

The composite primary outcome of VTE or major bleeding was more common in the no prophylaxis group than the prophylaxis group (8.7% vs 5.1%, P = 0.002), though this outcome was driven by higher rates of major bleeding (6.9% vs 2.9%, P < 0.001) rather than VTE (1.9% vs 2.2%, P = 0.62). There was no difference in length of stay or in-hospital mortality between groups. Pharmacological VTE prophylaxis was independently associated with lower rates of major bleeding (OR = 0.42, 95%CI: 0.25-0.68, P = 0.0005), but was not protective against VTE on multivariable analysis.

CONCLUSION

Pharmacological VTE prophylaxis was not associated with a significant reduction in the rate of VTE in patients with liver disease, though no increase in major bleeding events was observed.

Efficacy and safety of anticoagulation for atrial fibrillation in patients with cirrhosis: A systematic review and meta-analysis

OBJECTIVE

The atrial fibrillation-related stroke is clearly prevented by anticoagulation treatment, however, management of anticoagulation for AF in patients with cirrhosis represents a challenge due to bleeding concerns. To address this issue, a systematic review and meta-analysis of the literature was performed.

METHODS

A literature search for studies reporting the incidence of AF in patients with cirrhosis was conducted using MEDLINE, EMBASE and Cochrane Database, from inception through July 2018.

RESULTS

7 cohort studies including 19,798 patients with AF and cirrhosis were identified. The use of anticoagulation (%) among included studies ranged from 8.3% to 53.9%. Anticoagulation use for AF in patients with cirrhosis was significantly associated with a reduced risk of stroke, with a pooled HR of 0.58 (95%CI: 0.35-0.96). When compared with no anticoagulation, the use of anticoagulation was not significantly associated with a higher risk of bleeding, with a pooled HR of 1.45 (95%CI: 0.96-2.17). Compared to warfarin, the use of direct oral anticoagulants (DOACs) was associated with a lower risk of bleeding among AF patients with cirrhosis.

CONCLUSION

Our study demonstrates that anticoagulation use for AF in patients with cirrhosis is associated with a reduced risk of stroke, without increasing significantly the risk of bleeding, when compared to those without anticoagulation.

Cancer-Associated Thrombosis in Cirrhotic Patients with Hepatocellular Carcinoma

It is common knowledge that cancer patients are more prone to develop venous thromboembolic complications (VTE). It is therefore not surprising that patients with hepatocellular carcinoma (HCC) present with a significant risk of VTE, with the portal vein being the most frequent site (PVT). However, patients with HCC are peculiar as both cancer and liver cirrhosis are conditions that can perturb the hemostatic balance towards a prothrombotic state. Because HCC-related hypercoagulability is not clarified at all, the aim of the present review is to summarize the currently available knowledge on epidemiology and pathogenesis of non-malignant thrombotic complications in patients with liver cirrhosis and HCC. They are at increased risk to develop both PVT and non-splanchnic VTE, indicating that both local and systemic factors can foster the development of site-specific thrombosis. Recent studies have suggested multiple and often interrelated mechanisms through which HCC can tip the hemostatic balance of liver cirrhosis towards hypercoagulability. Described mechanisms include increased fibrinogen concentration/polymerization, thrombocytosis, and release of tissue factor-expressing extracellular vesicles. Currently, there are no specific guidelines on the use of thromboprophylaxis in this unique population. There is the urgent need of prospective studies assessing which patients have the highest prothrombotic profile and would therefore benefit from early thromboprophylaxis.

Determinants of treatment duration in the prevention of recurrent venous thromboembolism: a protocol for a balanced vignette experiment

INTRODUCTION

Venous thromboembolism (VTE) is a condition that annually occurs in approximately 1‰ of the world's population. Patients who have already had a VTE are at elevated risk for a recurrent VTE. Recurrent events increase the risk of long-term sequelae and can be fatal. Adequate secondary prophylaxis is thus needed to prevent such events. Patients with VTE are often prone to bleeding, and pharmacological prophylaxis exacerbates bleeding risk. Expert opinions on the optimum duration of secondary prophylaxis in VTE still vary substantially. The existence of treatment guidelines has not led to uniformity of VTE secondary prophylaxis strategies, which means that physicians still adhere to individual risk calculi in determining treatment duration.

METHODS AND ANALYSIS

The aim of this study is to establish what factors lie at the root of this variance in VTE secondary prophylactic treatment strategies, and what risk factors are deemed of particular importance in determining the perceived risks and benefits of variable treatment durations. To do this, we created a survey based on a D-efficient and G-efficient balanced experimental vignette design. This protocol covers all aspects of how this survey was set up and how it was implemented. The analysis of the experimental data will be carried out using mixed-effects methods, which are beneficial in scenarios with high interindividual variance and correlated (eg, repeated-measures) responses. We propose the use of maximal random effects structures insofar as possible.

ETHICS AND DISSEMINATION

All data are de-identified, and any identifying characteristics of the respondents will not be reported in a final manuscript or elsewhere. A paper describing the expert interviews is currently under peer review. A manuscript that contains the analysis of the results of the experiment described in this protocol is being drafted, and will also be submitted to a peer-reviewed journal.

Differential Kinetics of Coagulation Factors and Natural Anticoagulants in Patients with Liver Cirrhosis: Potential Clinical Implications

Background

Advanced liver diseases are associated with profound alterations of the coagulation system increasing the risk not only of bleeding, but also of thromboembolic complications. A recent milestone study has shown that prophylactic anticoagulation in liver cirrhosis patients results in a reduced frequency of hepatic decompensation. Yet, INR measurement, one of the most widely applied tests to assess liver function, only inaccurately predicts the risk of hepatic decompensation related to alterations of the coagulation system. To assess the relationship between selected coagulation factors / natural anticoagulants with INR, MELD score, and hepatic decompensation, we performed the present pilot study. A total number of 92 patients with various stages of liver cirrhosis were included and prospectively followed for at least 6 months. We found that important natural anticoagulants, namely antithrombin and protein C, as well as factor XI (which may also serve as an anticoagulant) decreased earlier and by a larger magnitude than one would expect from classical coagulation test results. The correlation between these factors and INR was only moderate. Importantly, reduced plasma activities of natural anticoagulants but not INR or MELD score were independent predictors of hepatic encephalopathy (P = 0.013 and 0.003 for antithrombin and protein C, respectively).

Conclusion

In patients with liver cirrhosis plasma activities of several natural anticoagulants are earlier and stronger affected than routine coagulation tests. Reduced activities of natural anticoagulants may be predictive for the development of hepatic encephalopathy.

Hemostatic balance in patients with liver cirrhosis: Report of a consensus conference

Patients with cirrhosis present with hemostatic alterations secondary to reduced availability of pro-coagulant and anti-coagulant factors. The net effect of these changes is a rebalanced hemostatic system. The Italian Association of the Study of the Liver (AISF) and the Italian Society of Internal Medicine (SIMI) promoted a consensus conference on the hemostatic balance in patients with cirrhosis. The consensus process started with the review of the literature by a scientific board of experts and ended with a formal consensus meeting in Rome in December 2014. The statements were graded according to quality of evidence and strength of recommendations, and approved by an independent jury. The statements presented here highlight strengths and weaknesses of current laboratory tests to assess bleeding and thrombotic risk in cirrhotic patients, the pathophysiology of hemostatic perturbations in this condition, and outline the optimal management of bleeding and thrombosis in patients with liver cirrhosis.

Epidemiology, Risk Factors, and In-Hospital Mortality of Venous Thromboembolism in Liver Cirrhosis: A Single-Center Retrospective Observational Study

BACKGROUND

Risk of venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), may be increased in liver cirrhosis. We conducted a single-center study to explore the epidemiology, risk factors, and in-hospital mortality of VTE in Chinese patients with liver cirrhosis.

MATERIAL/METHODS

All patients with liver cirrhosis who were consecutively admitted to our hospital between January 2011 and December 2013 were retrospectively included.

RESULTS

Of 2006 patients with liver cirrhosis included, 9 patients were diagnosed with or developed VTE during hospitalization, including 5 patients with a previous history of DVT, 1 patient with either a previous history of DVT or new onset of PE, and 3 patients with new onset of VTE (PE, n=1; DVT, n=2). Risk factors for VTE included a significantly higher proportion of hypertension and significantly higher red blood cells, hemoglobin, alanine aminotransferase, aspartate aminotransferase, prothrombin time (PT), international normalized ratio (INR), D-dimer, and Child-Pugh scores. The in-hospital mortality was significantly higher in patients with VTE than those without VTE (33.3% [3/9] versus 3.4% [67/1997], P<0.001).

CONCLUSIONS

VTE was observed in 0.4% of patients with liver cirrhosis during hospitalization and it significantly increased the in-hospital mortality. Elevated PT/INR aggravated the risk of VTE.

Epidemiology of venous thromboembolism in patients with liver diseases: a systematic review and meta-analysis

The risk of venous thromboembolism (VTE) may be increased in patients with liver diseases. A systematic review and meta-analysis were conducted to analyze the epidemiology of VTE in such patients. All relevant studies were searched via the PubMed, EMBASE, and Cochrane Library databases. The incidence and prevalence of VTE were pooled using random-effect models. Subgroup analyses were conducted according to the type of VTE [deep vein thrombosis (DVT), pulmonary embolism (PE)], type of liver disease (liver cirrhosis alone/unclassified liver diseases or non-cirrhotics), region in which the study was performed (USA/Europe/Asia), number of total observed patients with liver diseases (>1,000/<1,000 patients), study quality (high/low), and methods for identifying the cases (ICD codes/clinical charts). Of 4,843 papers initially identified, 20 were included. The incidence of VTE varied from 0.33 to 6.32 % in 14 studies with a pooled value of 1 % (95 % confidence interval (CI) 0.7-1.3 %). The pooled incidence of DVT and PE was 0.6 % (95 % CI 0.4-0.8 %) and 0.28 % (95 % CI 0.13-0.49 %), respectively. The prevalence of VTE varied from 0.6 to 4.69 % in six studies with a pooled value of 1.0 % (95 % CI 0.7-1.2 %). The pooled prevalence of DVT and PE was 0.7 % (95 % CI 0.6-0.9 %) and 0.36 % (95 % CI 0.13-0.7 %), respectively. The heterogeneity was statistically significant in the main and subgroup meta-analyses. In conclusion, about 1 % of patients with liver diseases develop or are diagnosed with VTE during their hospitalizations. However, the epidemiological data are very heterogeneous among studies.

Chemoprophylaxis Use and Risk of Venous Thromboembolism and Death in Adult Patients following Orthotopic Liver Transplantation

BACKGROUND

Coagulation abnormalities in end-stage liver disease may preclude patients from receiving venous thromboembolism (VTE) prophylaxis immediately following orthotopic liver transplantation.

METHODS

To identify risk factors for VTE and death following liver transplantation, a retrospective chart review was conducted in adult liver transplant recipients from January 1, 2001, to October 1, 2011.

RESULTS

In 716 transplantations in 701 patients, the overall incidence of VTE was 2.1%. The incidence was 3.6% in patients who received chemoprophylaxis compared to 1.4% in those without chemoprophylaxis (P = .06). Most patients (69.5%) did not receive chemoprophylaxis postsurgery during their hospitalization. Multivariate logistic regression modeling revealed no association between the use of chemoprophylaxis (adjusted odds ratio [OR] 1.5 [0.45-4.7], P = .53) and VTE. A significant positive association was observed between the use of chemoprophylaxis (adjusted OR 3.2 [1.3-8.0], P = .01) and death.

CONCLUSION

Use of chemoprophylaxis and increasing amounts of blood products following orthotopic liver transplant was associated with increased mortality. A significant positive association was observed between blood product administration and VTE, while chemoprophylaxis use was not significantly associated with VTE. Larger prospective studies are necessary to further examine the significance of this finding.

Coagulopathy in liver diseases: complication or therapy?

Coagulopathy in cirrhosis is a composite condition where liver synthetic deficit rebalances coagulation to a parallel reduction of both pro- and anticoagulant factors. Cirrhosis is therefore no longer considered a hypocoagulable state but rather a more unstable hemostatic balance with a lower threshold for tipping toward thrombosis or bleeding. Tendency to bleeding in cirrhosis is due to the reduction in the synthesis of procoagulants and a low platelet count as well as hyperfibrinolysis. Variceal hemorrhage is a frequent bleeding complication in decompensated cirrhosis. However, the possible contribution of coagulopathy as a precipitant or an aggravating factor is poorly documented and further data are required to clarify its real contributing role. Moreover, apart from the gastrointestinal tract, the occurrence of spontaneous and procedure-related bleeding elsewhere in the body, whilst not uncommon, is less than would be expected. By contrast, a large-scale population-based study has shown the propensity towards venous thrombosis in patients with liver diseases. Portal vein thrombosis (PVT) is a critical but frequent event occurring in up to 40% of patients with liver cirrhosis. PVT causes deterioration of the clinical course, the complications of portal hypertension and an increase in post-transplant mortality. The pathogenesis of PVT includes both local alterations, like blood flow reduction and endothelial activation, and systemic derangement. Systemic prohemostatic alterations include high von Willebrand factor, low ADAMTS-13, low levels of anticoagulants (antithrombin, proteins C and S) and increases in procoagulants like factor VIII. Low-molecular-weight heparin such as enoxaparin has proven to be safe and effective in both the treatment and prevention of PVT. In addition, patients in prophylaxis with enoxaparin showed a lower rate of decompensation and a better survival without bleeding complications. In such patients, circulating bacterial DNA, endotoxemia and markers of inflammation were attenuated compared to controls. These results therefore suggest a possible connection between enoxaparin, decrease of endotoxemia and reduction of portal hypertension. The approach to the coagulopathy in patients with liver diseases is changing: while the main goal for clinicians so far has been to reduce the risk of bleeding, the results of these new studies highlight the importance of preventing or treating thrombophilic disorders like PVT to avoid microcirculatory damage and eventually liver decompensation.

Deep vein thrombosis and pulmonary embolism in cirrhotic patients: Systematic review

Patients with liver cirrhosis were traditionally believed to be protected against development of blood clots. Lately, studies have shown that these patients may probably be at an increased risk of venous thrombotic complications. Although the hemostatic changes in the chronic liver disease patients and the factors that may predict bleeding vs thrombotic complications remains an area of active research, it is believed that the coagulation cascade is delicately balanced in these patients because of parallel reduced hepatic synthesis of pro and anticoagulant factors. Thrombotic state in cirrhotic patients is responsible for not only portal or non-portal thrombosis [deep vein thrombosis (DVT) and pulmonary embolism (PE)]; it has also been associated with progression of liver fibrosis. The use of anticoagulants in cirrhosis patients is a challenging, and often a scary situation. This review summarizes the current literature on the prevalence of venous thrombosis (DVT and PE), risk factors and safety of prophylactic and therapeutic anticoagulation in patients with chronic liver disease.

Risk factors for venous thromboembolism in patients with chronic liver disease

BACKGROUND

Pharmacologic prophylaxis for venous thromboembolism (VTE) in patients with chronic liver disease (CLD) presents a unique challenge because of coagulopathies associated with the disease. When evaluating whether these patients require VTE prophylaxis upon hospitalization, it would be advantageous if risk factors for the development of VTE in this population were known.

OBJECTIVE

To evaluate risk factors associated with the development of VTE in patients with CLD.

METHODS

A retrospective case-control study was conducted. Patients admitted to the University of Kentucky Chandler Hospital from October 2006 to July 2010 with a diagnosis of CLD and VTE were matched in a 1:3 fashion with CLD patients without VTE. The primary objective was to determine whether there were significant differences in laboratory values between the 2 groups.

RESULTS

During this time, 27 patients with CLD (1.0%) were diagnosed with VTE. These patients had significantly lower median aspartate aminotransferase (AST) (47 vs 70 U/L, p = 0.04), alanine transaminase (ALT) (24.5 vs 36 U/L, p = 0.02), albumin (2.1 vs 2.4 g/dL, p = 0.02) and hematocrit (Hct) (28.3% vs 32%, p = 0.03) values compared to the control patients. Patients with albumin lower than 1.9 g/dL had a 5.1 times greater risk of VTE compared to patients with albumin of 2.8 g/dL and higher (OR 5.14, 95% CI 1.05-25.2).

CONCLUSIONS

Patients with CLD who developed VTE had significantly lower AST, ALT, albumin, and Hct compared to those of control patients. Studies are necessary to further examine the significance of this finding.

Hypercoagulability in cirrhosis: causes and consequences

Decreased levels of most coagulation factors and thrombocytopenia are the main haemostatic abnormalities of cirrhosis. As a consequence, this condition was, until recently, considered as the prototype acquired coagulopathy responsible for bleeding. However, recent evidence suggests that it should, rather, be regarded as a condition associated with normal or even increased thrombin generation. The bleeding events that occur in these patients should, therefore, be explained by the superimposed conditions that frequently occur in this setting. Due to elevated levels of factor VIII (procoagulant driver) in combination with decreased protein C (anticoagulant driver), which are typically found in patients with cirrhosis, a procoagulant imbalance, defined as a partial resistance to the in vitro anticoagulant action of thrombomodulin, can be demonstrated. Whether this in vitro hypercoagulability is truly representative of what occurs in vivo remains to be established. However, the hypothesis that it may have clinical consequences is attractive and deserves attention. The possible consequences that we discuss herein include whether (i) cirrhosis is a condition associated with increased risk of venous thromboembolism or portal vein thrombosis; (ii) the hypercoagulability associated with cirrhosis has any other role outside coagulation (i.e. progression of liver fibrosis); and (iii) anticoagulation should be used in cirrhosis. Although apparently provocative, considering anticoagulation as a therapeutic option in patients with cirrhosis is now supported by a rationale of increasing strength. There may be subgroups of patients who benefit from anticoagulation to treat or prevent thrombosis and to slow hepatic fibrosis. Clinical studies are warranted to explore these therapeutic options.