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Balaceanu LA, Dina I. D-dimers in advanced liver cirrhosis: Useful biomarker or not? Am J Med Sci 2024:S0002-9629(24)01264-3. [PMID: 38788925 DOI: 10.1016/j.amjms.2024.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 02/03/2024] [Accepted: 05/20/2024] [Indexed: 05/26/2024]
Abstract
In clinical practice, the d-dimer levels rule out venous thromboembolism and diagnose disseminated intravascular coagulation. d-dimers increase in both physiological and pathological conditions. Liver cirrhosis, especially in the final stages, is characterized by complex coagulation and fibrinolysis factor disorders. Multiple mechanisms tried to explain the increased d-dimer levels in patients with liver cirrhosis and ascites. The d-dimer cut-off level used to rule out venous thromboembolism in cirrhosis is higher than that used to confirm the diagnosis of VTE or DIC in noncirrhotic patients. The cut-off d-dimer level used for the prognosis of thrombotic events is not standardized in advanced liver cirrhosis. Thus, it is necessary to update the clinical guidelines regarding the usefulness of d-dimer testing in advanced liver cirrhosis and the cut-off d-dimer levels, which should vary based on the detection method.
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Affiliation(s)
- Lavinia Alice Balaceanu
- Internal Medicine Department, "Carol Davila" University of Medicine and Pharmacy, Emergency Clinical Hospital "Sf. Ioan," Bucharest, Romania.
| | - Ion Dina
- Gastroenterology Department, "Carol Davila" University of Medicine and Pharmacy, Emergency Clinical Hospital "Sf. Ioan," Bucharest, Romania
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Bromfield B, Tellez R, Hughes DL, Brown R, Andrzejewski M, Bawa A, Lin FP, Tublin M, Triulzi D, Ganoza A, Duarte-Rojo A. TEG-based transfusion protocol is associated with decreased blood product use without increased risk of hemoperitoneum. Hepatol Commun 2023; 7:e0292. [PMID: 37889553 PMCID: PMC10615392 DOI: 10.1097/hc9.0000000000000292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 08/14/2023] [Indexed: 10/28/2023] Open
Abstract
BACKGROUND Thromboelastography (TEG) informs the need for blood product transfusions to prevent procedural bleeding complications in patients with cirrhosis. We aimed to evaluate the impact of using a TEG-based transfusion protocol on blood product utilization before paracentesis and the post-paracentesis hemoperitoneum (PPH) incidence. METHODS We conducted an ambispective analysis of patients with cirrhosis who underwent paracentesis from 2017 to 2021. In May 2019, we enacted a TEG-based transfusion protocol to guide pre-paracentesis blood product use. Patients with platelets < 20,000 or international normalized ratio ≥ 4 underwent TEG and received blood products if r value > 10 min or MA <30 mm. Patients were divided into pre-TEG and post-TEG protocol cohorts based on the date of paracentesis. Pre-paracentesis blood product transfusions in the form of platelets, fresh frozen plasma, and cryoprecipitates were recorded. PPH was defined as a decrease in hemoglobin of ≥1 g and the presence of blood on diagnostic imaging and/or the need for therapeutic intervention. RESULTS A total of 483 patients underwent 1281 paracenteses. The main etiologies of cirrhosis were alcohol (43%) and NASH (25%), and the mean MELD-sodium was 22±6. Pre-TEG and post-TEG protocol cohort sizes were similar: 253 patients and 607 paracenteses versus 230 patients and 674 paracenteses. After TEG-protocol implementation, blood product transfusions decreased significantly (228 vs. 49 products, p<0.001) with associated cost savings. One patient in each cohort developed PPH. CONCLUSION Implementation of a pre-paracentesis TEG-based transfusion protocol for patients with cirrhosis successfully resulted in decreased blood product use with no associated increase in incidence of PPH.
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Affiliation(s)
- Brittany Bromfield
- Department of Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Roberto Tellez
- Department of Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Dempsey L. Hughes
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, USA
| | - Rebecca Brown
- University of Pittsburgh School of Medicine, Pennsylvania, USA
| | - Margaret Andrzejewski
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Aditi Bawa
- Department of Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Fei-Pi Lin
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Mitchell Tublin
- Department of Radiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Darrell Triulzi
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Armando Ganoza
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Andres Duarte-Rojo
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, USA
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Yang DJ, Tan YY, Zhou HJ, Li CJ. Anticoagulation therapy for portal vein thrombosis in patients with liver cirrhosis. Shijie Huaren Xiaohua Zazhi 2023; 31:562-570. [DOI: 10.11569/wcjd.v31.i13.562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/07/2023] [Accepted: 06/21/2023] [Indexed: 07/08/2023] Open
Abstract
BACKGROUND Portal vein thrombosis (PVT) is a frequent complication of cirrhosis, which is significantly associated with progressive hepatic decompensation such as ascites and a high mortality risk. Anticoagulation may associate with higher PVT regression rates, but the safety of anticoagulation should be considered.
AIM To investigate the efficacy and safety of anticoagulation therapy for PVT in patients with liver cirrhosis.
METHODS We conducted a retrospective study of cirrhotic patients diagnosed with PVT from January 2018 to December 2021, comparing those who received anticoagulation therapy to those who did not. Thirty-two patients received low molecular weight heparin (LMWH), warfarin, or rivaroxaban (anticoagulation group), and 52 were untreated (non-anticoagulation group). All patients were followed to assess the evolution of PVT (thrombus regression, stable, and progression) and the adverse effects of anticoagulation therapy.
RESULTS A total of 84 patients were followed for a median 13 mo (IQR: 6-24 mo). Thirty-two patients (38.1%) received anticoagulation therapy. Anticoagulation therapy was associated with a higher PVT regression rate (50.0% vs 23.1%, P = 0.010) (univariable hazard ratio [HR] for regression of PVT with anticoagulation = 0.300, 95% confidence interval [CI]: 0.116-0.773, P = 0.013; multivariable HR for regression of PVT with anticoagulation = 0.185, 95%CI: 0.061-0.560, P = 0.003). Anticoagulation therapy was stopped in six patients because of adverse effects, of which two were due to abdominal pain, two due to gastrointestinal bleeding, and two due to hematuria. Symptoms improved after drug withdrawal.
CONCLUSION Our findings support anticoagulation therapy in cirrhotic patients with non-malignant PVT, since anticoagulation seems safe and associated with superior PVT regression rates.
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Affiliation(s)
- Dong-Jie Yang
- Department of Clinical Medicine, Changsha Medical University, Changsha 410219, Hunan Province, China
| | - Yu-Yong Tan
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha 410011, Hunan Province, China
| | - He-Jun Zhou
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha 410011, Hunan Province, China
| | - Chen-Jie Li
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha 410011, Hunan Province, China
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Pasta A, Calabrese F, Giannini EG. Assessing the Short-Term Prognosis of Patients with Cirrhosis Using the DIC Scores. Thromb Haemost 2023; 123:744-746. [PMID: 36808405 DOI: 10.1055/a-2039-1575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Affiliation(s)
- Andrea Pasta
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Francesco Calabrese
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Edoardo G Giannini
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
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Benevento F, Pecorelli A, Stefanescu H, Sparchez Z, Vukotic R, Pettinari I, Grigoras CA, Tovoli F, Ravaioli F, Stefanini B, Andreone P, Piscaglia F. Presence of Hepatocellular Carcinoma Does Not Affect Course and Response to Anticoagulation of Bland Portal Vein Thrombosis in Cirrhotic Patients. J Hepatocell Carcinoma 2023; 10:473-482. [PMID: 37007210 PMCID: PMC10065221 DOI: 10.2147/jhc.s390777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 03/15/2023] [Indexed: 03/29/2023] Open
Abstract
Background Malignancies are generally considered a risk factor for deep vein thrombosis and may hamper the recanalisation of thrombosed veins. Aim We investigate whether the natural course and response to anticoagulant treatment of bland portal vein thrombosis (PVT) in patients with cirrhosis complicated by hepatocellular carcinoma (HCC) differ from those without HCC. Methods Retrospective study in two hepatology referral centres, in Italy and Romania where patients with a diagnosis of PVT on cirrhosis and follow-up of at least 3 months with repeated imaging were included. Results A total of 162 patients with PVT and matching inclusion and exclusion criteria were identified: 30 with HCC were compared to 132 without HCC. Etiologies, Child-Pugh Score (7 vs 7) and MELD scores (11 vs 12, p=0.3679) did not differ. Anticoagulation was administered to 43% HCC vs 42% nonHCC. The extension of PVT in the main portal trunk was similar: partial/total involvement was 73.3/6.7% in HCC vs 67.4/6.1% in nonHCC, p=0.760. The remainder had intrahepatic PVT. The recanalization rate was 61.5% and 60.7% in HCC/nonHCC in anticoagulated patients (p=1). Overall PVT recanalisation, including treated and untreated patients, was observed in 30% of HCC vs 37.9% of nonHCC, p=0.530. Major bleeding incidence was almost identical (3.3% vs 3.8%, p=1). Progression of PVT after stopping anticoagulation did not differ (10% vs 15.9%, respectively, HCC/nHCC, p=0.109). Conclusion The course of bland non-malignant PVT in cirrhosis is not affected by the presence of active HCC. Treatment with anticoagulation in patients with active HCC is safe and as effective as in nonHCC patients, this can potentially allow us to use otherwise contraindicated therapies (ie TACE) if a complete recanalization is achieved with anticoagulation.
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Affiliation(s)
- Francesca Benevento
- Department of Medicine and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Anna Pecorelli
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Horia Stefanescu
- Gastroenterology Department, Liver Unit & Ultrasound Laboratory, Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | - Zeno Sparchez
- Gastroenterology Department, Liver Unit & Ultrasound Laboratory, Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | - Ranka Vukotic
- Department of Medicine and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
- Medicina Interna 4, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Irene Pettinari
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Crina-Anca Grigoras
- Gastroenterology Department, Liver Unit & Ultrasound Laboratory, Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | - Francesco Tovoli
- Department of Medicine and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
- Division of Internal Medicine, Hepatobiliary and Immunoallergic Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Federico Ravaioli
- Department of Medicine and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Bernardo Stefanini
- Department of Medicine and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Pietro Andreone
- Divisione di Medicina Interna a Indirizzo Metabolico-Nutrizionale, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | - Fabio Piscaglia
- Department of Medicine and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
- Division of Internal Medicine, Hepatobiliary and Immunoallergic Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Correspondence: Fabio Piscaglia, Email
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Biolato M, Vitale F, Galasso T, Gasbarrini A, Grieco A. Minimum platelet count threshold before invasive procedures in cirrhosis: Evolution of the guidelines. World J Gastrointest Surg 2023; 15:127-141. [PMID: 36896308 PMCID: PMC9988645 DOI: 10.4240/wjgs.v15.i2.127] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 12/09/2022] [Accepted: 02/07/2023] [Indexed: 02/27/2023] Open
Abstract
Cirrhotic patients with severe thrombocytopenia are at increased risk of bleeding during invasive procedures. The need for preprocedural prophylaxis aimed at reducing the risk of bleeding in cirrhotic patients with thrombocytopenia who undergo scheduled procedures is assessed via the platelet count; however, establishing a minimum threshold considered safe is challenging. A platelet count ≥ 50000/μL is a frequent target, but levels vary by provider, procedure, and specific patient. Over the years, this value has changed several times according to the different guidelines proposed in the literature. According to the latest guidelines, many procedures can be performed at any level of platelet count, which should not necessarily be checked before the procedure. In this review, we aim to investigate and describe how the guidelines have evolved in recent years in the evaluation of the minimum platelet count threshold required to perform different invasive procedures, according to their bleeding risk.
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Affiliation(s)
- Marco Biolato
- Department of Medical and Surgical Sciences, CEMAD, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
- Department of Internal Medicine, Catholic University of Sacred Heart, Rome 00168, Italy
| | - Federica Vitale
- Department of Internal Medicine, Catholic University of Sacred Heart, Rome 00168, Italy
| | - Tiziano Galasso
- Department of Internal Medicine, Catholic University of Sacred Heart, Rome 00168, Italy
| | - Antonio Gasbarrini
- Department of Medical and Surgical Sciences, CEMAD, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
- Department of Internal Medicine, Catholic University of Sacred Heart, Rome 00168, Italy
| | - Antonio Grieco
- Department of Medical and Surgical Sciences, CEMAD, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
- Department of Internal Medicine, Catholic University of Sacred Heart, Rome 00168, Italy
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La Mura V, Bitto N, Tripodi A. Rational hemostatic management in cirrhosis: from old paradigms to new clinical challenges. Expert Rev Hematol 2022; 15:1031-1044. [PMID: 36342412 DOI: 10.1080/17474086.2022.2144217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Patients with cirrhosis are at risk of both thrombotic and hemorrhagic events. Traditional hemostatic tests are inadequate to assess the complex and fragile balance of hemostasis in this setting, especially in advanced stages of disease such as decompensated cirrhosis or acute on chronic liver failure (ACLF). Furthermore, the indiscriminate use of pro-hemostatic agents for prophylaxis and treatment of bleeding episodes is still debated and often contraindicated. Alongside, splanchnic, and peripheral thrombotic events are frequent in this population and require management that involves a careful balance between risks and benefits of antithrombotic therapy. AREAS COVERED This review aims to address the state of the art on the clinical management of the hemostatic balance of cirrhosis in terms of established knowledge and future challenges. EXPERT OPINION The old paradigm of cirrhosis as a naturally anticoagulated condition has been challenged by more sophisticated global tests of hemostasis. Integrating this information in the clinical decision-making is still challenging for physicians and experts in hemostasis.
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Affiliation(s)
- Vincenzo La Mura
- Fondazione I.R.C.C.S. Ca' Granda, Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Niccolò Bitto
- Fondazione I.R.C.C.S. Ca' Granda, Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy.,Department of Biomedical Sciences for Health, Università degli studi di Milano, Milan, Italy
| | - Armando Tripodi
- Fondazione I.R.C.C.S. Ca' Granda, Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
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Huang Q, Pang M, Zeng Q, He X, Zheng R, Ge M, Li K. The frequency and risk factors of major complications after thermal ablation of liver tumours in 2,084 ablation sessions. Front Surg 2022; 9:1010043. [PMID: 36189384 PMCID: PMC9520062 DOI: 10.3389/fsurg.2022.1010043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 08/29/2022] [Indexed: 12/24/2022] Open
Abstract
Background To assess the frequency of major complications after thermal ablation of liver tumours and to determine risk factors for adverse events. Methods A retrospective study was conducted between January 2015 and January 2021. A total of 2,084 thermal ablation sessions in 1,592 patients with primary and metastatic liver tumours were evaluated. The frequency of major complications was evaluated according to the Society of Interventional Radiology Standards, and putative predictors of adverse events were analysed using simple and multivariate logistic regression. Results Thermal ablation-related mortality was 0.1% (2/2,084), with an overall major complication rate of 5.6% (117/2,084). The most frequent major complication was symptomatic pleural effusion (2.9%, 60/2,084). Multivariate logistic regression analysis revealed that a total maximum diameter of lesions >3 cm, microwave ablation (MWA) and MWA combined with radiofrequency ablation, intrahepatic cholangiocarcinoma and postoperative systemic inflammatory response syndrome were independent prognostic factors for major complications. Conclusions Thermal ablation of liver tumours is a safe procedure with an acceptable incidence of major complications. The risk factors identified in this study will help to stratify high-risk patients.
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Affiliation(s)
- Qiannan Huang
- Department of Ultrasound, Guangdong Key Laboratory of Liver Disease Research, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Mengya Pang
- Department of Anesthesiology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Qingjing Zeng
- Department of Ultrasound, Guangdong Key Laboratory of Liver Disease Research, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xuqi He
- Department of Ultrasound, Guangdong Key Laboratory of Liver Disease Research, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Rongqin Zheng
- Department of Ultrasound, Guangdong Key Laboratory of Liver Disease Research, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Mian Ge
- Department of Anesthesiology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- Correspondence: Kai Li Mian Ge
| | - Kai Li
- Department of Ultrasound, Guangdong Key Laboratory of Liver Disease Research, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- Correspondence: Kai Li Mian Ge
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Gallo P, Terracciani F, Di Pasquale G, Esposito M, Picardi A, Vespasiani-Gentilucci U. Thrombocytopenia in chronic liver disease: Physiopathology and new therapeutic strategies before invasive procedures. World J Gastroenterol 2022; 28:4061-4074. [PMID: 36157107 PMCID: PMC9403422 DOI: 10.3748/wjg.v28.i30.4061] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 04/21/2022] [Accepted: 07/18/2022] [Indexed: 02/06/2023] Open
Abstract
Chronic liver disease is characterized by several hematological derangements resulting in a complex and barely rebalanced haemostatic environment. Thrombocytopenia is the most common abnormality observed in these patients and recent advances have led to researchers focus the attention on the multifactorial origin of thrombocytopenia and on the key role of thrombopoietin (TPO) in its physiopathology. Severe thrombocytopenia (platelet count < 50000/μL) complicates the management of patients with chronic liver disease by increasing the potential risk of bleeding for invasive procedures, which may be therefore delayed or canceled even if lifesaving. In the very last years, the development of new drugs which exceed the limits of the current standard of care (platelet transfusions, either immediately before or during the procedure) paves the way to a new scenario in the management of this population of patients. Novel agents, such as the TPO-receptor agonists avatrombopag and lusutrombopag, have been developed in order to increase platelet production as an alternative to platelet transfusions. These agents have demonstrated a good profile in terms of efficacy and safety and will hopefully allow reducing limitations and risks associated with platelet transfusion, without any delay in scheduled interventions. Altogether, it is expected that patients with chronic liver disease will be able to face invasive procedures with one more string in their bow.
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Affiliation(s)
- Paolo Gallo
- Clinical Medicine and Hepatology Unit, Campus Bio-Medico University, Roma 00128, Italy
| | - Francesca Terracciani
- Clinical Medicine and Hepatology Unit, Campus Bio-Medico University, Roma 00128, Italy
| | - Giulia Di Pasquale
- Clinical Medicine and Hepatology Unit, Campus Bio-Medico University, Roma 00128, Italy
| | - Matteo Esposito
- Clinical Medicine and Hepatology Unit, Campus Bio-Medico University, Roma 00128, Italy
| | - Antonio Picardi
- Clinical Medicine and Hepatology Unit, Campus Bio-Medico University, Roma 00128, Italy
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Zanetto A, Campello E, Spiezia L, Burra P, Simioni P, Senzolo M. Staging the pre-procedural prophylaxis in decompensated cirrhosis. Dig Liver Dis 2022; 54:1130-1132. [PMID: 35641404 DOI: 10.1016/j.dld.2022.04.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 04/27/2022] [Indexed: 12/12/2022]
Affiliation(s)
- Alberto Zanetto
- Department of Surgery, Gastroenterology and Multivisceral Transplant Unit, Oncology, and Gastroenterology, Padua University Hospital, Via Giustiniani 2, Padua 35128, Italy
| | - Elena Campello
- Department of Medicine, General Internal Medicine, Thrombotic and Hemorrhagic Diseases Unit, Padua University Hospital, Via Giustiniani 2, Padua 35128, Italy
| | - Luca Spiezia
- Department of Medicine, General Internal Medicine, Thrombotic and Hemorrhagic Diseases Unit, Padua University Hospital, Via Giustiniani 2, Padua 35128, Italy
| | - Patrizia Burra
- Department of Surgery, Gastroenterology and Multivisceral Transplant Unit, Oncology, and Gastroenterology, Padua University Hospital, Via Giustiniani 2, Padua 35128, Italy
| | - Paolo Simioni
- Department of Medicine, General Internal Medicine, Thrombotic and Hemorrhagic Diseases Unit, Padua University Hospital, Via Giustiniani 2, Padua 35128, Italy
| | - Marco Senzolo
- Department of Surgery, Gastroenterology and Multivisceral Transplant Unit, Oncology, and Gastroenterology, Padua University Hospital, Via Giustiniani 2, Padua 35128, Italy.
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Orme ME, Bentley R, Marcella S, Peck-Radosavljevic M, Perard R, Wedemeyer H, Yoshiji H, Agarwal K, Dusheiko G. Systematic Review with Meta-Analysis: Efficacy and Safety of Lusutrombopag for Severe Thrombocytopenia in Patients with Chronic Liver Disease Undergoing Invasive Procedures. Adv Ther 2022; 39:4169-4188. [PMID: 35836089 PMCID: PMC9402754 DOI: 10.1007/s12325-022-02235-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 06/17/2022] [Indexed: 11/25/2022]
Abstract
Introduction Lusutrombopag is an oral thrombopoietin receptor agonist (TPO-RA). Clinical trials have shown lusutrombopag’s efficacy in reducing need for preoperative platelet transfusion in patients with chronic liver disease (CLD) and severe thrombocytopenia. This analysis assessed efficacy and safety of lusutrombopag in patients with severe thrombocytopenia and CLD undergoing planned invasive procedures. Methods An electronic database search (through 1 December 2020) identified three randomised, placebo-controlled, double-blind clinical trials comparing lusutrombopag with placebo in patients with CLD and platelet count below 50 × 109/L scheduled to undergo a procedure with a perioperative bleeding risk. A random-effects meta-analysis examined treatment effect, with Cochrane Collaboration’s tool assessing risk of bias. Results The meta-analysis included 343 (lusutrombopag 3 mg, n = 173; placebo, n = 170) patients. More patients met the criteria for treatment response (platelet count at least 50 × 109/L and increase of at least 20 × 109/L from baseline anytime during the study) with lusutrombopag versus placebo (risk ratio [RR] 6.39; 95% confidence interval [CI] 3.69, 11.07; p < 0.0001). The primary efficacy outcome, proportion of patients requiring no platelet transfusion and no rescue therapy for bleeding for at least 7 days post procedure, was achieved by more patients treated with lusutrombopag versus placebo (RR 3.42; 95% CI 1.86, 6.26; p = 0.0001). The risk of any bleeding event was significantly lower with lusutrombopag compared to placebo (RR 0.55; 95% CI 0.32, 0.95; p = 0.03); conversely, thrombosis event rates were similar between lusutrombopag and placebo (RR 0.79; 95% CI 0.19, 3.24; p = 0.74). Conclusion This meta-analysis showed that treatment of severe thrombocytopenia with lusutrombopag in patients with CLD prior to a planned invasive procedure was efficacious and safe in increasing platelet counts, avoiding the need for platelet transfusions, and reducing risk of bleeding, thereby enhancing the certainty of evidence supporting the efficacy and safety of lusutrombopag. Supplementary Information The online version contains supplementary material available at 10.1007/s12325-022-02235-w.
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Affiliation(s)
- Michelle E Orme
- ICERA Consulting Ltd., 17 Redbridge Close, Swindon, Wiltshire, UK.
| | | | | | - Markus Peck-Radosavljevic
- Abteilung Innere Medizin und Gastroenterologie (IMuG), mit Zentrale Aufnahme und Erstversorgung (ZAE), Klinikum Klagenfurt am Wörthersee, Klagenfurt, Austria
| | | | - Heiner Wedemeyer
- Department of Gastroenterology, Hepatology, and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Hitoshi Yoshiji
- Department of Gastroenterology, Nara Medical University, Kashihara, Nara Prefecture, Japan
| | - Kosh Agarwal
- Institute of Liver Studies, King's College Hospital, London, UK
| | - Geoffrey Dusheiko
- University College London Medical School and King's College Hospital, London, UK
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Li Z, Xu WT, Xu XB, Qi XS. Heparins for prevention and treatment of venous thromboembolism in cirrhosis: Research advances. Shijie Huaren Xiaohua Zazhi 2022; 30:381-386. [DOI: 10.11569/wcjd.v30.i9.381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Current evidence suggests that liver cirrhosis may increase the risk of venous thromboembolism (VTE). In cirrhosis, common types of VTE include portal vein thrombosis (PVT), deep vein thrombosis, and pulmonary embolism (PE). Heparins are the most commonly prescribed anticoagulants for the prevention and treatment of VTE. However, the indications, choice, dosage, and monitoring of heparins in cirrhosis remain inconclusive. This paper aims to review the advances in the research of heparins for the prevention and treatment of VTE in cirrhosis to optimize the treatment strategy.
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Affiliation(s)
- Zhe Li
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, Liaoning Province, China,Postgraduate College, Shenyang Pharmaceutical University, Shenyang 110016, Liaoning Province, China
| | - Wen-Tao Xu
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, Liaoning Province, China,Postgraduate College, Shenyang Pharmaceutical University, Shenyang 110016, Liaoning Province, China
| | - Xiang-Bo Xu
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, Liaoning Province, China,Postgraduate College, Shenyang Pharmaceutical University, Shenyang 110016, Liaoning Province, China
| | - Xing-Shun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, Liaoning Province, China,Postgraduate College, Shenyang Pharmaceutical University, Shenyang 110016, Liaoning Province, China
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13
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Mastrorilli G, Fiorentino F, Tucci C, Lombardi G, Aghemo A, Colombo GL. Cost Analysis of Platelet Transfusion in Italy for Patients with Chronic Liver Disease and Associated Thrombocytopenia Undergoing Elective Procedures. Clinicoecon Outcomes Res 2022; 14:205-220. [PMID: 35422645 PMCID: PMC9005228 DOI: 10.2147/ceor.s354470] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 03/23/2022] [Indexed: 11/23/2022]
Abstract
Purpose Platelet transfusions (PT) are commonly used as prophylaxis in patients with chronic liver disease (CLD) and severe thrombocytopenia (TCP) before invasive procedures, in order to reduce risk of bleeding. The aim of this cost analysis was to generate a comprehensive estimate of costs of platelet transfusions in Italy, focusing on patients with severe TCP due to CLD undergoing an elective procedure. Methods The research was conducted in different phases: 1) assessment of a pre-specified framework for the identification of processes related to PT; 2) estimation of resource consumption through Delphi technique and collection of unit costs through literature; 3) development of a cost analysis to estimate the overall average costs per PT, focusing on a representative patient with CLD and severe TCP. Robustness of results was tested in a sensitivity analysis. Results Despite the lack of some cost components estimation and uncertainty related to event probability, the analysis showed a total cost of 5297 € for each PT in patients with CLD and severe TCP. The total cost was largely driven by direct costs (4863 €) associated with platelet collection, transfusion, and management of refractoriness, which accounted for 92% of total. Conclusion In an environment of limited resources, it is crucial for the healthcare service to have accurate and inclusive information on transfusion costs, incorporating not only the cost of blood products but also those related to collection and management. The analysis showed that platelet collection and administration costs add substantially to the cost of platelet products themselves. As expected, the highest cost was the transfusion process itself (44% of total), followed by refractoriness (43% of total). Since limited literature exists concerning these cost estimates, this analysis represents a step forward in understanding the economic burden of patients with CLD and severe TCP scheduled to undergo an invasive procedure.
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Affiliation(s)
| | | | - Carmen Tucci
- Real World Solutions, IQVIA Solutions Italy s.r.l., Milan, Italy
| | - Gloria Lombardi
- Real World Solutions, IQVIA Solutions Italy s.r.l., Milan, Italy
- Correspondence: Gloria Lombardi, Real World Solutions, IQVIA Solutions Italy s.r.l., Via Fabio Filzi 29, Milan, 20124, Italy, Tel +39 331 6801813, Email
| | - Alessio Aghemo
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Division of Internal Medicine and Hepatology, Department of Gastroenterology, Humanitas Research Hospital IRCCS, Rozzano, Italy
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14
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Gadani S, Partovi S, Levitin A, Zerona N, Sengupta S, D’Amico G, Diago Uso T, Menon KVN, Quintini C. Narrative review of portal vein thrombosis in cirrhosis: pathophysiology, diagnosis, and management from an interventional radiology perspective. Cardiovasc Diagn Ther 2022; 12:135-146. [PMID: 35282661 PMCID: PMC8898691 DOI: 10.21037/cdt-21-98] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 10/25/2021] [Indexed: 09/01/2023]
Abstract
OBJECTIVE This paper examines the incidence, clinical presentation, and pathophysiology of portal vein thrombosis (PVT) in cirrhosis. Additionally, we have reviewed the literature regarding the current status of medical and interventional radiology management of PVT and have proposed a novel algorithm for the management given different clinical scenarios. Lastly two representative cases displaying endovascular treatment options are provided. BACKGROUND Portal vein thrombus in the setting of cirrhosis is an increasingly recognized clinical issue with debate on its pathophysiology, natural course, and optimal treatment. Approximately one-third of patients are asymptomatic, and detection of the thrombus is an incidental finding on imaging performed for other reasons. In 30% to 50% of patients, PVT resolves spontaneously. However, there is increased post-transplant mortality in patients with completely occlusive PVT, therefore effective early revascularization strategies are needed for patients with complete PVT who are expected to undergo liver transplant. Additionally, no consensus has been reached regarding PVT treatment in terms of timing and type of interventions as well as type and duration of anticoagulation. METHODS Computerized literature search as well as discussion with experts in the field. CONCLUSIONS Management of PVT is complex, as many variables affect which treatments can be used. Anticoagulation appears to be the optimal first-line treatment in patients with acute PVT but without bleeding varices or mesenteric ischemia. Minimally invasive treatments include various methods of mechanical thrombectomy, chemical thrombolysis, and transjugular intrahepatic portosystemic shunt (TIPS) placement with or without variceal embolization. Definitive recommendations are difficult due to lack of high quality data and continued research is needed to evaluate the efficacy of different anticoagulants as well as the timing and use of various minimally invasive therapies in specific circumstances.
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Affiliation(s)
- Sameer Gadani
- Imaging Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Sasan Partovi
- Imaging Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Abraham Levitin
- Imaging Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Nicholas Zerona
- Imaging Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Shreya Sengupta
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Giuseppe D’Amico
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Teresa Diago Uso
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - K. V. Narayanan Menon
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Cristiano Quintini
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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15
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Luther J, Friedman LS. Management of Thrombocytopenia and Coagulopathy in Patients with Chronic Liver Disease Undergoing Therapeutic Endoscopic Interventions. Clin Liver Dis 2022; 26:1-12. [PMID: 34802655 DOI: 10.1016/j.cld.2021.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Management of coagulopathy in patients with advanced liver disease undergoing therapeutic endoscopic procedures is complex. Improvements in the understanding of hemostasis at a physiologic level have highlighted the inaccuracy of currently available clinical tests, like platelet count and prothrombin time, in estimating hemostasis in patients with cirrhosis. With identification of novel factors that contribute to bleeding risk in patients with cirrhosis, there is a dearth of clinical trial data that account for all potentially relevant factors and that examine interventions to reduce bleeding risk. Precise recommendations regarding transfusion strategies based on hemostatic test results in patients with cirrhosis are impractical.
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Affiliation(s)
- Jay Luther
- MGH Alcohol Liver Center, Boston, MA, USA; Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Blake 4, 55 Fruit Street, Boston, MA 02114, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Lawrence S Friedman
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Blake 4, 55 Fruit Street, Boston, MA 02114, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA; Department of Medicine, Newton-Wellesley Hospital, Newton, MA, USA; Department of Medicine, Tufts University School of Medicine, Boston, MA, USA.
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16
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Procedural bleeding risk, rather than conventional coagulation tests, predicts procedure related bleeding in cirrhosis. Eur J Gastroenterol Hepatol 2022; 34:192-199. [PMID: 32976185 DOI: 10.1097/meg.0000000000001948] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Standard coagulation parameters are used to guide prophylactic blood product transfusion prior to invasive procedures in cirrhotic patients despite limited high-quality evidence. AIMS We aimed to describe coagulation parameters and prophylactic blood product use in cirrhotic patients having invasive procedures, and the influence of both on periprocedural bleeding. METHODS We conducted a cohort study of cirrhotic patients undergoing invasive procedures at a referral hospital. Procedures were classified into low or moderate-high bleeding risk. Prophylactic blood component was defined as fresh frozen plasma, cryoprecipitate or platelet transfusion prior to procedures. Univariate and multivariate logistic regression was performed to identify factors associated with procedure-related bleeding. RESULTS We identified 566 procedures in 233 cirrhotic patients. Prophylactic blood product was given before 16% of high-risk and 11% of low-risk procedures (P = 0.18). Eight (8.3%) high-risk procedures were complicated by postprocedural bleeding, six of which occurred in patients without significant coagulopathy. The bleeding rate for low-risk procedures was 0.4%. For patients with international normalized ratio >1.5, platelet count <50 x 109/L, or both, the rate of bleeding was comparable between those given and not given prophylactic blood products (3.1 vs. 1.9%; P = 0.63). After adjusting for age, sex, platelet count, international normalized ratio, acute kidney injury, sepsis and model of end-stage liver disease, the only factor significantly predicting procedure-related bleeding was the procedural bleeding risk category (P < 0.01). CONCLUSIONS Procedure-related bleeding in cirrhotic patients cannot be accurately predicted by INR or platelet count, nor prevented by blood component prophylaxis using these parameters. Procedure-related bleeding is best predicted by the bleeding risk status of procedures.
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17
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Licata A, Zerbo M, Como S, Cammilleri M, Soresi M, Montalto G, Giannitrapani L. The Role of Vitamin Deficiency in Liver Disease: To Supplement or Not Supplement? Nutrients 2021; 13:nu13114014. [PMID: 34836267 PMCID: PMC8620546 DOI: 10.3390/nu13114014] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 10/28/2021] [Accepted: 11/02/2021] [Indexed: 12/12/2022] Open
Abstract
Over the past few years, growing interest has been shown for the impact of dietary requirements and nutritional factors on chronic diseases. As a result, nutritional programs have been reinforced by public health policies. The precise role of micronutrients in chronic liver disease is currently receiving particular attention since abnormalities in vitamin levels are often detected. At present, treatment programs are focused on correcting vitamin deficiencies, which are frequently correlated to higher rates of comorbidities with poor outcomes. The literature reviewed here indicates that liver diseases are often related to vitamin disorders, due to both liver impairment and abnormal intake. More specific knowledge about the role of vitamins in liver disease is currently emerging from various results and recent evidence. The most significant benefits in this area may be observed when improved vitamin intake is combined with a pharmacological treatment that may also affect the progression of the liver disease, especially in the case of liver tumors. However, further studies are needed.
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Affiliation(s)
- Anna Licata
- Internal Medicine & Hepatology Section, Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties—PROMISE, University of Palermo Medical School, 90127 Palermo, Italy; (M.Z.); (S.C.); (M.C.); (M.S.); (G.M.); (L.G.)
- Correspondence: ; Tel.: +39-091-655-2280; Fax: +39-091-655-2156
| | - Maddalena Zerbo
- Internal Medicine & Hepatology Section, Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties—PROMISE, University of Palermo Medical School, 90127 Palermo, Italy; (M.Z.); (S.C.); (M.C.); (M.S.); (G.M.); (L.G.)
| | - Silvia Como
- Internal Medicine & Hepatology Section, Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties—PROMISE, University of Palermo Medical School, 90127 Palermo, Italy; (M.Z.); (S.C.); (M.C.); (M.S.); (G.M.); (L.G.)
| | - Marcella Cammilleri
- Internal Medicine & Hepatology Section, Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties—PROMISE, University of Palermo Medical School, 90127 Palermo, Italy; (M.Z.); (S.C.); (M.C.); (M.S.); (G.M.); (L.G.)
| | - Maurizio Soresi
- Internal Medicine & Hepatology Section, Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties—PROMISE, University of Palermo Medical School, 90127 Palermo, Italy; (M.Z.); (S.C.); (M.C.); (M.S.); (G.M.); (L.G.)
| | - Giuseppe Montalto
- Internal Medicine & Hepatology Section, Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties—PROMISE, University of Palermo Medical School, 90127 Palermo, Italy; (M.Z.); (S.C.); (M.C.); (M.S.); (G.M.); (L.G.)
| | - Lydia Giannitrapani
- Internal Medicine & Hepatology Section, Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties—PROMISE, University of Palermo Medical School, 90127 Palermo, Italy; (M.Z.); (S.C.); (M.C.); (M.S.); (G.M.); (L.G.)
- Institute for Biochemical Research and Innovation, National Research Council (CNR), 90146 Palermo, Italy
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18
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Zhang YR, Wang H, Zhou N, Zhang YD, Lin Y, Wu LY, Wei SF, Ma YY, Wang CX. A Multidisciplinary Team Approach to the Treatment of Liver Cirrhosis. J Inflamm Res 2021; 14:5443-5450. [PMID: 34712056 PMCID: PMC8548059 DOI: 10.2147/jir.s328334] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 08/19/2021] [Indexed: 12/16/2022] Open
Abstract
Objective To explore the feasibility of treating cirrhosis using a multidisciplinary team approach (MDT) and to pinpoint the key factors influencing its implementation. Methods The data of 307 patients with decompensated cirrhosis were studied retrospectively. Patients who received more than two treatment measures were assigned to the MDT group (n=228), and patients who received symptomatic medical drug treatment only were assigned to the traditional treatment group (n=79). The follow-up period ranged from 4 to 10 years, and the average follow-up period was 5.7 years. The results of the biochemical tests for hepatitis B virus deoxyribonucleic acid, hepatitis C virus ribonucleic acid, and autoantibodies to liver disease were analyzed. Results The differences in gender and Child-Pugh grade of liver function between the two groups were not statistically significant. The MDT group had obvious advantages over the traditional treatment group in occupational composition, etiology composition, 5-year survival rate and annual hospitalization times. The leading causes of death in the MDT group, in descending order, were liver cancer, infection, mesenteric thrombosis, and non-hepatic disease, and, in the medical treatment group, they were liver failure, gastrointestinal bleeding, infection, and liver cancer. There was a significant statistical difference between the two groups (p < 0.05). In the multidisciplinary treatment, etiological treatment was the most widely used treatment, accounting for 79.8%, followed by endoscopic treatment (33.3%), peritoneal drainage and ascites reinfusion (25%), splenectomy combined with devascularization (11.4%) and stem cell transplantation and liver transplantation (1.8%). Conclusion An MDT can improve the efficacy and prognosis of patients with cirrhosis and improve patient compliance. After multi-disciplinary intervention, the mortality spectrum of long-term survival patients with cirrhosis changes, and the mortality rate of liver cancer and non-liver disease increases.
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Affiliation(s)
- Yue-Rong Zhang
- Department of Gastroenterology, University-Town Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Hui Wang
- Department of Infectious Diseases, The First People's Hospital of Lanzhou, Gansu, 730050, People's Republic of China
| | - Ning Zhou
- Department of Infectious Diseases, The First People's Hospital of Lanzhou, Gansu, 730050, People's Republic of China
| | - Yao-Di Zhang
- Department of Gastroenterology, University-Town Hospital of Chongqing Medical University, Chongqing, People's Republic of China.,Department of Infectious Diseases, The First People's Hospital of Lanzhou, Gansu, 730050, People's Republic of China
| | - Yan Lin
- Department of Gastroenterology, University-Town Hospital of Chongqing Medical University, Chongqing, People's Republic of China.,Department of Infectious Diseases, The First People's Hospital of Lanzhou, Gansu, 730050, People's Republic of China
| | - Li-Yang Wu
- Department of Gastroenterology, University-Town Hospital of Chongqing Medical University, Chongqing, People's Republic of China.,Department of Infectious Diseases, The First People's Hospital of Lanzhou, Gansu, 730050, People's Republic of China
| | - Shi-Fang Wei
- Department of Infectious Diseases, The First People's Hospital of Lanzhou, Gansu, 730050, People's Republic of China
| | - Yan-Yun Ma
- Department of Infectious Diseases, The First People's Hospital of Lanzhou, Gansu, 730050, People's Republic of China.,Department of Laboratory, The First People's Hospital of Lanzhou, Gansu, 730050, People's Republic of China
| | - Chun-Xia Wang
- Department of Laboratory, The First People's Hospital of Lanzhou, Gansu, 730050, People's Republic of China
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19
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Ronca V, Barabino M, Santambrogio R, Opocher E, Hodson J, Bertolini E, Birocchi S, Piccolo G, Battezzati P, Cattaneo M, Podda GM. Impact of Platelet Count on Perioperative Bleeding in Patients With Cirrhosis Undergoing Surgical Treatments of Liver Cancer. Hepatol Commun 2021; 6:423-434. [PMID: 34716696 PMCID: PMC8793986 DOI: 10.1002/hep4.1806] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 07/20/2021] [Accepted: 07/26/2021] [Indexed: 12/14/2022] Open
Abstract
In patients with cirrhosis with severe thrombocytopenia (platelet count [PC] <50 × 109/L) and undergoing invasive procedures, it is common clinical practice to increase the PC with platelet transfusions or thrombopoietin receptor agonists to reduce the risk of major periprocedural bleeding. The aim of our study was to investigate the association between native PC and perioperative bleeding in patients with cirrhosis undergoing surgical procedures for the treatment of hepatocellular carcinoma (HCC). We retrospectively evaluated 996 patients with cirrhosis between 1996 and 2018 who underwent surgical treatments of HCC by liver resection (LR) or radiofrequency ablation (RFA) without prophylactic platelet transfusions. Patients were allocated to the following three groups based on PC: high (>100 × 109/L), intermediate (51‐100 × 109/L), and low (≤50 × 109/L). PC was also analyzed as a continuous covariate on multivariable analysis. The primary endpoint was major perioperative bleeding. The overall event rate of major perioperative bleeding was 8.9% and was not found to differ significantly between the high, intermediate, and low platelet groups (8.1% vs. 10.2% vs. 10.8%, P = 0.48). On multivariable analysis, greater age, aspartate aminotransferase, lower hemoglobin, and treatment with LR (vs. RFA) were found to be significant independent predictors of major perioperative bleeding, with associations with disease etiology and year of surgery also observed. After adjusting for these factors, the association between PC and major perioperative bleeding remained nonsignificant. Conclusion: Major perioperative bleeding was not significantly associated with PC in patients with cirrhosis undergoing surgical treatment of HCC, even when their PC was <50 × 109/L. With the limit of a retrospective analysis, our data do not support the recommendation of increasing PC in patients with severe thrombocytopenia in order to decrease their perioperative bleeding risk.
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Affiliation(s)
- Vincenzo Ronca
- Unità di Medicina IIAzienda Socio Sanitaria Territoriale (ASST) Santi Paolo e CarloDipartimento di Scienze della SaluteUniversità degli Studi di MilanoMilanoItaly
- Present address:
Liver Transplant and Hepatobiliary UnitUniversity Hospital of Birmingham National Health Service (NHS) Foundation TrustBirminghamUnited Kingdom
| | - Matteo Barabino
- Unità di Chirurgia EpatobilliareASST Santi Paolo e CarloDipartimento di Scienze della SaluteUniversità degli Studi di MilanoMilanoItaly
| | - Roberto Santambrogio
- Unità di Chirurgia EpatobilliareASST Santi Paolo e CarloDipartimento di Scienze della SaluteUniversità degli Studi di MilanoMilanoItaly
- Present address:
Unità di Chirurgia GeneraleASST Fatebenefratelli SaccoMilanoItaly
| | - Enrico Opocher
- Unità di Chirurgia EpatobilliareASST Santi Paolo e CarloDipartimento di Scienze della SaluteUniversità degli Studi di MilanoMilanoItaly
- Unità di Chirurgia IIASST Santi Paolo e CarloDipartimento di Scienze della SaluteUniversità degli Studi di MilanoMilanoItaly
| | - James Hodson
- Institute of Translational MedicineUniversity Hospitals Birmingham NHS Foundation TrustBirminghamUnited Kingdom
| | - Emanuela Bertolini
- Unità di GastroenterologiaASST Santi Paolo e CarloDipartimento di Scienze della SaluteUniversità degli Studi di MilanoMilanoItaly
| | - Simone Birocchi
- Unità di Medicina IIAzienda Socio Sanitaria Territoriale (ASST) Santi Paolo e CarloDipartimento di Scienze della SaluteUniversità degli Studi di MilanoMilanoItaly
| | - Gaetano Piccolo
- Unità di Chirurgia EpatobilliareASST Santi Paolo e CarloDipartimento di Scienze della SaluteUniversità degli Studi di MilanoMilanoItaly
| | - PierMaria Battezzati
- Unità di GastroenterologiaASST Santi Paolo e CarloDipartimento di Scienze della SaluteUniversità degli Studi di MilanoMilanoItaly
| | - Marco Cattaneo
- Unità di Medicina IIAzienda Socio Sanitaria Territoriale (ASST) Santi Paolo e CarloDipartimento di Scienze della SaluteUniversità degli Studi di MilanoMilanoItaly
| | - Gian Marco Podda
- Unità di Medicina IIAzienda Socio Sanitaria Territoriale (ASST) Santi Paolo e CarloDipartimento di Scienze della SaluteUniversità degli Studi di MilanoMilanoItaly
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20
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Ren W, Zhang J, Chen Y, Wen M, Su Y, Zhao Y, Lu S, Wu J. Evaluation of Coagulation, Fibrinolysis and Endothelial Biomarkers in Cirrhotic Patients With or Without Portal Venous Thrombosis. Clin Appl Thromb Hemost 2021; 26:1076029620982666. [PMID: 33356499 PMCID: PMC7768576 DOI: 10.1177/1076029620982666] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
To evaluate variations in coagulation, fibrinolysis and endothelial marker expression in cirrhotic patients and to explore their clinical value and predictive performance in cirrhotic patients with or without portal vein thrombosis (PVT), we performed a case-control study with 175 cirrhotic patients and 50 healthy individuals. 99 patients had PVT and another 76 patients did not. All participants were evaluated for plasma levels of conventional hemostatic markers. Thrombin-antithrombin complex (TAT), plasmin-α2-plasmin inhibitor complex (PIC), thrombomodulin (TM), tissue plasminogen activator inhibitor complex (t-PAIC), von Willebrand factor antigen (vWF: Ag) and coagulation factor Ⅷ (FⅧ: c) were also assessed and the ratio of TAT/t-PAIC was calculated. We analyzed differences in these biomarkers among the three groups and constructed receiver operating characteristic (ROC) curves. Patients with PVT exhibited significantly higher TAT and TAT/t-PAIC than cirrhotic patients without PVT (both P < 0.001). Areas under the curve (AUC) of ROC analyses for TAT and TAT/t-PAIC were 0.68 and 0.66, the cut-off levels were 1.55 ng/ml and 0.46, with sensitivities and specificities of 78.79% and 51.32% regarding TAT, 39.8% and 90.79% regarding TAT/t-PAIC. Levels of FⅧ: c and vWF: Ag in patients with PVT were significantly lower than those without PVT (p = 0.026 and p = 0.027, respectively). The AUCROC, cut-off level, sensitivity and specificity of FⅧ: c were 0.64, 111.1%, 66.67% and 60%, respectively. For vWF: Ag they were 0.61, 429%, 89.66% and 38.71%, respectively. Cirrhotic patients have disorders of coagulation, fibrinolysis and the endothelial system. TAT, TAT/t-PAIC, FⅧ: c and vWF: Ag can be used as potential biomarkers for predicting PVT in cirrhotic patients.
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Affiliation(s)
- Wenhua Ren
- Department of Clinical Laboratory, Beijing Jishuitan Hospital, Beijing, China
| | - Jing Zhang
- Department of Hepatology, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Yuying Chen
- Department of Laboratory Medicine, Peking University Fourth School of Clinical Medicine, Beijing Jishuitan Hospital, Xicheng District, Beijing, China
| | - Meng Wen
- Department of Clinical Laboratory, Beijing Jishuitan Hospital, Beijing, China
| | - Yu Su
- Department of Clinical Laboratory, Beijing Jishuitan Hospital, Beijing, China
| | - Yujing Zhao
- Department of Clinical Laboratory, Beijing Jishuitan Hospital, Beijing, China
| | - Shan Lu
- Department of Clinical Laboratory, Beijing Jishuitan Hospital, Beijing, China
| | - Jun Wu
- Department of Clinical Laboratory, Beijing Jishuitan Hospital, Beijing, China.,Department of Laboratory Medicine, Peking University Fourth School of Clinical Medicine, Beijing Jishuitan Hospital, Xicheng District, Beijing, China
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21
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Giannini EG, Kano T, Ochiai T, Bentley R, Shrestha P, Afdhal N. Bleeding events in lusutrombopag-treated thrombocytopenic patients. Eur J Clin Invest 2021; 51:e13503. [PMID: 33523482 PMCID: PMC8243945 DOI: 10.1111/eci.13503] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/22/2021] [Accepted: 01/26/2021] [Indexed: 12/12/2022]
Affiliation(s)
- Edoardo Giovanni Giannini
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, IRCCS-Ospedale Policlinico San Martino, Genoa, Italy
| | - Takeshi Kano
- Global Project Management Department, Shionogi & Co., Ltd., Osaka, Japan
| | | | - Roy Bentley
- US Global Market Access, Shionogi Inc., Florham Park, NJ, USA
| | - Pomy Shrestha
- Product Safety and Pharmacovigilance, Shionogi Inc., Florham Park, NJ, USA
| | - Nezam Afdhal
- Liver Center, Beth Israel Deaconess Medical Center, Boston, MA, USA
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22
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Alvaro D, Caporaso N, Giannini EG, Iacobellis A, Morelli M, Toniutto P, Violi F. Procedure-related bleeding risk in patients with cirrhosis and severe thrombocytopenia. Eur J Clin Invest 2021; 51:e13508. [PMID: 33539542 PMCID: PMC8244048 DOI: 10.1111/eci.13508] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 12/16/2020] [Accepted: 01/29/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Gaps of knowledge still exist about the potential association between severe thrombocytopenia and increased risk of procedure-associated bleeding in patients with liver disease. METHODS In this narrative review, we aimed at examining the association between procedure-related bleeding risk and platelet count in patients with cirrhosis and severe thrombocytopenia in various settings. We updated to 2020 a previously conducted literature search using MEDLINE/PubMed and EMBASE. The search string included clinical studies, adult patients with chronic liver disease and thrombocytopenia undergoing invasive procedures, any interventions and comparators, and haemorrhagic events of any severity as outcome. RESULTS The literature search identified 1276 unique publications, and 15 studies met the inclusion criteria and were analysed together with those identified by the previous search. Most of the new studies included in our analysis did not assess the association between post-procedural bleeding risk and platelet count alone in patients with chronic liver disease. Furthermore, some results could have been biased by prophylactic platelet transfusions. A few studies found that severe thrombocytopenia may be predictive of bleeding following percutaneous liver biopsy, dental extractions, percutaneous ablation of liver tumours and endoscopic polypectomy. CONCLUSIONS Currently available literature cannot support definitive conclusions about the appropriate target platelet counts to improve the risk of bleeding in cirrhotic patients who underwent invasive procedures; moreover, it showed enormous variability in the use of prophylactic platelet transfusions.
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Affiliation(s)
- Domenico Alvaro
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Nicola Caporaso
- Department of Clinical Medicine and Surgery, University of Naples 'Federico II', Naples, Italy
| | - Edoardo Giovanni Giannini
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, IRCCS-Ospedale Policlinico San Martino, Genoa, Italy
| | - Angelo Iacobellis
- Division of Gastroenterology, Fondazione IRCCS Casa Sollievo della Sofferenza, Foggia, Italy
| | | | - Pierluigi Toniutto
- Hepatology and Liver Transplantation Unit, Azienda Sanitaria Universitaria Integrata, Academic Hospital, Udine, Italy
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Zhou J, Liu C, Ma L, Chen J, Luo T, Li F, Wang J, Zeng X, Chen S. Complications and management of elective endoscopic cyanoacrylate injection with lauromacrogol for gastric varices. Eur J Gastroenterol Hepatol 2021; 33:680-685. [PMID: 33731585 DOI: 10.1097/meg.0000000000002099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To report the complications and evaluate the risk factors of elective endoscopic cyanoacrylate injection with lauromacrogol for gastric varices in cirrhotic patients. METHODS A total of 583 elective endoscopic tissue adhesives procedures were performed in 439 patients in our hospital from January 2015 to December 2016. The clinical characteristics and complications were retrospectively collected and evaluated. RESULTS The median age was 56 ± 11 years, and 290 (66.1%) patients were male. The main etiology of liver cirrhosis was hepatitis virus (63.3%). Two hundred fifty-nine (59.0%) patients were classified as Child-Pugh Class A. Bleeding occurred in 44 patients (7.5%) during procedures. Two patients developed distant embolism (0.5%; one pulmonary, one cerebra). In perioperative period, fever was a common complication; however, only 16 cases had high fever and one case had sepsis. Bleeding was observed in 7 (1.2%) patients. Overall incidence of the major perioperative complication was 3.8%. The major postoperative complication rate was 10.4% (60/582, 26 rebleeds, 27 ascites increase, 12 new-onset portal vein thrombosis). The complication-related death was 1.6% (one death from embolism, five deaths from rebleeding, one death from refractory ascites). Injection point was the only factor related to the major perioperative complications [odds ratio (OR) = 1.581, 95% CI, 1.086-2.301; P < 0.05]. Etiology of cirrhosis and injection point were independent risk factors of major postoperative complications (OR = 1.830, 95% CI, 1.005-3.331, P = 0.048; OR = 1.373, 95% CI, 1.089-1.731, P = 0.007). CONCLUSION The incidence of complications after elective endoscopic cyanoacrylate injection with lauromacrogol for gastric varices was low. The injection point was the risk factor for both perioperative and postoperative complications.
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Affiliation(s)
- Ji Zhou
- Department of Gastroenterology and Hepatology
| | - Chengfeng Liu
- Department of Gastroenterology and Hepatology
- Liver Cancer Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Lili Ma
- Department of Endoscopy Center
| | - Jie Chen
- Department of Gastroenterology and Hepatology
| | | | - Feng Li
- Department of Gastroenterology and Hepatology
| | - Jian Wang
- Department of Gastroenterology and Hepatology
| | | | - Shiyao Chen
- Department of Gastroenterology and Hepatology
- Department of Endoscopy Center
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von Meijenfeldt FA, van den Boom BP, Adelmeijer J, Roberts LN, Lisman T, Bernal W. Prophylactic fresh frozen plasma and platelet transfusion have a prothrombotic effect in patients with liver disease. J Thromb Haemost 2021; 19:664-676. [PMID: 33219597 PMCID: PMC7986736 DOI: 10.1111/jth.15185] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 11/10/2020] [Accepted: 11/16/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Patients with liver disease acquire complex changes in their hemostatic system, resulting in prolongation of the international normalized ratio and thrombocytopenia. Abnormalities in these tests are commonly corrected with fresh frozen plasma (FFP) or platelet transfusions before invasive procedures. Whether these prophylactic transfusions are beneficial and truly indicated is increasingly debated. In this study, we studied ex vivo effects of FFP and platelet transfusions in patients with liver disease-associated hemostatic changes in a real-life clinical setting. METHODS We included 19 patients who were deemed to require prophylactic FFP transfusion by their treating physician and 13 that were prescribed platelet transfusion before a procedure. Hemostatic status was assessed in blood samples taken before and after transfusion and compared with healthy controls (n = 20). RESULTS Ex vivo thrombin generation was preserved in patients with liver disease before FFP transfusion. Following FFP transfusion, both in and ex vivo thrombin generation significantly increased, as evidenced by a 92% and 38% increase in thrombin-antithrombin and prothrombin fragment 1 + 2 levels, respectively, and a 20% increase in endogenous thrombin potential. Platelet counts increased from 28 [21-41] × 109 /L before to 43 [39-64] × 109 /L after platelet transfusion (P < .01), and was accompanied by increases in in vivo markers of hemostatic activation. CONCLUSIONS FFP and platelet transfusion resulted in increased thrombin generation and platelet counts in patients with liver disease, indicating a prothrombotic effect. However, whether all transfusions were truly indicated and had a clinically relevant effect is questionable.
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Affiliation(s)
- Fien A. von Meijenfeldt
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver TransplantationDepartment of SurgeryUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - Bente P. van den Boom
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver TransplantationDepartment of SurgeryUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - Jelle Adelmeijer
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver TransplantationDepartment of SurgeryUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - Lara N. Roberts
- King's Thrombosis CentreDepartment of Haematological MedicineKing's College HospitalLondonUK
| | - Ton Lisman
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver TransplantationDepartment of SurgeryUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - William Bernal
- Liver Intensive Care UnitInstitute of Liver StudiesKing College HospitalLondonUK
- Institute of Liver StudiesKing College HospitalLondonUK
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Zanetto A, Rinder HM, Senzolo M, Simioni P, Garcia‐Tsao G. Reduced Clot Stability by Thromboelastography as a Potential Indicator of Procedure-Related Bleeding in Decompensated Cirrhosis. Hepatol Commun 2021; 5:272-282. [PMID: 33553974 PMCID: PMC7850311 DOI: 10.1002/hep4.1641] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 10/10/2020] [Accepted: 10/27/2020] [Indexed: 02/06/2023] Open
Abstract
In patients with decompensated cirrhosis, procedure-related bleeding is a potentially lethal complication. Routine coagulation tests such as international normalized ratio and platelet count do not predict bleeding risk. We investigated whether thromboelastography (TEG) can identify patients with cirrhosis who are at risk of procedure-related bleeding. As a part of a prospective study on hemostasis in decompensated cirrhosis, patients had TEG performed on admission and were followed prospectively during hospitalization for the development of procedure-related bleeding. Eighty patients with cirrhosis were included. Among the 72 who had procedures performed, 7 had procedure-related bleeding, which was major in three cases (two following paracentesis and one following thoracentesis). Conventional coagulation tests were comparable between bleeding and nonbleeding patients, whereas TEG parameters of k-time (4.5 minutes vs. 2.2 minutes; P = 0.02), α-angle (34° vs. 59°; P = 0.003), and maximum amplitude (37 mm vs. 50 mm; P = 0.004) were significantly different (all indicative of hypocoagulability). TEG maximum amplitude (MA), a marker of overall clot stability, accurately discriminated between patients who had major, life-threatening bleeding (all with MA < 30 mm) and those who had mild or no bleeding (all with MA > 30 mm), whereas a platelet count < 50 × 109/L could not discriminate between bleeding (minor or major) and nonbleeding patients. Conclusion: In a prospective cohort of hospitalized patients with decompensated cirrhosis, TEG parameters associated with hypocoagulability appeared to predict procedure-related bleeding, particularly a TEG MA < 30 mm. If results are validated in a larger cohort, this could be a threshold to identify patients with decompensated cirrhosis at higher risk for procedure-related bleeding, in whom to consider preprocedural prophylaxis.
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Affiliation(s)
- Alberto Zanetto
- Digestive Disease SectionInternal MedicineYale School of MedicineNew HavenCTUSA
- VA‐Connecticut Healthcare SystemWest HavenCTUSA
- Gastroenterology and Multivisceral Transplant UnitDepartment of Surgery, Oncology, and GastroenterologyPadova University HospitalPadovaItaly
| | - Henry M. Rinder
- Laboratory MedicineYale School of MedicineNew HavenCTUSA
- HematologyInternal MedicineYale School of MedicineNew HavenCTUSA
| | - Marco Senzolo
- Gastroenterology and Multivisceral Transplant UnitDepartment of Surgery, Oncology, and GastroenterologyPadova University HospitalPadovaItaly
| | - Paolo Simioni
- Thrombotic and Hemorrhagic Diseases UnitGeneral Internal MedicinePadova University HospitalPadovaItaly
| | - Guadalupe Garcia‐Tsao
- Digestive Disease SectionInternal MedicineYale School of MedicineNew HavenCTUSA
- VA‐Connecticut Healthcare SystemWest HavenCTUSA
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Violi F, Loffredo L, Pastori D. Anticoagulation in patients with advanced liver disease: an open issue. Intern Emerg Med 2021; 16:61-71. [PMID: 33073317 DOI: 10.1007/s11739-020-02526-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 09/30/2020] [Indexed: 12/14/2022]
Abstract
Liver disease has been long considered as a risk factor for bleeding for the presence of prolongation of global tests of clotting activation and low platelet count. For this reason, the use of anticoagulants in patients with liver disease and an indication to anticoagulation, such as atrial fibrillation of venous thrombosis, has been poorly considered. Furthermore, recent studies underscored the fact that patients with chronic liver disease may experience thrombosis in portal as well as systemic circulation and treatment with anticoagulants should be considered. The introduction of direct oral anticoagulants has increased therapeutic options for thromboprophylaxis; however, evidence on their safety and efficacy in specific populations, such as patients with liver disease, is still scarce and needs further investigation. Thus, atrial fibrillation patients with coexistent liver disease have been excluded from clinical trials with direct oral anticoagulants. Here, we provide an overview on mechanisms of thrombosis in patients with advanced chronic liver disease and a summary of evidence on the use of oral anticoagulants in patients with liver disease and portal vein thrombosis or atrial fibrillation.
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Affiliation(s)
- Francesco Violi
- Department of Clinical, Internal, Anesthesiologic and Cardiovascular Sciences, I Clinica Medica, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy.
- Mediterranea Cardiocentro, via Orazio 2, 80122, Naples, Italy.
| | - Lorenzo Loffredo
- Department of Clinical, Internal, Anesthesiologic and Cardiovascular Sciences, I Clinica Medica, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Daniele Pastori
- Department of Clinical, Internal, Anesthesiologic and Cardiovascular Sciences, I Clinica Medica, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
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Ahmed Z, Singal AK, Kamath PS. Anticoagulants and Their Monitoring. Clin Liver Dis (Hoboken) 2020; 16:146-148. [PMID: 33163166 PMCID: PMC7609710 DOI: 10.1002/cld.946] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 02/11/2020] [Indexed: 02/04/2023] Open
Affiliation(s)
- Zunirah Ahmed
- Division of Gastroenterology and HepatologyBaylor College of MedicineHoustonTX
| | - Ashwani K. Singal
- Division of Transplant HepatologyAvera Transplant InstituteUniversity of South Dakota Sanford School of MedicineSioux FallsSD
| | - Patrick S. Kamath
- Division of Gastroenterology and HepatologyMayo Clinic and Mayo Medical SchoolRochesterMN
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Visweshwar N, Zhang Y, Joseph H, Jaglal M, Ayala I. Chronic pain in patients with hemophilia: is it preventable? Blood Coagul Fibrinolysis 2020; 31:346-352. [PMID: 32815911 DOI: 10.1097/mbc.0000000000000939] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
: Current management of chronic pain in patients with hemophilia (PWH) focuses on pain relief with analgesics and symptom control. The clinical practice of managing chronic pain in PWH varies considerably across hemophilia treatment centers. Here, we aim to study the appropriate intervention of hemophilic arthropathy for prevention and treatment of chronic pain in PWH. Medline, Embase, Cochrane databases were searched for randomized controlled trials, and the European Hemophilia Therapy Standardization Board, The World Federation of Hemophilia, Nordic Hemophilia Guidelines, American Society of the International Pain Physicians and the Medical and Scientific Advisory Council guidelines were studied through November 2019 for chronic pain in PWH for a narrative review. We found no standardized approach for the prevention and management of chronic pain in PWH. Evidence suggests that prophylactic factor concentrate therapy, programmed exercise and educational intervention may help PWH manage their chronic pain.
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Affiliation(s)
| | - Yumeng Zhang
- Department Internal Medicine, University of South Florida
| | | | | | - Irmel Ayala
- Hemophilia Treatment Center, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
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29
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Rashidi-Alavijeh J, Ceylan AS, Wedemeyer H, Kleefisch M, Willuweit K, Lange CM. Standard coagulation tests are superior to thromboelastometry in predicting outcome of patients with liver cirrhosis. PLoS One 2020; 15:e0236528. [PMID: 32722691 PMCID: PMC7386616 DOI: 10.1371/journal.pone.0236528] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 07/07/2020] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Jassin Rashidi-Alavijeh
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Ayse S. Ceylan
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Heiner Wedemeyer
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Martin Kleefisch
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Katharina Willuweit
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Christian M. Lange
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- * E-mail:
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30
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Zanetto A, Senzolo M, Blasi A. Perioperative management of antithrombotic treatment. Best Pract Res Clin Anaesthesiol 2020; 34:35-50. [PMID: 32334786 DOI: 10.1016/j.bpa.2020.01.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 12/13/2019] [Accepted: 01/06/2020] [Indexed: 01/10/2023]
Abstract
End-stage liver disease is characterized by multiple and complex alterations of hemostasis that are associated with an increased risk of both bleeding and thrombosis. Liver transplantation further challenges the feeble hemostatic balance of patients with decompensated cirrhosis, and the management of antithrombotic treatment during and after transplant surgery, which is particularly difficult. Bleeding was traditionally considered the major concern during and early after surgery, but it is increasingly recognized that transplant recipients may also develop thrombotic complications. Pathophysiology of hemostatic complications during and after transplantation is multifactorial and includes pre-, intra-, and postoperative risk factors. Risk stratification is important, as it helps the identification of high-risk recipients in whom antithrombotic prophylaxis should be considered. In recipients who develop thrombosis during or after surgery, prompt treatment is indicated to prevent graft failure, retransplantation, and death.
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Affiliation(s)
- Alberto Zanetto
- Gastroenterology, Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Padova, Italy
| | - Marco Senzolo
- Gastroenterology, Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Padova, Italy
| | - Annabel Blasi
- Anesthesia Department, Hospital Clinic de Barcelona, Barcelona, Spain.
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Noronha Ferreira C, Reis D, Cortez-Pinto H, Tato Marinho R, Gonçalves A, Palma S, Leite I, Rodrigues T, Pedro AJ, Alexandrino P, Serejo F, Sobral Dias M, Ferreira P, Vasconcelos M, Damião F, Xavier Brito L, Baldaia C, Fatela N, Ramalho F, Velosa J. Anticoagulation in Cirrhosis and Portal Vein Thrombosis Is Safe and Improves Prognosis in Advanced Cirrhosis. Dig Dis Sci 2019; 64:2671-2683. [PMID: 30852769 DOI: 10.1007/s10620-019-05572-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Accepted: 02/28/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND The role of portal vein thrombosis (PVT) in the natural history of cirrhosis is controversial. AIMS We analyzed the safety and effect of anticoagulant therapy (AT) on PVT recanalization and orthotopic liver transplant (OLT)-free survival. METHODS Eighty consecutive patients from a prospective registry of cirrhosis and non-tumoral PVT at a tertiary center were analyzed. AT effect on PVT recanalization and OLT-free survival was determined by time-dependent Cox regression analysis. RESULTS Average MELD score was 15 ± 7. Portal hypertension-related complications at PVT diagnosis were present in 65 (81.3%) patients. Isolated portal vein trunk/branch thrombosis was present in 53 (66.3%) patients. AT was started in 37 patients. AT was stopped in 17 (45.9%) patients, in 4 (10.8%) due to bleeding events. No variceal bleeding occurred while on AT. Anticoagulation was restarted in 6/17 (35.2%) patients due to rethrombosis. In 67 patients with adequate follow-up imaging, AT significantly increased the rate of PVT recanalization compared with those who did not receive anticoagulation [51.4% (18/35) vs 6/32 (18.8%), p = 0.005]. OLT-free survival after a median follow-up of 25 (1-146) months was 32 (40%). Although there was no significant effect of AT on overall OLT-free survival, OLT-free survival was higher among patients with MELD ≥ 15 receiving AT compared to those who did not (p = 0.011). Baseline MELD at PVT detection independently predicted PVT recanalization (HR 1.11, 95% CI 1.01-1.21, p = 0.027) and mortality/OLT (HR 1.12, 95% CI 1.05-1.19, p < 0.001). CONCLUSIONS Although AT did not improve overall OLT-free survival, it was associated with higher survival in advanced cirrhosis. Anticoagulation increased PVT recanalization and should be maintained after PVT recanalization to avoid rethrombosis.
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Affiliation(s)
- Carlos Noronha Ferreira
- Serviço De Gastrenterologia e Hepatologia, Hospital de Santa Maria - Centro Hospitalar Universitário Lisboa Norte, Avenida Egas Moniz, 1649-035, Lisbon, Portugal.
| | - Daniela Reis
- Serviço De Gastrenterologia e Hepatologia, Hospital de Santa Maria - Centro Hospitalar Universitário Lisboa Norte, Avenida Egas Moniz, 1649-035, Lisbon, Portugal
| | - Helena Cortez-Pinto
- Serviço De Gastrenterologia e Hepatologia, Hospital de Santa Maria - Centro Hospitalar Universitário Lisboa Norte, Avenida Egas Moniz, 1649-035, Lisbon, Portugal
| | - Rui Tato Marinho
- Serviço De Gastrenterologia e Hepatologia, Hospital de Santa Maria - Centro Hospitalar Universitário Lisboa Norte, Avenida Egas Moniz, 1649-035, Lisbon, Portugal
| | - Afonso Gonçalves
- Serviço De Imagiologia, Hospital de Santa Maria - Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Sónia Palma
- Serviço De Imagiologia, Hospital de Santa Maria - Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Inês Leite
- Serviço De Imagiologia, Hospital de Santa Maria - Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Tiago Rodrigues
- Serviço De Imagiologia, Hospital de Santa Maria - Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Ana Júlia Pedro
- Serviço De Medicina II, Hospital De Santa Maria - Centro Hospitalar Lisboa, Lisbon, Portugal
| | - Paula Alexandrino
- Serviço De Gastrenterologia e Hepatologia, Hospital de Santa Maria - Centro Hospitalar Universitário Lisboa Norte, Avenida Egas Moniz, 1649-035, Lisbon, Portugal
| | - Fátima Serejo
- Serviço De Gastrenterologia e Hepatologia, Hospital de Santa Maria - Centro Hospitalar Universitário Lisboa Norte, Avenida Egas Moniz, 1649-035, Lisbon, Portugal
| | - Margarida Sobral Dias
- Serviço De Gastrenterologia e Hepatologia, Hospital de Santa Maria - Centro Hospitalar Universitário Lisboa Norte, Avenida Egas Moniz, 1649-035, Lisbon, Portugal
| | - Paula Ferreira
- Serviço De Gastrenterologia e Hepatologia, Hospital de Santa Maria - Centro Hospitalar Universitário Lisboa Norte, Avenida Egas Moniz, 1649-035, Lisbon, Portugal
| | - Mariana Vasconcelos
- Serviço De Gastrenterologia e Hepatologia, Hospital de Santa Maria - Centro Hospitalar Universitário Lisboa Norte, Avenida Egas Moniz, 1649-035, Lisbon, Portugal
| | - Filipe Damião
- Serviço De Gastrenterologia e Hepatologia, Hospital de Santa Maria - Centro Hospitalar Universitário Lisboa Norte, Avenida Egas Moniz, 1649-035, Lisbon, Portugal
| | - Leonor Xavier Brito
- Serviço De Gastrenterologia e Hepatologia, Hospital de Santa Maria - Centro Hospitalar Universitário Lisboa Norte, Avenida Egas Moniz, 1649-035, Lisbon, Portugal
| | - Cilenia Baldaia
- Serviço De Gastrenterologia e Hepatologia, Hospital de Santa Maria - Centro Hospitalar Universitário Lisboa Norte, Avenida Egas Moniz, 1649-035, Lisbon, Portugal
| | - Narcisa Fatela
- Serviço De Gastrenterologia e Hepatologia, Hospital de Santa Maria - Centro Hospitalar Universitário Lisboa Norte, Avenida Egas Moniz, 1649-035, Lisbon, Portugal
| | - Fernando Ramalho
- Serviço De Gastrenterologia e Hepatologia, Hospital de Santa Maria - Centro Hospitalar Universitário Lisboa Norte, Avenida Egas Moniz, 1649-035, Lisbon, Portugal
| | - José Velosa
- Serviço De Gastrenterologia e Hepatologia, Hospital de Santa Maria - Centro Hospitalar Universitário Lisboa Norte, Avenida Egas Moniz, 1649-035, Lisbon, Portugal
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Kabbani AR, Tergast TL, Manns MP, Maasoumy B. [Treatment strategies for acute-on-chronic liver failure]. Med Klin Intensivmed Notfmed 2019; 116:3-16. [PMID: 31463674 PMCID: PMC7095250 DOI: 10.1007/s00063-019-00613-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 07/17/2019] [Accepted: 07/31/2019] [Indexed: 12/15/2022]
Abstract
Acute-on-chronic liver failure (ACLF) is a newly defined syndrome in patients with liver cirrhosis characterized by acute hepatic decompensation (jaundice, ascites, hepatic encephalopathy, bacterial infection and gastrointestinal bleeding), single or multiple organ failure and a high mortality (>15% within 28 days). The affected organ systems include not only the liver but also the circulation, lungs, kidneys, brain and/or coagulation. Pathophysiologically decisive is an uncontrolled inflammation that is induced by specific triggers and on the basis of previously (possibly not diagnosed) compensated as well as already decompensated liver cirrhosis leads to a severe systemic clinical syndrome, ACLF. The course during the first 72 h is decisive for the prognosis. In addition to treatment of the respective organ or system failure, the underlying triggers should be quickly identified and if necessary specifically treated. Often, however, these cannot (no longer) be determined with any certainty, in particular recent alcohol consumption as well as bacterial and viral infections play an important role. A specific treatment for the ACLF is (currently) not established. Some experimental approaches are currently being tested, including administration of granulocyte colony-stimulating factor (GCSF). Additionally, suitable patients should be presented to a liver transplantation center in a timely manner.
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Affiliation(s)
| | | | | | - B Maasoumy
- Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland.
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Turco L, de Raucourt E, Valla DC, Villa E. Anticoagulation in the cirrhotic patient. JHEP Rep 2019; 1:227-239. [PMID: 32039373 PMCID: PMC7001584 DOI: 10.1016/j.jhepr.2019.02.006] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 01/29/2019] [Accepted: 02/11/2019] [Indexed: 12/11/2022] Open
Abstract
In the past, patients with liver cirrhosis were thought to be prone to increased bleeding risk. However, those with compensated liver cirrhosis actually have normal coagulative balance, which can become altered when liver function worsens, or infection, bleeding, or acute kidney insufficiency occur. When this happens, it is now recognized that patients with liver cirrhosis are at higher risk of thrombotic rather than haemorrhagic complications. Anticoagulation plays a favourable role both when used therapeutically or prophylactically. Successful anticoagulation is associated with a lower rate of decompensation and with improved survival. To date, treatment has involved the use of low molecular weight heparins and vitamin K antagonists. Preliminary data suggest that novel non-vitamin K antagonist oral anticoagulants can be used safely in patients with liver cirrhosis.
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Affiliation(s)
- Laura Turco
- Department of Gastroenterology, University of Modena & Reggio Emilia and Azienda Ospedaliero-Universitaria di Modena, Italy.,PhD Program in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Emmanuelle de Raucourt
- Service d'hématologie biologique, CHU Paris Nord-Val de Seine - Hôpital Beaujon, Clichy, France
| | | | - Erica Villa
- Department of Gastroenterology, University of Modena & Reggio Emilia and Azienda Ospedaliero-Universitaria di Modena, Italy
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Fortea JI, Puente Á, Ezcurra I, Cuadrado A, Arias-Loste MT, Cabezas J, Llerena S, Iruzubieta P, Rodríguez-Lope C, Huelin P, Casafont F, Fábrega E, Crespo J. Management of haemostatic alterations and associated disorders in cirrhosis in Spain: A national survey. Dig Liver Dis 2019; 51:95-103. [PMID: 29960901 DOI: 10.1016/j.dld.2018.06.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Revised: 05/17/2018] [Accepted: 06/01/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Knowledge of haematological abnormalities in cirrhosis has greatly improved in recent years. AIMS To evaluate how Spanish Digestive Disease specialists manage haemostatic alterations and associated disorders in patients with cirrhosis. METHODS All members of the Spanish Association for the Study of the Liver and Spanish Society of Digestive Pathology were invited to fill in a web-based questionnaire. RESULTS 135 professionals, 93 hepatologists and 42 non-hepatologists responded to the survey. The concept of rebalanced haemostasis was known by 74.8% of them. Most specialists corrected the INR and thrombocytopenia before invasive procedures with moderate risk of bleeding or major surgery and in severe gastrointestinal bleeding. The threshold of platelets and, especially, INR used to administer blood products varied greatly. Pharmacological prophylaxis of venous thromboembolism prevailed, but it was highly dependent on the INR and platelet figures. Most participants initiated anticoagulation regardless of the degree of portal vein thrombosis, even in patients ineligible for transplantation. In potential candidates, only 56% maintained it indefinitely or until liver transplantation. No major differences between hepatologists and non-hepatologists were found. CONCLUSIONS A significant variability and certain deviation from current guidelines was observed among Spanish Digestive Disease specialists regarding management of haemostatic alterations and associated disorders in cirrhosis.
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Affiliation(s)
- José Ignacio Fortea
- Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander, Spain; Marqués de Valdecilla Research Institute (IDIVAL), Santander, Spain; CIBER of Hepatic and Digestive Diseases (CIBERehd), Madrid, Spain.
| | - Ángela Puente
- Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander, Spain; Marqués de Valdecilla Research Institute (IDIVAL), Santander, Spain; CIBER of Hepatic and Digestive Diseases (CIBERehd), Madrid, Spain
| | - Iranzu Ezcurra
- Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander, Spain
| | - Antonio Cuadrado
- Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander, Spain; Marqués de Valdecilla Research Institute (IDIVAL), Santander, Spain; CIBER of Hepatic and Digestive Diseases (CIBERehd), Madrid, Spain
| | - María Teresa Arias-Loste
- Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander, Spain; Marqués de Valdecilla Research Institute (IDIVAL), Santander, Spain; CIBER of Hepatic and Digestive Diseases (CIBERehd), Madrid, Spain
| | - Joaquín Cabezas
- Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander, Spain; Marqués de Valdecilla Research Institute (IDIVAL), Santander, Spain; CIBER of Hepatic and Digestive Diseases (CIBERehd), Madrid, Spain
| | - Susana Llerena
- Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander, Spain; Marqués de Valdecilla Research Institute (IDIVAL), Santander, Spain; CIBER of Hepatic and Digestive Diseases (CIBERehd), Madrid, Spain
| | - Paula Iruzubieta
- Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander, Spain; Marqués de Valdecilla Research Institute (IDIVAL), Santander, Spain; CIBER of Hepatic and Digestive Diseases (CIBERehd), Madrid, Spain
| | - Carlos Rodríguez-Lope
- Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander, Spain; Marqués de Valdecilla Research Institute (IDIVAL), Santander, Spain; CIBER of Hepatic and Digestive Diseases (CIBERehd), Madrid, Spain
| | - Patricia Huelin
- Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander, Spain; Marqués de Valdecilla Research Institute (IDIVAL), Santander, Spain; CIBER of Hepatic and Digestive Diseases (CIBERehd), Madrid, Spain
| | - Fernando Casafont
- Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander, Spain; Marqués de Valdecilla Research Institute (IDIVAL), Santander, Spain; CIBER of Hepatic and Digestive Diseases (CIBERehd), Madrid, Spain
| | - Emilio Fábrega
- Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander, Spain; Marqués de Valdecilla Research Institute (IDIVAL), Santander, Spain; CIBER of Hepatic and Digestive Diseases (CIBERehd), Madrid, Spain
| | - Javier Crespo
- Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander, Spain; Marqués de Valdecilla Research Institute (IDIVAL), Santander, Spain; CIBER of Hepatic and Digestive Diseases (CIBERehd), Madrid, Spain
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35
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Blasi A, Calvo A, Prado V, Reverter E, Reverter JC, Hernández-Tejero M, Aziz F, Amoros A, Cardenas A, Fernández J. Coagulation Failure in Patients With Acute-on-Chronic Liver Failure and Decompensated Cirrhosis: Beyond the International Normalized Ratio. Hepatology 2018; 68:2325-2337. [PMID: 29790188 DOI: 10.1002/hep.30103] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 05/14/2018] [Indexed: 12/22/2022]
Abstract
Balanced hemostasis with hypocoagulable and hypercoagulable features may occur in acute-on-chronic liver failure (ACLF). The characteristics and prognostic impact of the coagulation profile in ACLF are unknown. Consecutive patients with ACLF (n = 36) and acute decompensation (AD; n = 24) were included. Blood samples for thromboelastometry (TE) were obtained at admission and 72 hours thereafter. The coagulation profile was evaluated in patients with and without ACLF and in those with and without systemic inflammatory response syndrome. The impact of the coagulation profile on transfusion requirements, bleeding events, and short-term survival was assessed. At admission, patients with ACLF showed more hypocoagulable characteristics compared to AD subjects, with prolonged time to initial fibrin formation and clot formation time and decreased maximum clot firmness and alpha-angle values. TE parameters worsened at 72 hours in ACLF but improved in patients with AD. Prevalence of a hypocoagulable profile (three or more TE parameters outside range) was significantly higher in patients with ACLF either at admission (61% versus 29% in AD; P = 0.03) or during follow-up. Hypocoagulability correlated with systemic inflammation and was associated with higher 28-day (45% versus 16%; P = 0.02) and 90-day (52% versus 19%; P = 0.01) mortality rates but not with transfusion requirements or bleeding. Prolonged time to initial fibrin formation (extrinsic TE assay >80 seconds) and Model for End-Stage Liver Disease score at baseline were independent predictors of 28-day mortality. Conclusion: Patients with ACLF frequently show hypocoagulable features with prolonged time to initial fibrin formation and clot formation time and reduced clot firmness; these alterations worsen after admission, correlate with systemic inflammation, and translate into higher short-term mortality; hypofibrinolysis could contribute to organ failure in ACLF.
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Affiliation(s)
- Annabel Blasi
- Anesthesiology Department, Hospital Clínic, and University of Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS) y Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD)
| | - Andrea Calvo
- Anesthesiology Department, Hospital Clínic, and University of Barcelona, Spain
| | - Verónica Prado
- Liver Unit, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, and University of Barcelona
| | - Enric Reverter
- Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS) y Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD).,Liver Unit, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, and University of Barcelona
| | | | - María Hernández-Tejero
- Liver Unit, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, and University of Barcelona
| | - Fátima Aziz
- Liver Unit, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, and University of Barcelona
| | - Alex Amoros
- European Foundation for the Study of Chronic Liver Failure
| | - Andres Cardenas
- Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS) y Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD).,GI/Liver Unit, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, and University of Barcelona, Barcelona, Spain
| | - Javier Fernández
- Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS) y Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD).,Liver Unit, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, and University of Barcelona.,European Foundation for the Study of Chronic Liver Failure
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36
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Giannini EG, Bodini G, Furnari M, Marabotto E. Bleeding after paracentesis in patients with decompensated cirrhosis and acute kidney injury: The perfect storm. Liver Int 2018; 38:2101. [PMID: 30223302 DOI: 10.1111/liv.13962] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- Edoardo G Giannini
- Gastroenterology Unit, Department of Internal Medicine, Ospedale Policlinico San Martino-IRCCS per l'Oncologia, University of Genoa, Genoa, Italy
| | - Giorgia Bodini
- Gastroenterology Unit, Department of Internal Medicine, Ospedale Policlinico San Martino-IRCCS per l'Oncologia, University of Genoa, Genoa, Italy
| | - Manuele Furnari
- Gastroenterology Unit, Department of Internal Medicine, Ospedale Policlinico San Martino-IRCCS per l'Oncologia, University of Genoa, Genoa, Italy
| | - Elisa Marabotto
- Gastroenterology Unit, Department of Internal Medicine, Ospedale Policlinico San Martino-IRCCS per l'Oncologia, University of Genoa, Genoa, Italy
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Veronese LR, Miller M, Spearman WC. Thromboelastography in mild, chronic liver disease: challenging conventional coagulation tests preceding liver biopsy. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2018. [DOI: 10.1080/22201181.2018.1510234] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- LR Veronese
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
| | - M Miller
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
| | - WC Spearman
- Division of Hepatology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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La Mura V, Braham S, Tosetti G, Branchi F, Bitto N, Moia M, Fracanzani AL, Colombo M, Tripodi A, Primignani M. Harmful and Beneficial Effects of Anticoagulants in Patients With Cirrhosis and Portal Vein Thrombosis. Clin Gastroenterol Hepatol 2018; 16:1146-1152.e4. [PMID: 29066371 DOI: 10.1016/j.cgh.2017.10.016] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 10/07/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Vitamin K antagonists (VKAs) promote recanalization of portal vein thrombosis (PVT) in patients with cirrhosis. However, the benefit of PVT recanalization might be offset by major and minor bleeding associated with use of anticoagulants. We evaluated harmful and beneficial effects of VKA in patients with PVT and cirrhosis. METHODS We performed a retrospective study of 63 consecutive patients with cirrhosis given anticoagulants for the first detection of non-neoplastic PVT from 2003 to 2015 in Italy. We collected data on bleeding events in these patients and compared them with those from patients without cirrhosis with venous thromboembolism (VTE) (n = 160) for up to 4 years. Time in the therapeutic range, based on the international normalized ratio, was used to determine the quality of anticoagulation. We also collected data from 139 patients with cirrhosis who did not receive VKAs (controls), to analyze portal hypertension-related events. We performed survival analyses to determine the effects of VKA in patients with PVT vs controls. RESULTS The group with VTE and the group with PVT were comparable in age, sex, and time in the therapeutic range, but patients with VTE received VKAs for a longer time period (31.1 ± 16.9 mo vs 23.3 ± 16.2 mo; P = .002). The incidence of major or minor bleeding was higher in patients with PVT than patients with VTE (major, 24% vs 7%; P = .012; minor, 29% vs 19%; P = .024). Patients with PVT had a higher rate of major bleeding from the upper-gastrointestinal tract than patients with VTE (P = .019), but there were no significant differences in other types of major bleeding (P = .376). Patients with PVT and controls had the same rate of upper-gastrointestinal bleeding. Complete recanalization in patients with PVT receiving VKA (n = 31) was independently associated with increased portal hypertension-related event-free and transplantation-free survival times. CONCLUSIONS In a retrospective analysis of 63 patients with cirrhosis given anticoagulants for PVT, we found VKA use to increase risk of minor bleeding, compared with patients without cirrhosis given VKA. However, this risk is offset by the ability of VKA to increase portal hypertension-related, event-free, and transplantation-free survival of patients with PVT recanalization. Portal hypertension, rather than anticoagulants, could account for the difference in risk of major bleeding between patients with PVT vs patients with VTE.
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Affiliation(s)
- Vincenzo La Mura
- A. M. and A. Migliavacca-Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Cà Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy; Internal Medicine, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Donato, Department of Biomedical Sciences for Health, University of Milan, San Donato Milanese, Italy.
| | - Simon Braham
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Cà Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Giulia Tosetti
- A. M. and A. Migliavacca-Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Cà Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Federica Branchi
- A. M. and A. Migliavacca-Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Cà Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Niccolò Bitto
- Internal Medicine, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Donato, Department of Biomedical Sciences for Health, University of Milan, San Donato Milanese, Italy
| | - Marco Moia
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Cà Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Anna Ludovica Fracanzani
- Internal Medicine, Department of Pathophysiology and Transplantation, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Cà Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Massimo Colombo
- Department of Internal Medicine, Humanitas Clinical and Research Center (MI), Rozzano, Italy
| | - Armando Tripodi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Cà Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Massimo Primignani
- A. M. and A. Migliavacca-Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Cà Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
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Bianchini M, Cavani G, Bonaccorso A, Turco L, Vizzutti F, Sartini A, Gitto S, Merighi A, Banchelli F, Villa E, Schepis F. Low molecular weight heparin does not increase bleeding and mortality post-endoscopic variceal band ligation in cirrhotic patients. Liver Int 2018; 38:1253-1262. [PMID: 29469184 DOI: 10.1111/liv.13728] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 02/12/2018] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Anticoagulants are commonly indicated in cirrhotic patients due to high rate of (pro)thrombotic conditions. Low molecular weight heparin (LMWH) is safe in patients with esophageal varices. However, the safety of LMWH is unknown in patients undergoing prophylactic endoscopic variceal ligation (EVL). To define the 4-week risk of bleeding and death after prophylactic EVL in cirrhotic patients continuously treated with LMWH. METHODS All EVLs performed at a tertiary Italian Center from 2009 to 2016 were retrospectively reviewed. Patients treated with LMWH were classified as on-LMWH; the remaining as no-LMWH. Endoscopic characteristics at first and index EVL (that preceding an endoscopy either showing a bleeding episode or the absence of further treatable varices) and clinical events within 4 weeks from the procedures were recorded. RESULTS AND CONCLUSIONS Five hundred fifty-three EVLs were performed in 265 patients (in 215 as a primary prophylaxis): 169 EVLs in 80 on-LMWH and 384 in 185 no-LMWH (4.9 ± 1.1 vs 4.8 ± 1.0 bands/session, respectively; P = .796). Six patients bled (2.2%) without between-groups difference (3.8% on-LMWH vs 1.6% no-LMWH, Log-rank P = .291). Large varices with red marks (100% vs 51.4%, P = .032), number of bands (5.6 ± 0.5 vs 4.6 ± 1.2, P = .004), underlying portal vein thrombosis (66.7% vs 23.6%, P = .033), and creatinine (2.2 ± 2.7 vs 1.0 ± 0.8 mg/dL, P = .001) at index EVL were significantly different between bleeders and non-bleeders. Six patients died within 4-week from index EVL, without between-groups difference (2.5% on-LMWH vs 2.2% no-LMWH, Log-rank P = .863). LMWH does not increase the risk of post-procedural bleeding and does not affect survival of cirrhotic patients undergoing prophylactic EVL.
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Affiliation(s)
- Marcello Bianchini
- Division of Gastroenterology, Modena Hospital, University of Modena and Reggio Emilia, Modena, Italy
| | - Giulia Cavani
- Division of Gastroenterology, Modena Hospital, University of Modena and Reggio Emilia, Modena, Italy
| | - Ambra Bonaccorso
- Division of Gastroenterology, Modena Hospital, University of Modena and Reggio Emilia, Modena, Italy
| | - Laura Turco
- Division of Gastroenterology, Modena Hospital, University of Modena and Reggio Emilia, Modena, Italy
| | - Francesco Vizzutti
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Alessandro Sartini
- Division of Gastroenterology, Modena Hospital, University of Modena and Reggio Emilia, Modena, Italy
| | - Stefano Gitto
- Division of Gastroenterology, Modena Hospital, University of Modena and Reggio Emilia, Modena, Italy
| | - Alberto Merighi
- Division of Gastroenterology, Modena Hospital, University of Modena and Reggio Emilia, Modena, Italy
| | - Federico Banchelli
- Statistics Unit, Department of Clinical, Diagnostic and Public Health Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Erica Villa
- Division of Gastroenterology, Modena Hospital, University of Modena and Reggio Emilia, Modena, Italy
| | - Filippo Schepis
- Division of Gastroenterology, Modena Hospital, University of Modena and Reggio Emilia, Modena, Italy
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40
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Russo FP, Imondi A, Lynch EN, Farinati F. When and how should we perform a biopsy for HCC in patients with liver cirrhosis in 2018? A review. Dig Liver Dis 2018; 50:640-646. [PMID: 29636240 DOI: 10.1016/j.dld.2018.03.014] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 03/07/2018] [Accepted: 03/09/2018] [Indexed: 12/11/2022]
Abstract
The role of liver biopsy in the diagnosis of hepatocellular carcinoma (HCC) has changed over time. The diagnostic algorithm for this tumor is nowadays mainly based on radiological imaging, relegating histology to controversial cases, in which imaging techniques cannot establish a clear-cut diagnosis. This most commonly happens in small lesions, where biopsies frequently become mandatory, or in larger hypovascularized lesions. In this case however, the histological examination may not be reliable enough to grade the lesion, as different cell clones, deriving from sequential mutations, can originate heterogeneous cell populations. The risk of complications of liver biopsy, such as tumor seeding and intra-abdominal bleeding, needs to be reconsidered in light of new scientific evidence and of the technical improvements that have been introduced. Furthermore, increasing knowledge of the immunohistochemical and molecular characteristics of hepatocellular carcinoma opens a new scenario in which biopsy may play a decisive role in defining prognosis, and even treatment, by identifying the patient populations who could most benefit from target-driven hepatocellular carcinoma treatments, and therefore improving the success rate of experimental therapies. All the above reasons suggest that, overall, the role of liver biopsy in the management of HCC needs a reappraisal.
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Affiliation(s)
- Francesco Paolo Russo
- Section of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University Hospital Padua, Padua, Italy
| | - Angela Imondi
- Section of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University Hospital Padua, Padua, Italy
| | - Erica Nicola Lynch
- Section of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University Hospital Padua, Padua, Italy
| | - Fabio Farinati
- Section of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University Hospital Padua, Padua, Italy.
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Turco L, Schepis F, Villa E. The Role of Anticoagulation in Treating Portal Hypertension. CURRENT HEPATOLOGY REPORTS 2018; 17:200-208. [PMID: 30546994 PMCID: PMC6267395 DOI: 10.1007/s11901-018-0406-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW To revise experimental and clinical data supporting a less traditional role of anticoagulation for treating portal hypertension in patients with cirrhosis. RECENT FINDINGS Portal hypertension is the main driver of complications such as ascites, variceal hemorrhage, and hepatic encephalopathy, with inflammation as a key component. The traditional view of cirrhosis as a pro-hemorrhagic condition has recently changed, prothrombotic complications being recognized as frequently as the hemorrhagic ones. Several data indicate a close relationship between inflammation, prothrombotic status, worsening of hepatic fibrosis, and portal hypertension both in animal models and in patients with chronic liver disease. These findings indicate that anticoagulation may represent a potent tool to act on fibrogenesis and therefore consequently to treat portal hypertension. All anticoagulants have good to optimal safety profiles and can be used in patients with advanced chronic liver disease with confidence. SUMMARY Anticoagulation has a role as a pleiotropic treatment of portal hypertension in cirrhosis.
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Affiliation(s)
- Laura Turco
- Division of Gastroenterology, Azienda Ospedaliero-Universitaria di Modena and University of Modena and Reggio Emilia, Modena, Italy
- WomenInHepatology Network, Modena, Italy
| | - Filippo Schepis
- Division of Gastroenterology, Azienda Ospedaliero-Universitaria di Modena and University of Modena and Reggio Emilia, Modena, Italy
| | - Erica Villa
- Division of Gastroenterology, Azienda Ospedaliero-Universitaria di Modena and University of Modena and Reggio Emilia, Modena, Italy
- WomenInHepatology Network, Modena, Italy
- Department of Gastroenterology, University of Modena and Reggio Emilia, Via del Pozzo 71, 41124 Modena, Italy
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42
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Giannini EG, Giambruno E, Brunacci M, Plaz Torres MC, Furnari M, Bodini G, Zentilin P, Savarino V. Low Fibrinogen Levels Are Associated with Bleeding After Varices Ligation in Thrombocytopenic Cirrhotic Patients. Ann Hepatol 2018; 17:830-835. [PMID: 30145561 DOI: 10.5604/01.3001.0012.0775] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND AIM EVBL is a procedure frequently performed in cirrhotic patients for primary prophylaxis of bleeding. Patients with cirrhosis display various degrees of alteration of common coagulation parameters, and it is not known whether these alterations may predict post-EVBL bleeding. To evaluate factors predictive of post-endoscopic variceal band ligation (EVBL) bleeding in cirrhotic patients with thrombocytopenia. METHODS We included 109 patients with cirrhosis undergoing EVBL for primary prophylaxis of variceal bleeding. Common coagulation parameters (INR, fibrinogen levels) and complete haemogram were obtained in all patients and evaluated subdividing patients in bleeders and non bleeders following EVBL. RESULTS The incidence of post-EVBL bleeding was 5.5% (6 patients). INR and platelet counts, considered as continuous or dichotomous variables according to common cut-offs (i.e., INR>1.5, platelet count <50x109/L) were not predictors of post-EVBL bleeding. Patients who bled had significantly lower fibrinogen levels [146 mg/dL (98 - 262) versus 230 mg/dL (104 - 638), P=0.009], and no other biochemical or clinical predictors of bleeding were identified. A fibrinogen cut-off of 179 mg/dL had 98.6% negative predictive value for bleeding. CONCLUSION low fibrinogen levels are associated with an increased risk of bleeding following prophylactic EVBL in cirrhotic patients, and might be used to stratify patients' risk. However, due to their preliminary nature, these findings need to be confirmed in larger populations.
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Affiliation(s)
- Edoardo G Giannini
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Ospedale Policlinico San Martino - IRCCS per l'Oncologia, Genoa, Italy
| | - Elisa Giambruno
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Ospedale Policlinico San Martino - IRCCS per l'Oncologia, Genoa, Italy
| | - Mattteo Brunacci
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Ospedale Policlinico San Martino - IRCCS per l'Oncologia, Genoa, Italy
| | - Maria Corina Plaz Torres
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Ospedale Policlinico San Martino - IRCCS per l'Oncologia, Genoa, Italy
| | - Manuele Furnari
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Ospedale Policlinico San Martino - IRCCS per l'Oncologia, Genoa, Italy
| | - Giorgia Bodini
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Ospedale Policlinico San Martino - IRCCS per l'Oncologia, Genoa, Italy
| | - Patrizia Zentilin
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Ospedale Policlinico San Martino - IRCCS per l'Oncologia, Genoa, Italy
| | - Vincenzo Savarino
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Ospedale Policlinico San Martino - IRCCS per l'Oncologia, Genoa, Italy
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Franchini M, Mannucci PM. Primary hyperfibrinolysis: Facts and fancies. Thromb Res 2018; 166:71-75. [PMID: 29665524 DOI: 10.1016/j.thromres.2018.04.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 03/28/2018] [Accepted: 04/11/2018] [Indexed: 12/12/2022]
Abstract
Fibrinolysis is a complex process that controls both hemostasis and thrombosis. The regulation of the fibrinolytic system is mediated through a wide array of cofactors and inhibitors that maintain the hemostatic balance in a delicate equilibrium. As a consequence, disturbances in the fibrinolysis pathway are associated with various disease states, ranging from thrombotic to hemorrhagic clinical phenotypes. In particular, a number of inherited and acquired disorders are associated with an enhanced fibrinolysis leading to a bleeding tendency that in some cases may be life-threatening. Hyperfibrinolysis has been classified into primary and secondary forms but such differentiation, which may have important treatment implications, is still controversial. This narrative review will be focused on inherited and acquired conditions associated with primary hyperfibrinolysis.
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Affiliation(s)
- Massimo Franchini
- Department of Transfusion Medicine and Hematology, Carlo Poma Hospital, Mantova, Italy; Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, University of Milan, Italy.
| | - Pier Mannuccio Mannucci
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, University of Milan, Italy
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Thromboembolic Events Secondary to Endoscopic Cyanoacrylate Injection: Can We Foresee Any Red Flags? Can J Gastroenterol Hepatol 2018; 2018:1940592. [PMID: 29850452 PMCID: PMC5903199 DOI: 10.1155/2018/1940592] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 01/20/2018] [Accepted: 01/31/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Gastric varices (GV) are associated with high morbidity and mortality in patients with portal hypertension. Endoscopic cyanoacrylate injection is the first-line recommended therapy for GV obliteration. This study aims to explore the reason behind related adverse events and better prevent its occurrence. METHODS A retrospective case series study was conducted from January 1, 2013, to December 31, 2016, to identify patients who experienced severe adverse events secondary to endoscopic cyanoacrylate injection. A literature review of similar cases was performed on two medical databases, Medline and Embase. RESULTS A total of 652 patients underwent cyanoacrylate injection at our center within the study duration. Five cases of severe adverse events related to the use of tissue adhesives were identified. Detailed clinical presentation, patient treatment, and outcomes were reviewed and analyzed. Twenty-seven similar cases were identified based on the literature review providing further insight into the study. CONCLUSION Although rare in incidence, systemic embolism associated with cyanoacrylate injection is often fatal or debilitating. This report may raise awareness in treatment protocol, including the necessity of preoperative angiographic studies, to avoid similar adverse events in clinical practice.
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Timing of Anticoagulation for Portal Vein Thrombosis in Liver Cirrhosis: An Italian Internist's Perspective. J Transl Int Med 2018; 6:6-10. [PMID: 29607297 DOI: 10.2478/jtim-2018-0002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Platelet Count Does Not Predict Bleeding in Cirrhotic Patients: Results from the PRO-LIVER Study. Am J Gastroenterol 2018; 113:368-375. [PMID: 29257146 DOI: 10.1038/ajg.2017.457] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Accepted: 11/06/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Thrombocytopenia is a hallmark for patients with cirrhosis and it is perceived as a risk factor for bleeding events. However, the relationship between platelet count and bleeding is still unclear. METHODS We investigated the relationship between platelet count and major or clinical relevant nonmajor bleedings during a follow-up of ∼4 years. RESULTS A total of 280 cirrhotic patients with different degrees of liver disease (67% males; age 64±37 years; 47% Child-Pugh B and C) were followed up for a median of 1,129 (interquartile range: 800-1,498) days yielding 953.12 patient-year of observation. The annual rate of any significant bleeding was 5.45%/year (3.57%/year and 1.89%/year for major and minor bleeding, respectively). Fifty-two (18.6%) patients experienced a major (n=34) or minor (n=18) bleeding event, predominantly from gastrointestinal origin. Platelet counts progressively decreased with the worsening of liver disease and were similar in patients with or without major or minor bleeding: a platelet count ≤50 × 103/μl was detected in 3 (6%) patients with and in 20 (9%) patients without any bleeding event. Conversely, prothrombin time-international normalized ratio was slightly higher in patients with overall or major bleeding. On Cox proportional hazard analysis, only a previous gastrointestinal bleeding (hazard ratio (HR): 1.96; 95% confidence interval: 1.11-3.47; P=0.020) and encephalopathy (HR: 2.05; 95% confidence interval: 1.16-3.62; P=0.013) independently predicted overall bleeding events. CONCLUSIONS Platelet count does not predict unprovoked major or minor bleeding in cirrhotic patients.
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Huang Q, Xu E, Tan L, Zeng Q, Zheng R, Li K. Thermal ablation of hepatocellular carcinoma in patients with abnormal coagulation function. Int J Hyperthermia 2017; 34:1038-1043. [PMID: 29082796 DOI: 10.1080/02656736.2017.1390787] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To evaluate the safety of thermal ablation for hepatocellular carcinoma (HCC) in patients with abnormal coagulation function. METHODS Fifty-seven HCC tumours in 50 patients were treated with thermal ablation. All patients had a meted platelet count <50 × 109/L or international normalised ratio (INR) ≥ 1.7. Gastroscopy before ablation, platelet concentrate or fresh frozen plasma transfusion during ablation and contrast enhanced ultrasoundgraphy (CEUS)-guided ablation to cease needle tract bleeding were performed to reduce haemorrhage. The incidences of haemorrhage and other major complications were recorded and patients were followed up to observe the local tumour progression (LTP), intrahepatic distant recurrence (IDR), overall survival (OS) and recurrence-free survival (RFS) rates. RESULTS Two incidences of needle tract bleeding and one needle tract bleeding together with bleeding at the suture of the spleen fossa were found. Three needle tract bleeding events were detected by CEUS and ceased after CEUS-guided complementary ablation. CEUS failed to detect bleeding at the suture of the spleen fossa. Therefore, a laparotomy was conducted for haemostasis. No other major complications were found after ablation. The median follow-up periods were 18.7 ± 12.0 months (range 1 ∼ 42 months) and 1 LTP and 15 IDRs occurred. The 1-, 2- and 3-year OS rates were 84.8%, 82.7% and 82.7%, and RFS rates were 67.9%, 64.0% and 64.0%, respectively. CONCLUSION With gastroscopy before ablation, platelet concentrate or fresh frozen plasma transfusion during ablation and CEUS-guided ablation to cease needle tract bleeding, thermal ablation is a safe treatment for HCC in patients with abnormal coagulation function.
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Affiliation(s)
- Qiannan Huang
- a Department of Ultrasound , The Third Affiliated Hospital, Sun Yat-sen University , Guangzhou , China
| | - Erjiao Xu
- a Department of Ultrasound , The Third Affiliated Hospital, Sun Yat-sen University , Guangzhou , China
| | - Lei Tan
- a Department of Ultrasound , The Third Affiliated Hospital, Sun Yat-sen University , Guangzhou , China
| | - Qingjing Zeng
- a Department of Ultrasound , The Third Affiliated Hospital, Sun Yat-sen University , Guangzhou , China
| | - Rongqin Zheng
- a Department of Ultrasound , The Third Affiliated Hospital, Sun Yat-sen University , Guangzhou , China
| | - Kai Li
- a Department of Ultrasound , The Third Affiliated Hospital, Sun Yat-sen University , Guangzhou , China
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Burra P, Belli LS, Ginanni Corradini S, Volpes R, Marzioni M, Giannini E, Toniutto P. Common issues in the management of patients in the waiting list and after liver transplantation. Dig Liver Dis 2017; 49:241-253. [PMID: 28096056 DOI: 10.1016/j.dld.2016.12.027] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 12/19/2016] [Accepted: 12/22/2016] [Indexed: 02/06/2023]
Abstract
The present document contains the recommendations of an expert panel of transplant hepatologists, appointed by the Italian Association for the Study of the Liver (AISF), on how to manage the most common aspects of liver transplantation: the topics covered include: new treatments for HCV in patients on the waiting list for liver transplantation; antiviral treatments in patients with HCV recurrence after liver transplantation; prophylaxis for HBV recurrence after liver transplantation; indications for liver transplantation in alcoholic liver disease; and Immunosuppressive therapy. The statements on each topic were approved by participants at the AISF Transplant Hepatologist Expert Meeting (organized by the Permanent Committee on Liver Transplantation in Mondello on 4-5 October 2015), and are graded according to the Oxford classification of levels of evidence.
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Affiliation(s)
- Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Italy.
| | | | | | - Riccardo Volpes
- Hepatology and Gastroenterology Unit, ISMETT-IRCCS, Palermo, Italy
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Napolitano G, Iacobellis A, Merla A, Niro G, Valvano MR, Terracciano F, Siena D, Caruso M, Ippolito A, Mannuccio PM, Andriulli A. Bleeding after invasive procedures is rare and unpredicted by platelet counts in cirrhotic patients with thrombocytopenia. Eur J Intern Med 2017; 38:79-82. [PMID: 27989373 DOI: 10.1016/j.ejim.2016.11.007] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 10/21/2016] [Accepted: 11/08/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND In cirrhotics with low circulating platelets (PLT), restoration of normal cell counts has been traditionally recommended before invasive procedures. However, there is neither consensus on the PLT transfusion threshold nor evidence of its clinical efficacy. PATIENTS In order to fill this gap of knowledge, we prospectively collected and analyzed data on circulating PLT counts [and International Normalized Ratio (INR)] values in a case series of 363 cirrhotics scheduled to undergo invasive investigations. PLT and/or fresh-frozen plasma (FFP) units were infused at the discretion of the attending physician, and the occurrence of post-procedural bleeding was related to pre-and post-infusion results. RESULTS 852 Procedures were carried out in 363 cirrhotics sub-grouped according to the Child-Pugh-Turcotte (CPT) classification (class A/B/C: 124/154/85). The infusion of PLT and/or FFP improved only marginally circulating PLT counts and INR values. Ten post-procedural bleeds occurred in the whole case series, i.e. 1 episode every 85 procedures or every 36 patients. Post-procedural bleeding was unrelated to the PLT counts, to the degree of INR abnormalities, nor to the CPT classes, but was more frequent in patients who underwent repeated investigations. In the 10 patients with the most profound alterations in PLT and/or INR values, no post-procedural bleeding occurred. CONCLUSIONS In cirrhotic patients with low PLT and/or abnormal INR values undergoing invasive investigations, post-procedural bleeding was rare and unpredicted by PLT counts or abnormal INR values. In particular, the recommendation to infuse platelets when counts are <50×103/L is not substantiated by this case series of cirrhotic patients.
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Affiliation(s)
- Grazia Napolitano
- Division of Gastroenterology, "Casa Sollievo Sofferenza" Hospital, IRCCS, San Giovanni Rotondo, Italy
| | - Angelo Iacobellis
- Division of Gastroenterology, "Casa Sollievo Sofferenza" Hospital, IRCCS, San Giovanni Rotondo, Italy.
| | - Antonio Merla
- Division of Gastroenterology, "Casa Sollievo Sofferenza" Hospital, IRCCS, San Giovanni Rotondo, Italy
| | - Grazia Niro
- Division of Gastroenterology, "Casa Sollievo Sofferenza" Hospital, IRCCS, San Giovanni Rotondo, Italy
| | - Maria Rosa Valvano
- Division of Gastroenterology, "Casa Sollievo Sofferenza" Hospital, IRCCS, San Giovanni Rotondo, Italy
| | - Fulvia Terracciano
- Division of Gastroenterology, "Casa Sollievo Sofferenza" Hospital, IRCCS, San Giovanni Rotondo, Italy
| | - Domenico Siena
- Division of Gastroenterology, "Casa Sollievo Sofferenza" Hospital, IRCCS, San Giovanni Rotondo, Italy
| | - Mariangela Caruso
- Division of Gastroenterology, "Casa Sollievo Sofferenza" Hospital, IRCCS, San Giovanni Rotondo, Italy
| | - Antonio Ippolito
- Division of Gastroenterology, "Casa Sollievo Sofferenza" Hospital, IRCCS, San Giovanni Rotondo, Italy
| | - Pier Mannucci Mannuccio
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, IRCCS Cà Granda, Policlinico Maggiore Hospital Foundation and University of Milan, Italy
| | - Angelo Andriulli
- Division of Gastroenterology, "Casa Sollievo Sofferenza" Hospital, IRCCS, San Giovanni Rotondo, Italy
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Mancuso A. Management of portal vein thrombosis in cirrhosis: More shadows than lights. Dig Liver Dis 2017; 49:228. [PMID: 27053401 DOI: 10.1016/j.dld.2016.03.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 03/15/2016] [Indexed: 12/11/2022]
Affiliation(s)
- Andrea Mancuso
- Medicina Interna 1, ARNAS Civico - Di Cristina - Benfratelli, Palermo, Italy; Epatologia e Gastroenterologia, Ospedale Niguarda Ca' Granda, Milano, Italy.
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