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Di Y, Li J, Ye C, Wang Z, Zhu Q. Thromboelastography parameters in chronic viral liver disease and liver resection: a retrospective study. Singapore Med J 2024; 65:438-443. [PMID: 37077056 DOI: 10.4103/singaporemedj.smj-2021-404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 07/26/2022] [Indexed: 04/21/2023]
Abstract
INTRODUCTION Thromboelastography (TEG) provides a global assessment of haemostasis and is potentially applicable to liver disease. The present study aimed to explore the utility of TEG for the evaluation of patients with chronic viral liver disease, which has previously not been investigated. METHODS Demographic characteristics and TEG parameters were collected before surgery. Child-Turcotte-Pugh (CTP) and model for end-stage liver disease (MELD) scores were used to categorise stages of liver cirrhosis. Liver resections were classified as low, medium and high complexity. RESULTS A total of 344 patients were included. Results showed significantly longer K-time, smaller α-angle and lower maximum amplitude (MA) with increasing liver disease severity as measured by the CTP and MELD scores ( P < 0.05 for all). After multivariable adjustment (including age, sex, liver disease aetiology, alanine aminotransferase [ALT], aspartate aminotransferase [AST], albumin, total bilirubin, haemoglobin and platelet count), TEG parameters (except R-times) were either weakly or inversely related to the severity of liver disease as defined by the MELD score (absolute r < 0.2 and P < 0.05 for all except R-times). R-times obtained before surgery were weakly correlated with perioperative blood loss ( r < 0.2 and P < 0.05 for all). CONCLUSIONS The correlation between TEG parameters and severity of liver disease was weak. In addition, R-times obtained before liver resection were weakly associated with perioperative blood loss after multivariable adjustments. TEG utility for haemostasis assessment and prediction of blood loss during liver resection should be further explored in high-quality studies.
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Affiliation(s)
- Ying Di
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an City, Shaanxi Province, China
| | - Jialu Li
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an City, Shaanxi Province, China
| | - Chunjuan Ye
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an City, Shaanxi Province, China
| | - Zheng Wang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an City, Shaanxi Province, China
| | - Qianqian Zhu
- Department of Anesthesiology, The Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen City, People's Republic of China
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Pezzino S, Luca T, Castorina M, Puleo S, Latteri S, Castorina S. Role of Perturbated Hemostasis in MASLD and Its Correlation with Adipokines. Life (Basel) 2024; 14:93. [PMID: 38255708 PMCID: PMC10820028 DOI: 10.3390/life14010093] [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: 11/30/2023] [Revised: 01/04/2024] [Accepted: 01/05/2024] [Indexed: 01/24/2024] Open
Abstract
The prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD) continues to rise, making it one of the most prevalent chronic liver disorders. MASLD encompasses a range of liver pathologies, from simple steatosis to metabolic dysfunction-associated steatohepatitis (MASH) with inflammation, hepatocyte damage, and fibrosis. Interestingly, the liver exhibits close intercommunication with fatty tissue. In fact, adipose tissue could contribute to the etiology and advancement of MASLD, acting as an endocrine organ that releases several hormones and cytokines, with the adipokines assuming a pivotal role. The levels of adipokines in the blood are altered in people with MASLD, and recent research has shed light on the crucial role played by adipokines in regulating energy expenditure, inflammation, and fibrosis in MASLD. However, MASLD disease is a multifaceted condition that affects various aspects of health beyond liver function, including its impact on hemostasis. The alterations in coagulation mechanisms and endothelial and platelet functions may play a role in the increased vulnerability and severity of MASLD. Therefore, more attention is being given to imbalanced adipokines as causative agents in causing disturbances in hemostasis in MASLD. Metabolic inflammation and hepatic injury are fundamental components of MASLD, and the interrelation between these biological components and the hemostasis pathway is delineated by reciprocal influences, as well as the induction of alterations. Adipokines have the potential to serve as the shared elements within this complex interrelationship. The objective of this review is to thoroughly examine the existing scientific knowledge on the impairment of hemostasis in MASLD and its connection with adipokines, with the aim of enhancing our comprehension of the disease.
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Affiliation(s)
- Salvatore Pezzino
- Mediterranean Foundation “GB Morgagni”, 95125 Catania, Italy (M.C.); (S.C.)
| | - Tonia Luca
- Mediterranean Foundation “GB Morgagni”, 95125 Catania, Italy (M.C.); (S.C.)
- Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95123 Catania, Italy;
| | | | - Stefano Puleo
- Mediterranean Foundation “GB Morgagni”, 95125 Catania, Italy (M.C.); (S.C.)
| | - Saverio Latteri
- Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95123 Catania, Italy;
| | - Sergio Castorina
- Mediterranean Foundation “GB Morgagni”, 95125 Catania, Italy (M.C.); (S.C.)
- Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95123 Catania, Italy;
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Koumar L, Senthamizhselvan K, Barathi D, Verma A, Rao P, Selvaraj J, Sanker V. Portal Vein Thrombosis in Patients With Cirrhosis of the Liver: Prevalence and Risk Factors. Cureus 2023; 15:e50134. [PMID: 38186444 PMCID: PMC10771608 DOI: 10.7759/cureus.50134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2023] [Indexed: 01/09/2024] Open
Abstract
INTRODUCTION Chronic liver disease very often culminates into cirrhosis and its associated complications. One of the serious complications is portal venous thrombosis, which can occur due to a variety of risk factors. One significant factor contributing to portal hypertension is portal vein thrombosis (PVT). In this study, we aimed to investigate the prevalence of PVT among patients with liver cirrhosis in a tertiary hospital and identify the factors associated with this complication. METHODOLOGY This was a cross-sectional observational study of 93 diagnosed liver cirrhosis patients treated at Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) hospital in southern India between June 2020 and January 2021. A thorough evaluation of the clinical condition of the patients and associated comorbidities was done. The patients then underwent Doppler ultrasound/CECT/MRI to look for PVT and its extent. The collected data were analyzed using Statistical Product and Service Solutions (SPSS, version 24) (IBM SPSS Statistics for Windows, Armonk, NY). Comparison between two proportions was done using two two-tailed Z-test/Fisher's exact tests. RESULTS Our study found a PVT prevalence of 17.2% in cirrhotic patients, with a higher prevalence of acute PVT than chronic PVT. Ascitic fluid infection, longer duration of cirrhosis, and increased cirrhosis severity were significantly associated with PVT development. We found no significant associations between PVT and gender, hypertension, smoking, diabetes, or the duration of alcohol intake. CONCLUSION This study highlights the importance of early screening for PVT using Doppler USG in all patients diagnosed with cirrhosis. Additionally, anticoagulation therapy for acute PVT may be considered in patients without bleeding risks.
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Affiliation(s)
- Lokesh Koumar
- Cardiology, Wolverhampton Heart and Lung Centre, New Cross Hospital, Wolverhampton, GBR
| | - Kuppusamy Senthamizhselvan
- Medical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
| | - Deepak Barathi
- Radiodiagnosis, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
| | - Amogh Verma
- Medicine, Rama Medical College Hospital and Research Centre, Hapur, IND
| | - Pallavi Rao
- Internal Medicine, Dr. Rajendra Prasad Government Medical College, Kangra, IND
| | - Jayachandran Selvaraj
- General Internal Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
| | - Vivek Sanker
- General Surgery, Noorul Islam Institute of Medical Science and Research Foundation (NIMS Medicity), Trivandrum, IND
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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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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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Martens K, McMurry HS, Koprowski S, Hum J, Haraga J, Jou JH, Shatzel JJ. Anticoagulation in Cirrhosis: Evidence for the Treatment of Portal Vein Thrombosis and Applications for Prophylactic Therapy. J Clin Gastroenterol 2022; 56:536-545. [PMID: 35537133 PMCID: PMC9189067 DOI: 10.1097/mcg.0000000000001713] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The clinical utility of anticoagulation for patients with cirrhosis and asymptomatic portal vein thrombosis (PVT) is widely debated. Complex hemostatic derangements in cirrhosis that increase risk of both bleeding and thrombosis, as well as a lack of randomized controlled data, limit conclusive assessments regarding optimal management of anticoagulation in this setting. In this review, we summarize the relevant literature pertaining to PVT in cirrhosis, including the effect of untreated PVT on the natural progression of liver disease and the overall impact of anticoagulation on clot burden and other relevant clinical outcomes. Apart from patients who are symptomatic or listed for liver transplantation, data supporting anticoagulation for the treatment of PVT is limited and without clear consensus guidelines. In patients with cirrhosis without PVT, emerging evidence for the role of prophylactic anticoagulation to mitigate the progression of fibrosis suggests an optimal risk-benefit tradeoff with decreased rates of liver decompensation and mortality, without a heightened risk of bleeding. In summation, as our understanding of the role of both prophylactic and therapeutic anticoagulation in cirrhosis continues to evolve, ongoing risk stratification of patients with asymptomatic PVT demands further attention.
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Affiliation(s)
- Kylee Martens
- Division of Hematology-Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland OR
| | | | - Steven Koprowski
- Division of Gastroenterology, Oregon Health & Science University, Portland OR
| | - Justine Hum
- Division of Gastroenterology, Oregon Health & Science University, Portland OR
| | - Jessica Haraga
- Division of Gastroenterology, University of California, Los Angeles, CA
| | - Janice H. Jou
- Division of Gastroenterology, Oregon Health & Science University, Portland OR
| | - Joseph J. Shatzel
- Division of Hematology-Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland OR
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McMurry HS, Jou J, Shatzel J. The hemostatic and thrombotic complications of liver disease. Eur J Haematol 2021; 107:383-392. [PMID: 34258797 DOI: 10.1111/ejh.13688] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 07/06/2021] [Accepted: 07/08/2021] [Indexed: 12/19/2022]
Abstract
Hepatic cirrhosis leads to numerous hematologic derangements resulting in a complex and tenuously rebalanced hemostatic milieu. The utility of common hematologic tests including the INR and aPTT in assessing hemostatic and thrombotic risk in patients with cirrhosis is limited, and consensus on transfusion thresholds and proper management of thrombotic complications continues to evolve. This review summarizes the pathophysiology of key derangements of hemostasis including those of platelets, von Willebrand factor, pro- and anticoagulation factors, and fibrin. Additionally, the pathogenesis, consequences, optimal management, and prevention of major thrombotic and bleeding complications in cirrhosis arte discussed.
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Affiliation(s)
- Hannah Stowe McMurry
- Divison of Internal Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Janice Jou
- Division of Gastroenterology and Hepatology, Oregon Health & Science University, Portland, OR, USA
| | - Joseph Shatzel
- Division of Hematology and Oncology, Oregon Health & Science University, Portland, OR, USA.,Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
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Sigal SH, Sherman Z, Jesudian A. Clinical Implications of Thrombocytopenia for the Cirrhotic Patient. ACTA ACUST UNITED AC 2020; 12:49-60. [PMID: 32341665 PMCID: PMC7166072 DOI: 10.2147/hmer.s244596] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 03/10/2020] [Indexed: 02/06/2023]
Abstract
Thrombocytopenia is a frequent complication in patients with cirrhosis. As many as 84% of patients with cirrhosis have thrombocytopenia, and it is an independent variable indicative of advanced disease and poor prognosis. Although there is great concern that it may aggravate bleeding during surgical procedures, there is limited evidence to inform decisions regarding the treatment of cirrhotic patients with thrombocytopenia undergoing invasive procedures. Finally, there is evidence that platelets play a significant role in liver regeneration. In this report, the clinical implications of thrombocytopenia in cirrhotic patients are reviewed. The utility of platelet counts in the prognosis of cirrhosis and relationship to complications of advanced liver disease, including portal hypertension, esophageal varices, and hepatocellular carcinoma. The impact of low platelet counts on bleeding complications during invasive procedures is outlined. Finally, the role of platelets and potential adverse impact in liver regeneration is reviewed.
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Affiliation(s)
- Samuel H Sigal
- Department of Medicine, Montefiore Medical Center, Bronx, NY, USA
| | - Zachary Sherman
- Department of Medicine, Weill Cornell Medical Center, New York, NY, USA
| | - Arun Jesudian
- Department of Medicine, Weill Cornell Medical Center, New York, NY, USA
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Zhang L, Hu B, Li W, Huang P, Zhang S, Zhong BY, Ni CF. 125I Irradiation Stent for Hepatocellular Carcinoma with Main Portal Vein Tumor Thrombosis: A Systematic Review. Cardiovasc Intervent Radiol 2020; 43:196-203. [PMID: 31602496 DOI: 10.1007/s00270-019-02346-y] [Citation(s) in RCA: 5] [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: 07/31/2019] [Accepted: 09/21/2019] [Indexed: 02/07/2023]
Abstract
A systematic review was conducted to provide an overview of the efficacy and safety of 125I irradiation stent placement for patients with hepatocellular carcinoma (HCC) and main portal vein tumor thrombosis (MPVTT). Six studies with 406 patients were included in the final analysis. The median overall survival for patients treated with 125I irradiation stent placement was 10.3 months. The most common radiation-related adverse event was leukopenia. The stent-related adverse events consisted of fever, abdominal pain, hemorrhage, and anorexia. No stent or seed migration was reported. Overall, the use of an 125I irradiation stent has the potential to act as an alternative therapy for patients with HCC with MPVTT.
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Affiliation(s)
- Lei Zhang
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, No. 188, Shizi Street, Suzhou, 215006, China
| | - Bo Hu
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, No. 188, Shizi Street, Suzhou, 215006, China
| | - Wei Li
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, No. 188, Shizi Street, Suzhou, 215006, China
| | - Peng Huang
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, No. 188, Shizi Street, Suzhou, 215006, China
| | - Shen Zhang
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, No. 188, Shizi Street, Suzhou, 215006, China
| | - Bin-Yan Zhong
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, No. 188, Shizi Street, Suzhou, 215006, China.
| | - Cai-Fang Ni
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, No. 188, Shizi Street, Suzhou, 215006, China.
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Kumar M, Ahmad J, Maiwall R, Choudhury A, Bajpai M, Mitra LG, Saluja V, Mohan Agarwal P, Bihari C, Shasthry SM, Jindal A, Bhardwaj A, Kumar G, Sarin SK. Thromboelastography-Guided Blood Component Use in Patients With Cirrhosis With Nonvariceal Bleeding: A Randomized Controlled Trial. Hepatology 2020; 71:235-246. [PMID: 31148204 DOI: 10.1002/hep.30794] [Citation(s) in RCA: 101] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 05/21/2019] [Indexed: 12/12/2022]
Abstract
Thromboelastography (TEG) provides a more comprehensive global coagulation assessment than routine tests (international normalized ratio [INR] and platelet [PLT] count), and its use may avoid unnecessary blood component transfusion in patients with advanced cirrhosis and significant coagulopathy who have nonvariceal upper gastrointestinal (GI) bleeding. A total of 96 patients with significant coagulopathy (defined in this study as INR >1.8 and/or PLT count < 50 × 109 /L) and nonvariceal upper GI bleed (diagnosed after doing upper gastrointestinal endoscopy, which showed ongoing bleed from a nonvariceal source) were randomly allocated to TEG-guided transfusion strategy (TEG group; n = 49) or standard-of-care (SOC) group (n = 47). In the TEG group, only 26.5% patients were transfused with all three blood components (fresh frozen plasma [FFP], PLTs, and cryoprecipitate) versus 87.2% in the SOC group (P < 0.001). Although 7 (14.3%) patients in the TEG group received no blood component transfusion, there were no such patients in the SOC group (P = 0.012). Also, there was a significantly lower use of blood components (FFP, PLTs, and cryoprecipitate) in the TEG group compared with the SOC group. Failure to control bleed, failure to prevent rebleeds, and mortality between the two groups were similar. Conclusion: In patients with advanced cirrhosis with coagulopathy and nonvariceal upper GI bleeding, TEG-guided transfusion strategy leads to a significantly lower use of blood components compared with SOC (transfusion guided by INR and PLT count), without an increase in failure to control bleed, failure to prevent rebleed, and mortality.
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Affiliation(s)
- Manoj Kumar
- Department of Hepatology and Liver Transplantation, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Juned Ahmad
- Department of Hepatology and Liver Transplantation, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Rakhi Maiwall
- Department of Hepatology and Liver Transplantation, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Ashok Choudhury
- Department of Hepatology and Liver Transplantation, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Meenu Bajpai
- Department of Transfusion Medicine, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Lalita G Mitra
- Department of Critical Care Medicine, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Vandana Saluja
- Department of Critical Care Medicine, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Prashant Mohan Agarwal
- Department of Critical Care Medicine, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Chhagan Bihari
- Department of Pathology, Institute of Liver & Biliary Sciences, New Delhi, India
| | | | - Ankur Jindal
- Department of Hepatology and Liver Transplantation, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Ankit Bhardwaj
- Department of Clinical Research, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Guresh Kumar
- Department of Biostatistics, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Shiv K Sarin
- Department of Hepatology and Liver Transplantation, Institute of Liver & Biliary Sciences, New Delhi, India
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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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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: 6] [Impact Index Per Article: 0.9] [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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Fujiyama S, Saitoh S, Kawamura Y, Sezaki H, Hosaka T, Akuta N, Kobayashi M, Suzuki Y, Suzuki F, Arase Y, Ikeda K, Kumada H. Portal vein thrombosis in liver cirrhosis: incidence, management, and outcome. BMC Gastroenterol 2017; 17:112. [PMID: 29070023 PMCID: PMC5657117 DOI: 10.1186/s12876-017-0668-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 10/12/2017] [Indexed: 12/26/2022] Open
Abstract
Background Portal vein thrombosis (PVT) is a serious complication in liver cirrhosis with portal hypertension. We examined the treatment, recurrence and prognosis of PVT in cirrhotic patients. Methods The study subjects were all 90 cirrhotic patients with PVT treated with danaparoid sodium (DS) at our department between July 2007 and September 2016. The mean age was 68 years and mean Child-Pugh score was 7. All patients received 2500 U/day of DS for 2 weeks, and repeated in those who developed PVT recurrence after the initial therapy. Results Complete response was noted in 49% (n = 44), partial response (shrinkage ≥70%) in 33% (n = 30), and no change (shrinkage <70%) in 18% (n = 16) of the patients after the initial course of treatment. DS treatment neither caused adverse events, particularly bleeding or thrombocytopenia, nor induced significant changes in serum albumin, total bilirubin, prothrombin time, and residual liver function. Re-treatment was required in 44 patients who showed PVT recurrence and 61% of these responded to the treatment. The cumulative recurrence rates at 1 and 2 posttreatment years were 26 and 30%, respectively. The recurrence rates were significantly lower in patients with acute type, compared to the chronic type (p = 0.0141). The cumulative survival rates at 1 and 3 years after treatment (including maintenance therapy with warfarin) were 83 and 60%, respectively, and were significantly higher in patients with acute type than chronic type (p = 0.0053). Conclusion We can expect prognostic improvement of liver cirrhosis by warfarin following two-week DS therapy for the treatment of PVT in patients with liver cirrhosis safety and effectiveness. An early diagnosis of PVT along with the evaluation of the volume of PVT on CT and an early intervention would contribute to the higher efficacy of the treatment.
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Affiliation(s)
- Shunichiro Fujiyama
- Department of Hepatology, Toranomon Hospital, Toranomon 2-2-2, Minato-ku, Tokyo, 105-8470, Japan.
| | - Satoshi Saitoh
- Department of Hepatology, Toranomon Hospital, Toranomon 2-2-2, Minato-ku, Tokyo, 105-8470, Japan
| | - Yusuke Kawamura
- Department of Hepatology, Toranomon Hospital, Toranomon 2-2-2, Minato-ku, Tokyo, 105-8470, Japan
| | - Hitomi Sezaki
- Department of Hepatology, Toranomon Hospital, Toranomon 2-2-2, Minato-ku, Tokyo, 105-8470, Japan
| | - Tetsuya Hosaka
- Department of Hepatology, Toranomon Hospital, Toranomon 2-2-2, Minato-ku, Tokyo, 105-8470, Japan
| | - Norio Akuta
- Department of Hepatology, Toranomon Hospital, Toranomon 2-2-2, Minato-ku, Tokyo, 105-8470, Japan
| | - Masahiro Kobayashi
- Department of Hepatology, Toranomon Hospital, Toranomon 2-2-2, Minato-ku, Tokyo, 105-8470, Japan
| | - Yoshiyuki Suzuki
- Department of Hepatology, Toranomon Hospital, Toranomon 2-2-2, Minato-ku, Tokyo, 105-8470, Japan
| | - Fumitaka Suzuki
- Department of Hepatology, Toranomon Hospital, Toranomon 2-2-2, Minato-ku, Tokyo, 105-8470, Japan
| | - Yasuji Arase
- Department of Hepatology, Toranomon Hospital, Toranomon 2-2-2, Minato-ku, Tokyo, 105-8470, Japan
| | - Kenji Ikeda
- Department of Hepatology, Toranomon Hospital, Toranomon 2-2-2, Minato-ku, Tokyo, 105-8470, Japan
| | - Hiromitsu Kumada
- Department of Hepatology, Toranomon Hospital, Toranomon 2-2-2, Minato-ku, Tokyo, 105-8470, Japan
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Shin KH, Kim IS, Lee HJ, Kim HH, Chang CL, Hong YM, Yoon KT, Cho M. Thromboelastographic Evaluation of Coagulation in Patients With Liver Disease. Ann Lab Med 2017; 37:204-212. [PMID: 28224766 PMCID: PMC5339092 DOI: 10.3343/alm.2017.37.3.204] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 09/14/2016] [Accepted: 01/23/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The aims of this study were to investigate the parameters of thromboelastography (TEG) for evaluating coagulopathy and to reveal an association with disease severity and/or transfusion requirement in patients with chronic liver disease (CLD) in a clinical laboratory setting. METHODS We enrolled two groups of adult patients with cirrhotic (N=123) and non-cirrhotic liver disease (N=52), as well as 84 healthy controls. Reaction time (R), kinetic time (K), α-angle (α), maximal amplitude (MA), and coagulation index (CI) were measured with kaolin-activated citrated blood with the TEG 5000 system (Haemonetics Corporation, USA). Platelet count, prothrombin time international normalized ratio (PT INR), albumin, bilirubin, and creatinine were simultaneously measured. The CLD severity was calculated by using the Child-Pugh (C-P) and Model for End-stage Liver Disease (MELD) scores. Transfusion history was also reviewed. RESULTS All TEG parameters, PT INR, and platelet count in the cirrhotic group showed significant differences from those in other groups. At least one or more abnormal TEG parameters were identified in 17.3% and 44.7% of patients in the non-cirrhotic and cirrhotic group, respectively. Patients with cirrhotic disease had hypocoagulability. A weak correlation between R and PT INR (r=0.173) was noted. The TEG parameters could not predict CLD severity using the C-P and MELD scores. Patients with normal TEG parameters did not receive transfusion. CONCLUSIONS Clinical application of TEG measurements in CLD can be informative for investigating coagulopathy or predicting the risk of bleeding. Further studies are warranted.
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Affiliation(s)
- Kyung Hwa Shin
- Department of Laboratory Medicine, Pusan National University School of Medicine and Biomedical Research Institute Research Institute, Pusan National University Hospital, Busan, Korea
| | - In Suk Kim
- Department of Laboratory Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea.
| | - Hyun Ji Lee
- Department of Laboratory Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Hyung Hoi Kim
- Department of Laboratory Medicine, Pusan National University School of Medicine and Biomedical Research Institute Research Institute, Pusan National University Hospital, Busan, Korea
| | - Chulhun L Chang
- Department of Laboratory Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Young Mi Hong
- Department of Internal Medicine, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Ki Tae Yoon
- Department of Internal Medicine, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Mong Cho
- Department of Internal Medicine, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
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Raparelli V, Basili S, Carnevale R, Napoleone L, Del Ben M, Nocella C, Bartimoccia S, Lucidi C, Talerico G, Riggio O, Violi F. Low-grade endotoxemia and platelet activation in cirrhosis. Hepatology 2017; 65:571-581. [PMID: 27641757 DOI: 10.1002/hep.28853] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 08/28/2016] [Indexed: 02/06/2023]
Abstract
UNLABELLED Patients with cirrhosis may display impaired or enhanced platelet activation, but the reasons for these equivocal findings are unclear. We investigated if bacterial lipopolysaccharide (LPS) is implicated in platelet activation. In a cross-sectional study, conducted in an ambulatory care clinic and hospital, comparing 69 cirrhosis patients and 30 controls matched for sex, age, and atherosclerotic risk factors, serum levels of LPS, soluble cluster of differentiation 40 ligand and p-selectin (two markers of platelet activation), and zonulin (a marker of gut permeability) were investigated. Ex vivo and in vitro studies were also performed to explore the effect of LPS on platelet activation. Compared to controls, cirrhosis patients displayed higher serum levels of LPS (6.0 [4.0-17.5] versus 57.4 [43.4-87.2] pg/mL, P < 0.0001), soluble cluster of differentiation 40 ligand (7.0 ± 2.2 versus 24.4 ± 13.3 ng/mL, P < 0.0001), soluble p-selectin (14.2 ± 4.05 versus 33.2 ± 15.2 ng/mL, P < 0.0001), and zonulin (1.87 ± 0.84 versus 2.54 ± 0.94 ng/mL, P < 0.006). LPS significantly correlated with zonulin (r = 0.45, P < 0.001). Ex vivo studies showed that platelets from cirrhosis patients were more responsive to the agonists independently from platelet count; this phenomenon was blunted by incubation with an inhibitor of Toll-like receptor 4. In vitro study by normal platelets showed that LPS alone (50-150 pg/mL) did not stimulate platelets but amplified platelet response to the agonists; Toll-like receptor 4 inhibitor blunted this effect. CONCLUSION LPS may be responsible for platelet activation and potentially contributes to thrombotic complications occurring in cirrhosis. (Hepatology 2017;65:571-581).
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Affiliation(s)
- Valeria Raparelli
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Stefania Basili
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Roberto Carnevale
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Laura Napoleone
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Maria Del Ben
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Cristina Nocella
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Simona Bartimoccia
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Cristina Lucidi
- Department of Clinical Medicine, Center for the Diagnosis and Treatment of Portal Hypertension, Sapienza University of Rome, Rome, Italy
| | - Giovanni Talerico
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Oliviero Riggio
- Department of Clinical Medicine, Center for the Diagnosis and Treatment of Portal Hypertension, Sapienza University of Rome, Rome, Italy
| | - Francesco Violi
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
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Violi F, Corazza GR, Caldwell SH, Perticone F, Gatta A, Angelico M, Farcomeni A, Masotti M, Napoleone L, Vestri A, Raparelli V, Basili S. Portal vein thrombosis relevance on liver cirrhosis: Italian Venous Thrombotic Events Registry. Intern Emerg Med 2016; 11:1059-1066. [PMID: 27026379 DOI: 10.1007/s11739-016-1416-8] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 02/17/2016] [Indexed: 02/07/2023]
Abstract
Portal vein thrombosis may occur in cirrhosis; nevertheless, its prevalence, and predictors are still elusive. To investigate this issue, the Italian Society of Internal Medicine undertook the "Portal vein thrombosis Relevance On Liver cirrhosis: Italian Venous thrombotic Events Registry" (PRO-LIVER). This prospective multicenter study includes consecutive cirrhotic patients undergoing Doppler ultrasound examination of the portal area to evaluate the prevalence and incidence of portal vein thrombosis over a 2-year scheduled follow-up. Seven hundred and fifty-three (68 % men; 64 ± 12 years) patients were included in the present analysis. Fifty percent of the cases were cirrhotic outpatients. Viral (44 %) etiology was predominant. Around half of the patients had a mild-severity disease according to the Child-Pugh score; hepatocellular carcinoma was present in 20 %. The prevalence of ultrasound-detected portal vein thrombosis was 17 % (n = 126); it was asymptomatic in 43 % of the cases. Notably, more than half of the portal vein thrombosis patients (n = 81) were not treated with anticoagulant therapy. Logistic step-forward multivariate analysis demonstrated that previous portal vein thrombosis (p < 0.001), Child-Pugh Class B + C (p < 0.001), hepatocellular carcinoma (p = 0.01), previous upper gastrointestinal bleeding (p = 0.030) and older age (p = 0.012) were independently associated with portal vein thrombosis. Portal vein thrombosis is a frequent complication of cirrhosis, particularly in patients with moderate-severe liver failure. The apparent undertreatment of patients with portal vein thrombosis is a matter of concern and debate, which should be addressed by planning interventional trials especially with newer oral anticoagulants. Clinicaltrials.gov identifier NCT01470547.
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Affiliation(s)
- Francesco Violi
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza-University of Rome, Viale del Policlinico 155, 00161, Rome, Italy.
| | - Gino Roberto Corazza
- First Department of Internal Medicine, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Stephen Hugh Caldwell
- Division of Gastroenterology and Hepatology, Digestive Health Center, University of Virginia, Charlottesville, VA, USA
| | - Francesco Perticone
- Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Angelo Gatta
- Department of Medicine, University of Padova, Padua, Italy
| | - Mario Angelico
- Liver Unit, University Hospital Tor Vergata, Rome, Italy
| | - Alessio Farcomeni
- Department of Public Health and Infectious Disease, Sapienza-University of Rome, Rome, Italy
| | - Michela Masotti
- First Department of Internal Medicine, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Laura Napoleone
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza-University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Annarita Vestri
- Department of Public Health and Infectious Disease, Sapienza-University of Rome, Rome, Italy
| | - Valeria Raparelli
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza-University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Stefania Basili
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza-University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
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Atrial fibrillation, liver disease, antithrombotics and risk of cerebrovascular events: A population-based cohort study. Int J Cardiol 2016; 223:829-837. [PMID: 27580216 DOI: 10.1016/j.ijcard.2016.08.297] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Accepted: 08/19/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Whether patients with atrial fibrillation (AF) and liver disease are also prone to cerebrovascular events and respond similarly favorably to antithrombotic therapy remains under-investigated. METHODS Patients ≥18years with newly-diagnosed AF in the period 2005 to 2009 were scrutinized from the "Longitudinal Health Insurance Database 2005" (1 million beneficiaries) of Taiwan's National Health Insurance Institute. Patients were categorized into the Liver (N=433) or the Non-liver (N=3490) cohort according to whether they had a diagnosis of advanced liver disease. Patients were then followed to determine cumulative incidence of hospitalization-requiring cerebrovascular events, preventive effects of antithrombotics, and predictors of cerebrovascular events by Cox regression analysis. RESULTS Within a mean follow-up of 3.3±1.4years, ischemic stroke (89.2 vs. 50.3 per 1000 person-years, adjusted HR 1.502, 95% CI 1.207-1.868, p<0.001) and overall cerebrovascular events (102.3 vs. 56.4 per 1000 person-years, adjusted HR 1.535, 95% CI 1.251-1.883, p<0.001) occurred significantly more often in the Liver than in the Non-liver cohort. Cox models identified aging (≥65years), DM, and CHA2DS-VASc score≥2 points as risk factors for overall cerebrovascular events in the Liver cohort, whereas antiplatelet agents (HR 0.932, 95% CI 0.128-6.803, p=NS) and vit-K antagonistic anticoagulants (HR 1.087, 95% CI 0.150-7.862, p=NS) showed no correlation. CONCLUSION AF patients comorbid with advanced liver disease are more vulnerable to ischemic and therein overall cerebrovascular events, especially in those with old age, DM, or high CHA2DS-VASc scores. This propensity to cerebrovascular events, however, can't be altered by antithrombotic therapy.
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De Pietri L, Bianchini M, Montalti R, De Maria N, Di Maira T, Begliomini B, Gerunda GE, di Benedetto F, Garcia-Tsao G, Villa E. Thrombelastography-guided blood product use before invasive procedures in cirrhosis with severe coagulopathy: A randomized, controlled trial. Hepatology 2016; 63:566-73. [PMID: 26340411 DOI: 10.1002/hep.28148] [Citation(s) in RCA: 282] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Accepted: 08/22/2015] [Indexed: 12/16/2022]
Abstract
UNLABELLED Bleeding is a feared complication of invasive procedures in patients with cirrhosis and significant coagulopathy (as defined by routine coagulation tests) and is used to justify preprocedure use of fresh frozen plasma (FFP) and/or platelets (PLT). Thromboelastography (TEG) provides a more comprehensive global coagulation assessment than routine tests (international normalized ratio [INR] and platelet count), and its use may avoid unnecessary blood product transfusion in patients with cirrhosis and significant coagulopathy (defined in this study as INR >1.8 and/or platelet count <50 × 10(9) /L) who will be undergoing an invasive procedure. Sixty patients were randomly allocated to TEG-guided transfusion strategy or standard of care (SOC; 1:1 TEG:SOC). The TEG group would receive FFP if the reaction time (r) was >40 min and/or PLT if maximum amplitude (MA) was <30 mm. All SOC patients received FFP and/or PLT per hospital guidelines. Endpoints were blood product use and bleeding complications. Baseline characteristics of the two groups were similar. Per protocol, all subjects in the SOC group received blood product transfusions versus 5 in the TEG group (100% vs. 16.7%; P < 0.0001). Sixteen SOC (53.3%) received FFP, 10 (33.3%) PLT, and 4 (13.3%) both FFP and PLT. In the TEG group, none received FFP alone (P < 0.0001 vs. SOC), 2 received PLT (6.7%; P = 0.009 vs. SOC), and 3 both FFP and PLT (not significant). Postprocedure bleeding occurred in only 1 patient (SOC group) after large-volume paracentesis. CONCLUSIONS In patients with cirrhosis and significant coagulopathy before invasive procedures, TEG-guided transfusion strategy leads to a significantly lower use of blood products compared to SOC (transfusion guided by INR and platelet count), without an increase in bleeding complications. Remarkably, even in patients with significant coagulopathy, postprocedure bleeding was rare, indicating that TEG thresholds should be reevaluated.
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Affiliation(s)
- Lesley De Pietri
- Division of Anesthesiology and Intensive Care Unit, Department of Surgery, AOU Policlinico di Modena, Modena, Italy
| | - Marcello Bianchini
- Gastroenterology Unit, Department of Internal Medicine, AOU Policlinico di Modena, Modena, Italy
| | - Roberto Montalti
- Transplantation Unit, Department of Surgery, Polytechnic University of Marche, Ancona, Italy
| | - Nicola De Maria
- Gastroenterology Unit, Department of Internal Medicine, AOU Policlinico di Modena, Modena, Italy
| | - Tommaso Di Maira
- Gastroenterology Unit, Department of Internal Medicine, AOU Policlinico di Modena, Modena, Italy
| | - Bruno Begliomini
- Division of Anesthesiology and Intensive Care Unit, Department of Surgery, AOU Policlinico di Modena, Modena, Italy
| | | | - Fabrizio di Benedetto
- Transplantation Unit, Department of Surgery, AOU Policlinico di Modena, Modena Italy
| | - Guadalupe Garcia-Tsao
- Gastroenterology Unit, Department of Internal Medicine, AOU Policlinico di Modena, Modena, Italy.,Yale University School of Medicine, Department of Internal Medicine, Section of Digestive Diseases, New Haven, Connecticut, United States
| | - Erica Villa
- Gastroenterology Unit, Department of Internal Medicine, AOU Policlinico di Modena, Modena, Italy
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Palmer WC, Di Leo M, Jovani M, Heckman MG, Diehl NN, Iyer PG, Wolfsen HC, Wallace MB. Management of high grade dysplasia in Barrett's oesophagus with underlying oesophageal varices: A retrospective study. Dig Liver Dis 2015; 47:763-8. [PMID: 26066379 DOI: 10.1016/j.dld.2015.05.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Revised: 05/10/2015] [Accepted: 05/14/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Endoscopic treatment of Barrett's oesophagus leading to high grade dysplasia with oesophageal varices may lead to bleeding complications. AIMS Estimate effectiveness of endoscopic band-ligation in oesophageal varices patients treated for high grade dysplasia, and compare to endoscopically treated non-oesophageal varices high grade dysplasia patients. METHODS Retrospective comparative study. All 8 high grade dysplasia patients with varices who were treated initially with band-ligation at Mayo Clinic between 8/1/1999 and 2/28/2014 were compared with reference group of 52 high grade dysplasia patients treated endoscopically. RESULTS One high grade dysplasia patients patient with oesophageal varices (12.5%) achieved complete remission of intestinal metaplasia defined by at least one followup endoscopy with normal biopsies, and 3 (37.5%) achieved complete remission of dysplasia defined by at least one followup endoscopy with non-dysplastic biopsies. 39 (75.0%) endomucosal resection/radiofrequency ablation patients experienced at least one followup endoscopy with normal biopsies, and 49 (94.2%) experienced non-dysplastic biopsies. Both of these endpoints occurred significantly more often in the endomucosal resection/radiofrequency ablation group compared to the high grade dysplasia with oesophageal varices group (p=0.016 and p=0.025, respectively). CONCLUSIONS High grade dysplastic Barrett's can be safely managed with band-ligation. However, resolution of Barrett's epithelium is rarely achieved with banding alone.
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Affiliation(s)
- William C Palmer
- Department of Gastroenterology and Hepatology, Mayo Clinic Jacksonville, USA.
| | - Milena Di Leo
- Division of Gastroenterology and Gastrointestinal Endoscopy, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, Milan, Italy
| | - Manol Jovani
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Milan, Italy
| | - Michael G Heckman
- Division of Biomedical Statistics and Informatics, Mayo Clinic Jacksonville, USA
| | - Nancy N Diehl
- Division of Biomedical Statistics and Informatics, Mayo Clinic Jacksonville, USA
| | - Prasad G Iyer
- Department of Gastroenterology and Hepatology, Mayo Clinic Rochester, USA
| | - Herbert C Wolfsen
- Department of Gastroenterology and Hepatology, Mayo Clinic Jacksonville, USA
| | - Michael B Wallace
- Department of Gastroenterology and Hepatology, Mayo Clinic Jacksonville, USA
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20
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Qi X, De Stefano V, Li H, Dai J, Guo X, Fan D. Anticoagulation for the treatment of portal vein thrombosis in liver cirrhosis: a systematic review and meta-analysis of observational studies. Eur J Intern Med 2015; 26:23-9. [PMID: 25566699 DOI: 10.1016/j.ejim.2014.12.002] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Revised: 12/03/2014] [Accepted: 12/09/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Systematic review and meta-analysis were performed to evaluate the safety and efficacy of anticoagulation for the treatment of portal vein thrombosis (PVT) in cirrhotic patients. METHODS The PubMed, EMBASE, Cochrane Library, and ScienceDirect databases were searched. The rates of bleeding complications and portal vein recanalization in patients who received anticoagulant therapy were pooled. The odds ratio (OR) with 95% confidence interval (CI) was calculated to express the difference in the rate of portal vein recanalization between anticoagulation and non-anticoagulation groups. All meta-analyses were conducted by using a random-effects model. RESULTS Sixteen of 960 initially identified papers were included. Two studies reported a low incidence of major anticoagulation-related complications (4% [2/55] and 3% [1/33]), but no lethal complications occurred. The rate of anticoagulation-related bleeding ranged from 0% to 18% with a pooled rate of 3.3% (95% CI=1.1%-6.7%). The heterogeneity was not significant in the meta-analysis. The total rate of portal vein recanalization ranged from 37% to 93% with a pooled rate of 66.6% (95% CI=54.7%-77.6%). The rate of complete portal vein recanalization ranged from 0% to 75% with a pooled rate of 41.5% (95% CI=29.2%-54.5%). However, the heterogeneity was significant in the 2 meta-analyses. The rate of complete portal vein recanalization was significantly higher in anticoagulation group than in non-anticoagulation group (OR=4.16, 95% CI=1.88-9.20, P=0.0004). The heterogeneity was not significant in the meta-analysis. CONCLUSION Anticoagulation could achieve a relatively high rate of portal vein recanalization in cirrhotic patients with PVT. Given that only a small number of non-randomized comparative studies are reported, randomized controlled trials are warranted to confirm the risk-to-benefit of anticoagulation in such patients, especially anticoagulation-related bleeding.
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Affiliation(s)
- Xingshun Qi
- Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China; Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China.
| | | | - Hongyu Li
- Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China.
| | - Junna Dai
- Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China.
| | - Xiaozhong Guo
- Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China.
| | - Daiming Fan
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China.
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21
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Gado A, Ebeid B, Axon A. Prevalence and outcome of peptic ulcer bleeding in patients with liver cirrhosis. ALEXANDRIA JOURNAL OF MEDICINE 2014. [DOI: 10.1016/j.ajme.2014.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Affiliation(s)
- Ahmed Gado
- Department of Medicine, Bolak Eldakror Hospital , Giza, Egypt
| | - Basel Ebeid
- Department of Tropical Medicine and Infectious Diseases, Beny Suef University , Beny Suef, Egypt
| | - Anthony Axon
- Department of Gastroenterology, The General Infirmary at Leeds , Leeds, United Kingdom
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22
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Mallett SV, Chowdary P, Burroughs AK. Clinical utility of viscoelastic tests of coagulation in patients with liver disease. Liver Int 2013; 33:961-74. [PMID: 23638693 DOI: 10.1111/liv.12158] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Accepted: 02/28/2013] [Indexed: 12/18/2022]
Abstract
The prothrombin time (PT) and international normalised ratio (INR) are used in scoring systems (Child-Pugh, MELD, UKELD) in chronic liver disease and as a prognostic tool and for dynamic monitoring of hepatic function in acute liver disease. These tests are known to be poor predictors of bleeding risk in liver disease; however, they continue to influence clinical management decisions. Recent work on coagulation in liver disease, in particular thrombin generation studies, has led to a paradigm shift in our understanding and it is now recognised that haemostasis is relatively well preserved. Whole blood global viscoelastic tests (TEG(®) /ROTEM(®) ) produce a composite dynamic picture of the entire coagulation process and have the potential to provide more clinically relevant information in patients with liver disease. We performed a systematic review of all relevant studies that have used viscoelastic tests (VET) of coagulation in patients with liver disease. Although many studies are observational and small in size, it is clear that VET provide additional information that is in keeping with the new concepts of how coagulation is altered in these patients. This review provides the basis for large scale, prospective outcome studies to establish the clinical value of these tests.
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Affiliation(s)
- Susan V Mallett
- Department of Anaesthesia, Royal Free London NHS Foundation Trust, London, UK
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23
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Yu S, Feng ZJ. Tissue factor pathway inhibitor and liver diseases. Shijie Huaren Xiaohua Zazhi 2013; 21:996-1001. [DOI: 10.11569/wcjd.v21.i11.996] [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] [Indexed: 02/06/2023] Open
Abstract
Tissue factor pathway inhibitor (TFPI) is a proteinase inhibitor that is synthesized by microvascular endothelial cells and can primarily exert anticoagulant and anti-inflammatory effects. In chronic liver disease and early liver cirrhosis, tissue factors are excessively expressed due to continuous stress, infections and inflammatory stimulation in liver microvascular endothelial cells, which may lead to the rise of TFPI concentration. In severe liver disease and liver cirrhosis complicated with portal vein thrombosis (PVT), the level of TFPI may decline for massive consumption. Recombinant TFPI (rTFPI) can effectively protect against PVT, reduce the mortality of disseminated or diffuse intravascular coagulation and improve inflammation. Understanding of the role of TFPI in liver diseases may provide potential strategy for the prevention and treatment of liver cirrhosis and its complications.
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24
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Jo YW, Choi JY, Ha CY, Min HJ, Lee OJ. The Clinical Features and Prognostic Factors of Nonvariceal Upper Gastrointestinal Bleeding in the Patients with Liver Cirrhosis. THE KOREAN JOURNAL OF HELICOBACTER AND UPPER GASTROINTESTINAL RESEARCH 2013. [DOI: 10.7704/kjhugr.2013.13.4.235] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Yoon-Won Jo
- Department of Internal Medicine, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Ja-Yoon Choi
- Department of Internal Medicine, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Chang-Yoon Ha
- Department of Internal Medicine, Gyeongsang National University School of Medicine, Jinju, Korea
- Gyeongsang Institute of Health Sciences, Jinju, Korea
| | - Hyun-Ju Min
- Department of Internal Medicine, Gyeongsang National University School of Medicine, Jinju, Korea
- Gyeongsang Institute of Health Sciences, Jinju, Korea
| | - Ok-Jae Lee
- Department of Internal Medicine, Gyeongsang National University School of Medicine, Jinju, Korea
- Gyeongsang Institute of Health Sciences, Jinju, Korea
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25
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Hall D, Lone N, Watson D, Stanworth S, Walsh T. Factors associated with prophylactic plasma transfusion before vascular catheterization in non-bleeding critically ill adults with prolonged prothrombin time: a case–control study. Br J Anaesth 2012; 109:919-27. [DOI: 10.1093/bja/aes337] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
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26
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Yang SC, Wu KL, Wang JH, Lee CH, Kuo YH, Tai WC, Chen CH, Chiou SS, Lu SN, Hu TH, Changchien CS, Chuah SK. The effect of systemic antibiotic prophylaxis for cirrhotic patients with peptic ulcer bleeding after endoscopic interventions. Hepatol Int 2012. [DOI: 10.1007/s12072-012-9378-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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27
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Yang L, Stanworth S, Hopewell S, Doree C, Murphy M. Is fresh-frozen plasma clinically effective? An update of a systematic review of randomized controlled trials. Transfusion 2012; 52:1673-86; quiz 1673. [PMID: 22257164 DOI: 10.1111/j.1537-2995.2011.03515.x] [Citation(s) in RCA: 204] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The clinical use of frozen plasma (FP) continues to increase, both in prophylactic and in therapeutic settings. In 2004, a systematic review of all published randomized controlled trials (RCTs) revealed a lack of evidence that supported the efficacy of FP use. This is an update that includes all new RCTs published since the original review. STUDY DESIGN AND METHODS Trials involving transfusion of FP up to July 2011 were identified from searches of MEDLINE, EMBASE, CINAHL, The Cochrane Library, and the UKBTS/SRI Transfusion Evidence Library. Methodologic quality was assessed. The primary outcome measure was the effect of FP on survival. RESULTS Twenty-one new trials were eligible for inclusion. These covered prophylactic and therapeutic FP use in liver disease, in cardiac surgery, for warfarin anticoagulation reversal, for thrombotic thrombocytopenic purpura treatment, for plasmapheresis, and in other settings, including burns, shock, and head injury. The largest number of recent RCTs were conducted in cardiac surgery; meta-analysis showed no significant difference for FP use for the outcome of 24-hours postoperative blood loss (weighted mean difference, -35.24 mL; 95% confidence interval, -84.16 to 13.68 mL). Overall, there was no significant benefit for FP use across all the clinical conditions. Only two of the 21 trials fulfilled all the criteria for quality assessment. CONCLUSION Combined with the 2004 review, 80 RCTs have investigated FP with no consistent evidence of significant benefit for prophylactic and therapeutic use across a range of indications evaluated. There has been little improvement in the overall methodologic quality of RCTs conducted in the past few years.
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Affiliation(s)
- Lucy Yang
- NHS Blood and Transplant, Oxford, UK
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28
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Nonvariceal upper gastrointestinal bleeding in patients with liver cirrhosis. Clinical features, outcomes and predictors of in-hospital mortality. A prospective study. Ann Hepatol 2011. [PMID: 21677330 DOI: 10.1016/s1665-2681(19)31540-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
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