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Li Z, Xu W, Wang L, Chai L, Ageno W, Romeiro FG, Li H, Qi X. Risk of Bleeding in Liver Cirrhosis Receiving Direct Oral Anticoagulants: A Systematic Review and Meta-analysis. Thromb Haemost 2023; 123:1072-1088. [PMID: 37336474 DOI: 10.1055/s-0043-1770100] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) are effective for the management of thromboembolic disorders. However, bleeding remains a major concern in cirrhotic patients receiving DOACs. METHODS PubMed, EMBASE, and Cochrane Library databases were searched. The incidence of bleeding episodes in cirrhotic patients receiving DOACs was pooled. Odds ratios (ORs) were calculated to compare the incidence of bleeding episodes in cirrhotic patients who received DOACs versus those who received conventional anticoagulants and did not receive anticoagulants. RESULTS Twenty-nine studies were included. All bleeding, major bleeding, fatal bleeding, gastrointestinal bleeding, and intracranial hemorrhage episodes were observed in 310/2,469, 100/1,388, 2/611, 166/1,886, and 5/1,147 cirrhotic patients receiving DOACs, respectively. Their pooled incidences were 13, 6, 0, 8, and 0%, respectively. They became higher in subgroup analyses of studies with advanced age, a longer treatment duration, and Child-Turcotte-Pugh class C. Compared with conventional anticoagulants, DOACs were associated with lower incidences of all bleeding (OR = 0.71, 95% confidence interval [CI] = 0.52-0.98) and major bleeding (OR = 0.55, 95% CI = 0.37-0.83) in cirrhotic patients, but not those of fatal bleeding (OR = 0.21, 95% CI = 0.04-1.28), gastrointestinal bleeding (OR = 0.78, 95% CI = 0.52-1.17), or intracranial hemorrhage (OR = 0.36, 95% CI = 0.12-1.12). The incidences of all bleeding (OR = 1.04, 95% CI = 0.22-4.79) and major bleeding (OR = 0.96, 95% CI = 0.26-3.61) did not significantly differ between cirrhotic patients with portal vein thrombosis (PVT) who received DOACs and those who did not receive anticoagulants. CONCLUSION DOACs carry a low risk of bleeding in liver cirrhosis. Age, treatment duration, and Child-Turcotte-Pugh class may be associated with bleeding in cirrhotic patients receiving DOACs. The risk of bleeding is not increased by DOACs in cirrhotic patients with PVT.
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Affiliation(s)
- Zhe Li
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Department of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China
| | - Wentao Xu
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Department of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China
| | - Le Wang
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Postgraduate College, China Medical University, Shenyang, China
| | - Lu Chai
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Department of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Fernando Gomes Romeiro
- Department of Internal Medicine, Botucatu Medical School, São Paulo State University (UNESP), São Paulo, Brazil
| | - Hongyu Li
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Department of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China
- Postgraduate College, China Medical University, Shenyang, China
| | - Xingshun Qi
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Department of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China
- Postgraduate College, China Medical University, Shenyang, China
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Lapenna L, Di Cola S, Gazda J, De Felice I, Gioia S, Merli M. New Indications for TIPSs: What Do We Know So Far? J Clin Exp Hepatol 2023; 13:794-803. [PMID: 37693277 PMCID: PMC10483008 DOI: 10.1016/j.jceh.2023.01.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 01/29/2023] [Indexed: 09/12/2023] Open
Abstract
Since 1988, transjugular intrahepatic portosystemic shunt (TIPS) has been an effective therapy for portal hypertension in many settings. Thanks to continuous technical improvements and a wiser selection of patients, excellent results have been achieved with this therapeutic strategy. The historical indications for TIPS placement, in the context of liver cirrhosis, such as refractory ascites and variceal bleeding are now well established and known. However, in recent years, new indications are emerging. These have been investigated and approved in some studies but are not yet included in guidelines and clinical practice. This review aims to highlight what is new for the role of TIPS in portal vein thrombosis (especially in patients awaiting liver transplantation), in recurrent ascites and not only refractory ascites, as a neoadjuvant therapy before abdominal surgery and, finally, in the setting of noncirrhotic portal hypertension. All these new aspects are addressed in this review with a critical approach based on the literature revision and clinical practice. Future research is needed to explore and validate the new role of TIPS in these scenarios.
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Affiliation(s)
- Lucia Lapenna
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Simone Di Cola
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Jakub Gazda
- 2nd Department of Internal Medicine, PJ Safarik University and L. Pasteur University Hospital in Kosice, Slovakia
| | - Ilaria De Felice
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Stefania Gioia
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Manuela Merli
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
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Guerrero A, Campo LD, Piscaglia F, Scheiner B, Han G, Violi F, Ferreira CN, Téllez L, Reiberger T, Basili S, Zamora J, Albillos A. Anticoagulation improves survival in patients with cirrhosis and portal vein thrombosis: The IMPORTAL competing-risk meta-analysis. J Hepatol 2023; 79:69-78. [PMID: 36858157 DOI: 10.1016/j.jhep.2023.02.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 01/19/2023] [Accepted: 02/13/2023] [Indexed: 03/03/2023]
Abstract
BACKGROUND & AIMS Previous meta-analyses demonstrated the safety and efficacy of anticoagulation in the recanalization of portal vein thrombosis in patients with cirrhosis. Whether this benefit translates into improved survival is unknown. We conducted an individual patient data (IPD) meta-analysis to assess the effect of anticoagulation on all-cause mortality in patients with cirrhosis and portal vein thrombosis. METHODS In this IPD meta-analysis, we selected studies comparing anticoagulation vs. no treatment in patients with cirrhosis and portal vein thrombosis from PubMed, Embase, and Cochrane databases (until June 2020) (PROSPERO no.: CRD42020140026). IPD were subsequently requested from authors. The primary outcome - the effect of anticoagulation on all-cause mortality - was assessed by a one-step meta-analysis based on a competing-risk model with liver transplantation as the competing event. The model was adjusted for clinically relevant confounders. A multilevel mixed-effects logistic regression model was used to determine the effect of anticoagulation on recanalization. RESULTS Individual data on 500 patients from five studies were included; 205 (41%) received anticoagulation and 295 did not. Anticoagulation reduced all-cause mortality (adjusted subdistribution hazard ratio 0.59; 95% CI 0.49-0.70), independently of thrombosis severity and recanalization. The effect of anticoagulation on all-cause mortality was consistent with a reduction in liver-related mortality. The recanalization rate was higher in the anticoagulation arm (adjusted odds ratio 3.45; 95% CI 2.22-5.36). The non-portal-hypertension-related bleeding rate was significantly greater in the anticoagulation group. CONCLUSIONS Anticoagulation reduces all-cause mortality in patients with cirrhosis and portal vein thrombosis independently of recanalization, but at the expense of increasing non-portal hypertension-related bleeding. PROSPERO REGISTRATION NUMBER CRD42020140026. IMPACT AND IMPLICATIONS Anticoagulation is effective in promoting recanalization of portal vein thrombosis in patients with cirrhosis, but whether this benefit translates into improved survival is controversial. Our individual patient data meta-analysis based on a competing-risk model with liver transplantation as the competing event shows that anticoagulation reduces all-cause mortality in patients with cirrhosis and portal vein thrombosis independently of recanalization. According to our findings, portal vein thrombosis may identify a group of patients with cirrhosis that benefit from long-term anticoagulation.
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Affiliation(s)
- Antonio Guerrero
- Servicio de Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto Salud Carlos III, Madrid, Spain
| | - Laura Del Campo
- Unidad de Bioestadística Clínica. Hospital Universitario Ramón y Cajal. Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Fabio Piscaglia
- Division of Internal Medicine, Hepatobiliary and Immunoallergic Diseases, IRCCS Azienda Ospedaliero Universitaria di Bologna, Italy
| | - Bernhard Scheiner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna. Rare Liver Disease (RALID) Center of the European Reference Network for Rare Hepatological Diseases (ERN RARE-LIVER), Medical University Vienna, Vienna, Austria
| | - Guohong Han
- Department of Liver Diseases and Digestive Interventional Radiology, Xi'an International Medical Center Hospital, Digestive Diseases Hospital, Northwest University, Xi'an, China; Department of Liver Disease and Digestive Interventional Radiology, Xijing Hospital of Digestive Diseases, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Francesco Violi
- Department of Internal Medicine, Anestesiology and Cardiovascular Sciences, Sapienza University, Roma, Italy
| | - Carlos-Noronha Ferreira
- Servico de Gastrenterologia e Hepatologia, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Clinica Universitaria de Gastrenterologia, Facultad de Medicina, Lisbon, Portugal
| | - Luis Téllez
- Servicio de Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto Salud Carlos III, Madrid, Spain
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna. Rare Liver Disease (RALID) Center of the European Reference Network for Rare Hepatological Diseases (ERN RARE-LIVER), Medical University Vienna, Vienna, Austria
| | - Stefania Basili
- Department of Internal Medicine, Anestesiology and Cardiovascular Sciences, Sapienza University, Roma, Italy
| | - Javier Zamora
- Unidad de Bioestadística Clínica. Hospital Universitario Ramón y Cajal. Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain; Institute of Metabolism and Systems Research, University of Birmingham, United Kingdom
| | - Agustín Albillos
- Servicio de Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto Salud Carlos III, Madrid, Spain.
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Yao C, Zhao M, Ibrahim B, Saab S. Anticoagulation for the Treatment of Portal Vein Thrombosis in Cirrhosis: A Systematic Review and Meta-Analysis of Comparative Studies. J Clin Exp Hepatol 2023; 13:404-413. [PMID: 37250883 PMCID: PMC10213860 DOI: 10.1016/j.jceh.2022.12.016] [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] [Received: 05/30/2022] [Revised: 12/13/2022] [Accepted: 12/24/2022] [Indexed: 05/31/2023] Open
Abstract
Background Portal vein thrombosis (PVT) leads to significant morbidity and mortality burden in patients with cirrhosis. An improved understanding of the utility of anticoagulation in patients with PVT will aid clinical decision making and inform future research. This meta-analysis aimed to evaluate the association between anticoagulation therapy and clinical outcomes in the context of treatment for PVT in cirrhosis. Methods Pubmed, Embase, and Web of Science were searched from inception to February 13, 2022, for studies comparing the use of anticoagulation to other modalities as treatment for PVT in cirrhosis. Pooled odds ratios (OR) were calculated using a random-effects model for PVT improvement, recanalization, progression, bleeding events, and all-cause mortality in treatment studies. Results We identified 944 records, of which 16 studies (n = 1126) examining anticoagulation as PVT treatment were included for subsequent analysis. Anticoagulation as PVT treatment was associated with PVT improvement (OR 3.64; 95% CI 2.56-5.17), PVT recanalization (OR 3.73; 95% CI 2.45-5.68), decreased PVT progression (OR 0.38; 95% CI 0.23-0.63), and decreased all-cause mortality (OR 0.47; 95% CI 0.29-0.75). The use of anticoagulation was not associated with bleeding events (OR 0.80; 95% CI 0.39-1.66). All analyses demonstrated low heterogeneity. Conclusions These results support the use of anticoagulation in cirrhosis as treatment for PVT. These findings may inform the clinical management of PVT and highlight the need for further studies such as large randomized controlled trials characterizing the safety and efficacy of anticoagulation for PVT in cirrhosis.
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Affiliation(s)
- Calvin Yao
- Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | - Matthew Zhao
- Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | - Brittney Ibrahim
- Departments of Surgery, University of California at Los Angeles, Los Angeles, CA, USA
| | - Sammy Saab
- Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
- Departments of Surgery, University of California at Los Angeles, Los Angeles, CA, USA
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Prakash S, Bies J, Hassan M, Mares A, Didia SC. Portal vein thrombosis in cirrhosis: A literature review. Front Med (Lausanne) 2023; 10:1134801. [PMID: 37181351 PMCID: PMC10169608 DOI: 10.3389/fmed.2023.1134801] [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] [Received: 12/30/2022] [Accepted: 03/03/2023] [Indexed: 05/16/2023] Open
Abstract
Portal Vein Thrombosis (PVT), a common complication of advanced liver disease, is defined as an obstruction of the portal vein due to thrombus formation that can extend to the superior mesenteric and splenic veins. It was believed that PVT occurred predominantly due to prothrombotic potential. However, recent studies have shown that decreased blood flow related to portal hypertension appears to increase PVT risk as per Virchow's triad. It is well known that there is a higher incidence of PVTs in cirrhosis with a higher MELD and Child Pugh score. The controversy for management of PVTs in cirrhotics lies in the individualized assessment of risks versus benefits of anticoagulation, since these patients have a complex hemostatic profile with both bleeding and procoagulant propensities. In this review, we will systematically compile the etiology, pathophysiology, clinical features, and management of portal vein thrombosis in cirrhosis.
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Affiliation(s)
- Swathi Prakash
- Department of Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, United States
| | - Jared Bies
- Department of Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, United States
| | - Mariam Hassan
- Department of Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, United States
| | - Adriana Mares
- Paul L. Foster School of Medicine, El Paso, TX, United States
| | - S. Claudia Didia
- Department of Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, United States
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Zhong X, Li S, Hu J, Lu J, Wang W, Hu M, Sun Q, Zhang S, Yang X, Yang C, Zhong L. Development and external validation of prognostic scoring models for portal vein thrombosis: a multicenter retrospective study. Thromb J 2023; 21:9. [PMID: 36691024 PMCID: PMC9869608 DOI: 10.1186/s12959-023-00455-w] [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] [Received: 10/16/2022] [Accepted: 01/18/2023] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Portal vein thrombosis is a common complication of liver cirrhosis and hepatocellular carcinoma; however, few studies have reported its long-term clinical prognosis. This study aimed to establish and validate easy-to-use nomograms for predicting gastrointestinal bleeding, portal vein thrombosis resolution, and mortality of patients with portal vein thrombosis. METHODS This multicenter retrospective cohort study included 425 patients with portal vein thrombosis who were divided into training (n = 334) and validation (n = 91) sets. Prediction models were developed using multivariate Cox regression analysis and evaluated using the consistency index and calibration plots. RESULTS Predictors of gastrointestinal bleeding included a history of gastrointestinal bleeding, superior mesenteric vein thrombosis, red color sign observed during endoscopy, and hepatic encephalopathy. Meanwhile, predictors of resolution of portal vein thrombosis included a history of abdominal infection, C-reactive protein and hemoglobin levels, and intake of thrombolytics. Predictors of death included abdominal infection, abdominal surgery, aspartate aminotransferase level, hepatic encephalopathy, and ascites. All models had good discriminatory power and consistency. Anticoagulation therapy significantly increased the probability of thrombotic resolution without increasing the risk of bleeding or death. CONCLUSIONS We successfully developed and validated three prediction models that can aid in the early evaluation and treatment of portal vein thrombosis.
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Affiliation(s)
- Xuan Zhong
- Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, 150, Jimo Road, Pudong New Area, Shanghai, 200120, China
| | - Shan Li
- Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, 150, Jimo Road, Pudong New Area, Shanghai, 200120, China
| | - Jiali Hu
- Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, 150, Jimo Road, Pudong New Area, Shanghai, 200120, China
| | - Jinlai Lu
- Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, 150, Jimo Road, Pudong New Area, Shanghai, 200120, China
| | - Wei Wang
- Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, 150, Jimo Road, Pudong New Area, Shanghai, 200120, China
| | - Miao Hu
- Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, 150, Jimo Road, Pudong New Area, Shanghai, 200120, China
| | - Qinjuan Sun
- Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, 150, Jimo Road, Pudong New Area, Shanghai, 200120, China
| | - Shuo Zhang
- Department of Gastroenterology, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xiaoqing Yang
- Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, 150, Jimo Road, Pudong New Area, Shanghai, 200120, China
| | - Changqing Yang
- Department of Gastroenterology, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Lan Zhong
- Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, 150, Jimo Road, Pudong New Area, Shanghai, 200120, China.
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Zhou Y, Zhuang Z, Yu T, Zhang W, Ma J, Yu J, Yan Z, Luo J. Long-term efficacy and safety of anticoagulant for cavernous transformation of the portal vein cirrhotic patient with extrahepatic portal vein obstruction. Thromb J 2023; 21:6. [PMID: 36631860 PMCID: PMC9832773 DOI: 10.1186/s12959-023-00449-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 01/05/2023] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND/AIMS Cavernous transformation of the portal vein (CTPV) in cirrhotic patients with extrahepatic portal vein obstruction (EHPVO) was a relatively rare disease and had no consensus on the treatment. Our study aimed to explore the value of anticoagulation with warfarin treatment for CTPV cirrhotic patients with EHPVO. METHODS From January 2015 to December 2019, the clinical characteristics of cirrhotic patients who were diagnosed as CTPV with EHPVO were retrospectively analyzed. Eligible patients were distributed into the anticoagulation group (n = 46) and control group (n = 38). The change of portal vein thrombosis, hepatic decompensation, survival and adverse events were evaluated between the two groups. RESULTS The median follow-up of our patients was 51 months in the anticoagulation group and 44 months in the control group. The progress rate of the portal vein was higher in patients from the control groups (n = 12) than in patients from the anticoagulation group (n = 4, p = 0.008). There was no significant difference between the partial recanalization rate and stable rate between the two groups. Patients in anticoagulation group developed less hepatic decompensation than those in control group (13.0% vs 34.2%, p = 0.021). The Kaplan-Meier curve showed that patients in the anticoagulation group had a better prognosis than patients in the control group (P < 0.022). There were no serious complications due to warfarin treatment. CONCLUSION For CTPV cirrhotic patients with EHPVO, anticoagulation with warfarin treatment was effective and safe. Anticoagulants could prevent portal vein thrombosis progression, hepatic decompensation and death. In addition, our results showed little benefit of anticoagulants on thrombosis recanalization.
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Affiliation(s)
- Yongjie Zhou
- grid.8547.e0000 0001 0125 2443Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China ,Shanghai Institution of Medical Imaging, Shanghai, China ,grid.8547.e0000 0001 0125 2443National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhiquan Zhuang
- grid.8547.e0000 0001 0125 2443Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China ,grid.8547.e0000 0001 0125 2443Department of Interventional Radiology, Xiamen Branch, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tianzhu Yu
- grid.8547.e0000 0001 0125 2443Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China ,Shanghai Institution of Medical Imaging, Shanghai, China
| | - Wen Zhang
- grid.8547.e0000 0001 0125 2443Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China ,Shanghai Institution of Medical Imaging, Shanghai, China ,grid.8547.e0000 0001 0125 2443National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jingqin Ma
- grid.8547.e0000 0001 0125 2443Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China ,Shanghai Institution of Medical Imaging, Shanghai, China ,grid.8547.e0000 0001 0125 2443National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jiaze Yu
- grid.8547.e0000 0001 0125 2443Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China ,Shanghai Institution of Medical Imaging, Shanghai, China ,grid.8547.e0000 0001 0125 2443National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhiping Yan
- grid.8547.e0000 0001 0125 2443Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China ,Shanghai Institution of Medical Imaging, Shanghai, China ,grid.8547.e0000 0001 0125 2443National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China ,grid.8547.e0000 0001 0125 2443Center for Tumor Diagnosis and Therapy, Jinshan Hospital, Fudan University, Shanghai, China
| | - Jianjun Luo
- grid.8547.e0000 0001 0125 2443Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China ,Shanghai Institution of Medical Imaging, Shanghai, China ,grid.8547.e0000 0001 0125 2443National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China ,grid.8547.e0000 0001 0125 2443Center for Tumor Diagnosis and Therapy, Jinshan Hospital, Fudan University, Shanghai, China
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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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Sacco M, Tardugno M, Lancellotti S, Ferretti A, Ponziani FR, Riccardi L, Zocco MA, De Magistris A, Santopaolo F, Pompili M, De Cristofaro R. ADAMTS-13/von Willebrand factor ratio: A prognostic biomarker for portal vein thrombosis in compensated cirrhosis. A prospective observational study. Dig Liver Dis 2022; 54:1672-1680. [PMID: 35778228 DOI: 10.1016/j.dld.2022.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 05/13/2022] [Accepted: 06/07/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND AIMS In cirrhosis, decreased portal flow velocity, thrombophilia factors, and portal hypertension are considered risk factors for portal vein thrombosis (PVT). In cirrhosis, the transformation of the stellate cells causes a progressive decrease of ADAMTS-13, while VWF multimers secretion by endothelial cells is strongly enhanced. This imbalance leads to an accumulation of ultra-large VWF multimers that in sinusoidal circulation could favor PVT both in intra- and extra-hepatic branches, mostly in decompensated cirrhosis. This prospective study was aimed at identifying possible clinical, biochemical, and hemostatic factors predictive for non-tumoral PVT in a cohort of patients with compensated cirrhosis. METHODS Seventynine compensated cirrhosis patients were prospectively followed for 48 months, receiving a periodic Doppler-ultrasound liver examination associated with an extensive evaluation of clinical, biochemical, and hemostatic profile. RESULTS Five patients developed PVT (cumulative prevalence = 6.3%), occurring 4-36 months after enrollment. In logistic regression analysis, the ADAMTS-13/VWF:GpIbR ratio < 0.4 was the only independent variable significantly associated with PVT (OR 14.6, 95% C.I.:1.36-157.2, p = 0.027). A Cox-regression-analysis confirmed this finding (HR = 7.7, p = 0.027). CONCLUSIONS The ADAMTS-13/VWF ratio < 0.4 measured in compensated cirrhosis could be a reliable predictive biomarker for PVT development, paving the way to novel therapeutic strategies to prevent and treat PVT in this clinical setting.
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Affiliation(s)
- Monica Sacco
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica S. Cuore, Facoltà di Medicina e Chirurgia "Agostino Gemelli", Roma, Italy
| | - Maira Tardugno
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica S. Cuore, Facoltà di Medicina e Chirurgia "Agostino Gemelli", Roma, Italy
| | - Stefano Lancellotti
- Servizio Malattie Emorragiche e Trombotiche, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Roma, Italy
| | - Antonietta Ferretti
- Servizio Malattie Emorragiche e Trombotiche, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Roma, Italy
| | - Francesca Romana Ponziani
- Dipartimento di Scienze Mediche e Chirurgiche, Hepatology Service, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica S. Cuore, Roma, Italy
| | - Laura Riccardi
- Dipartimento di Scienze Mediche e Chirurgiche, Hepatology Service, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica S. Cuore, Roma, Italy
| | - Maria Assunta Zocco
- Dipartimento di Scienze Mediche e Chirurgiche, Hepatology Service, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica S. Cuore, Roma, Italy
| | - Antonio De Magistris
- Dipartimento di Scienze Mediche e Chirurgiche, Hepatology Service, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica S. Cuore, Roma, Italy
| | - Francesco Santopaolo
- Dipartimento di Scienze Mediche e Chirurgiche, Hepatology Service, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica S. Cuore, Roma, Italy
| | - Maurizio Pompili
- Dipartimento di Scienze Mediche e Chirurgiche, Hepatology Service, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica S. Cuore, Roma, Italy
| | - Raimondo De Cristofaro
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica S. Cuore, Facoltà di Medicina e Chirurgia "Agostino Gemelli", Roma, Italy; Servizio Malattie Emorragiche e Trombotiche, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Roma, Italy.
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10
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Odriozola A, Puente Á, Cuadrado A, Rivas C, Anton Á, González FJ, Pellón R, Fábrega E, Crespo J, Fortea JI. Portal Vein Thrombosis in the Setting of Cirrhosis: A Comprehensive Review. J Clin Med 2022; 11:6435. [PMID: 36362663 PMCID: PMC9655000 DOI: 10.3390/jcm11216435] [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: 10/08/2022] [Revised: 10/26/2022] [Accepted: 10/28/2022] [Indexed: 08/06/2023] Open
Abstract
Portal vein thrombosis constitutes the most common thrombotic event in patients with cirrhosis, with increased rates in the setting of advanced liver disease. Despite being a well-known complication of cirrhosis, the contribution of portal vein thrombosis to hepatic decompensation and overall mortality is still a matter of debate. The incorporation of direct oral anticoagulants and new radiological techniques for portal vein recanalization have expanded our therapeutic arsenal. However, the lack of large prospective observational studies and randomized trials explain the heterogenous diagnostic and therapeutic recommendations of current guidelines. This article seeks to make a comprehensive review of the pathophysiology, clinical features, diagnosis, and treatment of portal vein thrombosis in patients with cirrhosis.
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Affiliation(s)
- Aitor Odriozola
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, 39008 Santander, Spain
| | - Ángela Puente
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, 39008 Santander, Spain
| | - Antonio Cuadrado
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, 39008 Santander, Spain
| | - Coral Rivas
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, 39008 Santander, Spain
| | - Ángela Anton
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, 39008 Santander, Spain
| | | | - Raúl Pellón
- Radiology Department, Marqués de Valdecilla University Hospital, 39008 Santander, Spain
| | - Emilio Fábrega
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, 39008 Santander, Spain
| | - Javier Crespo
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, 39008 Santander, Spain
| | - José Ignacio Fortea
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, 39008 Santander, Spain
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11
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Pan J, Wang L, Gao F, An Y, Yin Y, Guo X, Nery FG, Yoshida EM, Qi X. Epidemiology of portal vein thrombosis in liver cirrhosis: A systematic review and meta-analysis. Eur J Intern Med 2022; 104:21-32. [PMID: 35688747 DOI: 10.1016/j.ejim.2022.05.032] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 05/23/2022] [Accepted: 05/30/2022] [Indexed: 01/30/2023]
Abstract
BACKGROUND Portal vein thrombosis (PVT) may be associated with negative outcomes in patients with liver cirrhosis. However, the prevalence and incidence of PVT in liver cirrhosis are heterogeneous among studies and have not been sufficiently determined yet. METHODS The PubMed, EMBASE, and Cochrane Library databases were searched. Eligible studies would explore the prevalence and/or incidence of PVT in liver cirrhosis without hepatocellular carcinoma or abdominal surgery. Pooled proportion with 95% confidence interval (CI) was calculated using a random-effect model. Factors associated with the presence/occurrence of PVT were also extracted. RESULTS Among the 8549 papers initially identified, 74 were included. Fifty-four studies explored the prevalence of PVT in liver cirrhosis with a pooled prevalence of 13.92% (95%CI=11.18-16.91%). Based on cross-sectional data, Child-Pugh class B/C, higher D-dimer, ascites, and use of non-selective beta-blockers (NSBBs) were associated with the presence of PVT in liver cirrhosis. Twenty-three studies explored the incidence of PVT in liver cirrhosis with a pooled incidence of 10.42% (95%CI=8.16-12.92%). Based on cohort data, Child-Pugh class B/C, higher model of end-stage liver disease score, higher D-dimer, lower platelets count, decreased portal flow velocity, ascites, use of NSBBs, and moderate or high-risk esophageal varices could predict the occurrence of PVT in liver cirrhosis. CONCLUSION Approximately one seventh of cirrhotic patients have PVT, and one tenth will develop PVT. Progression of liver cirrhosis and portal hypertension seems to be in parallel with the risk of PVT. Prospective studies with detailed information about classification and extension of PVT in liver cirrhosis are needed.
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Affiliation(s)
- Jiahui Pan
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, PR China; Postgraduate College, Shenyang Pharmaceutical University, Shenyang 110016, PR China
| | - Le Wang
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, PR China; Postgraduate College, China Medical University, Shenyang 110122, PR China
| | - Fangbo Gao
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, PR China; Postgraduate College, Shenyang Pharmaceutical University, Shenyang 110016, PR China
| | - Yang An
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, PR China; Postgraduate College, Shenyang Pharmaceutical University, Shenyang 110016, PR China
| | - Yue Yin
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, PR China
| | - Xiaozhong Guo
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, PR China
| | - Filipe Gaio Nery
- Centro Hospitalar Universitário do Porto, Porto, Portugal; EpiUnit, Instituto de Saúde Pública da Universidade do Porto, Porto, Portugal
| | - Eric M Yoshida
- Division of Gastroenterology, Vancouver General Hospital, Vancouver, BC, Canada
| | - Xingshun Qi
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, PR China; Postgraduate College, Shenyang Pharmaceutical University, Shenyang 110016, PR China; Postgraduate College, China Medical University, Shenyang 110122, PR China.
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12
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McMurry H, Sabile JM, Elstrott B, Chobrutskiy B, Mohinani A, Patel S, Gowda S, Martens K, Shatzel J. Clinical predictors for thrombus progression in cirrhotic patients with untreated splanchnic vein thrombosis. Thromb Res 2022; 216:1-7. [PMID: 35660708 PMCID: PMC9464500 DOI: 10.1016/j.thromres.2022.05.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 05/07/2022] [Accepted: 05/23/2022] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Splanchnic vein thrombosis (SVT) occurs in a heterogenous group of patients secondary to a variety of risk factors including liver disease. Minimal data regarding natural history and outcomes of SVT exists to inform management decisions. As such, there is equipoise regarding the utility of anticoagulation in cirrhotic patients with SVT. We sought to identify clinical factors predictive of new or progressive thrombosis in a cohort of patients with untreated SVT. METHODS We conducted a retrospective cohort study of cirrhotic patients over 18 years of age diagnosed with SVT at the Oregon Health & Science University from 2015 to 2020, excluding those initially treated with anticoagulation. The primary study endpoint was a composite of the following: imaging-confirmed progression of SVT, development of cavernous transformation, intestinal ischemia, portal cholangiopathy or new venous or arterial thrombosis. RESULTS 261 patients were included in the analysis (median age 61 years, 68% male, 32% female). Forty percent of all patients experienced the primary composite endpoint. Multivariable logistic regression found that only the presence of pancreatitis or abdominal infection at diagnosis was associated with an increased likelihood of experiencing thrombus progression in patients with untreated SVT (OR 3.61, P = 0.02). There was a statistically significant overall survival difference between patients that did and did not experience the primary composite endpoint after controlling for confounding variables. (p = 0.0068). CONCLUSIONS Overall, only the presence of pancreatitis or intrabdominal infection were found to be significantly associated with thrombotic progression, with varices identified as marginally non-significant risk factor. Notably, thrombotic progression was associated with a significant reduction in overall survival.
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Affiliation(s)
- Hannah McMurry
- Division of Internal Medicine, Oregon Health & Science University, Portland, OR, United States of America,Corresponding author at: Department of Medicine, South Waterfront Office 3485, S. Bond Avenue, Portland, OR 97239, United States of America. (H. McMurry)
| | - Jean M.G. Sabile
- Division of Internal Medicine, Oregon Health & Science University, Portland, OR, United States of America
| | - Benjamin Elstrott
- Oregon Health and Science University Medical School, Portland, OR, United States of America
| | - Boris Chobrutskiy
- Division of Internal Medicine, Oregon Health & Science University, Portland, OR, United States of America
| | - Ajay Mohinani
- Division of Internal Medicine, Oregon Health & Science University, Portland, OR, United States of America
| | - Sarah Patel
- Division of Internal Medicine, Oregon Health & Science University, Portland, OR, United States of America
| | - Sonia Gowda
- Division of Internal Medicine, Oregon Health & Science University, Portland, OR, United States of America
| | - Kylee Martens
- Division of Hematology and Oncology, Oregon Health & Science University, Portland, OR, United States of America
| | - Joseph Shatzel
- Division of Hematology and Oncology, Oregon Health & Science University, Portland, OR, United States of America,Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, United States of America
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13
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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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14
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Wang L, Guo X, Shao X, Xu X, Zheng K, Wang R, Chawla S, Basaranoglu M, Qi X. Association of endoscopic variceal treatment with portal venous system thrombosis in liver cirrhosis: a case-control study. Therap Adv Gastroenterol 2022; 15:17562848221087536. [PMID: 35574427 PMCID: PMC9102139 DOI: 10.1177/17562848221087536] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 02/25/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The association of endoscopic variceal treatment (EVT) with portal venous system thrombosis (PVST) in liver cirrhosis is still unclear. METHODS PVST was assessed by contrast-enhanced CT or MRI in 406 cirrhotic patients from our prospective database. Case and control groups, which are defined as patients with and without PVST, respectively, were matched at a ratio of 1:1 according to age, gender, Child-Pugh class, and MELD score. History of EVT was reviewed. Logistic regression analysis was used to identify the risk factors for PVST. Odds ratios (ORs) were calculated. Subgroup analyses were further performed in terms of degree and location of PVST. RESULTS Overall, 109 patients each were included in case and control groups. The case group had a significantly higher proportion of patients who had undergone EVT than the control group (53.2% versus 18.3%; p < 0.001). In detail, the case group had significantly higher proportions of patients who had undergone EVT for controlling bleeding (45.9% versus 14.7%; p < 0.001), endoscopic variceal ligation (EVL) alone (19.3% versus 9.2%; p = 0.033), and EVL combined with endoscopic cyanoacrylate glue injection (24.8% versus 5.5%; p < 0.001). EVT was independently associated with PVST (OR = 4.258; p < 0.001). In subgroup analyses, EVT remained independently associated with partial PVST (OR = 10.063; p < 0.001), complete PVST/fibrotic cord (OR = 4.889; p = 0.008), thrombosis within main portal vein (OR = 5.985; p < 0.001), and thrombosis within superior mesenteric and splenic veins (OR = 5.747; p < 0.001). CONCLUSIONS EVT may lead to a higher risk of PVST, especially more severe PVST, in liver cirrhosis. Screening for and prophylaxis of PVST after EVT should be further explored.
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Affiliation(s)
| | | | | | - Xiangbo Xu
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, China
| | - Kexin Zheng
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, China
| | - Ran Wang
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, China
| | - Saurabh Chawla
- Division of Digestive Diseases, Department of Internal Medicine, School of Medicine, Emory University, Atlanta, GA, USA
| | - Metin Basaranoglu
- Division of Gastroenterology, Department of Internal Medicine, Medical School, Bezmialem Vakif University, Istanbul, Turkey
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15
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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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16
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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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17
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Abstract
Patients with cirrhosis of the liver are at high risk of developing portal vein thrombosis (PVT), which has a complex, multifactorial cause. The condition may present with a myriad of symptoms and can occasionally cause severe complications. Contrast-enhanced computed tomography (CT) is the gold standard for the diagnosis of PVT. There are uncertainties regarding the effect on PVT and its treatment outcome in patients with cirrhosis. The main challenge for managing PVT in cirrhosis is analyzing the risk of hemorrhage compared to the risk of thrombus extension leading to complications. All current knowledge regarding non-tumor PVT in cirrhosis, including epidemiology, risk factors, classification, clinical presentation, diagnosis, impact on natural history, and treatment, is discussed in the present article.
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Key Words
- ACLF, acute-on-chronic liver failure
- BCS, Budd–Chiari syndrome
- DOACs, direct-acting oral anticoagulants
- EASL, European Association for the Study of the Liver
- HCC, hepatocellular carcinoma
- HVPG, hepatic venous pressure gradient
- INR, international normalized ratio
- JAK2, Janus Kinase 2
- LMWH, low molecular weight heparin
- LT, liver transplant
- MELD, Model for End-Stage Liver Disease
- MTHFR, methyltetrahydrofolate reductase
- NASH, non-alcoholic steatohepatitis
- NO, nitric oxide
- NSBBs, non-selective beta-blockers
- PV, portal vein
- PVT, Portal vein thrombosis
- RCT, randomized controlled trial
- SMA, superior mesenteric artery
- SMV, superior mesenteric vein
- SVT, splanchnic vein thrombosis
- TIPS, Transjugular intrahepatic portosystemic shunt
- UNOS, United Network for Organ Sharing
- VEGF, vascular endothelial growth factors
- VKAs, vitamin K antagonists
- VKORC1, vitamin K epoxide reductase complex 1
- anticoagulation
- cirrhosis
- eNOS, endothelial nitric oxide synthase
- non-tumoral portal vein thrombosis
- portal hypertension
- rTPA, recombinant tissue plasminogen activator
- transjugular intrahepatic portosystemic shunt
- vWF, von Willebrand factor
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18
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Wang HL, Lu WJ, Zhang YL, Nie CH, Zhou TY, Zhou GH, Zhu TY, Wang BQ, Chen SQ, Yu ZN, Jing L, Sun JH. Comparison of Transjugular Intrahepatic Portosystemic Shunt in the Treatment of Cirrhosis With or Without Portal Vein Thrombosis: A Retrospective Study. Front Med (Lausanne) 2021; 8:737984. [PMID: 34671621 PMCID: PMC8523019 DOI: 10.3389/fmed.2021.737984] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 09/06/2021] [Indexed: 12/27/2022] Open
Abstract
Aim: The purpose of our study was to conduct a retrospective analysis to compare the effectiveness of transjugular intrahepatic portosystemic shunts (TIPS) in the treatment of patients with cirrhosis with or without portal vein thrombosis (PVT). Methods: We included a total of 203 cirrhosis patients successfully treated with TIPS between January 2015 and January 2018, including 72 cirrhosis patients with PVT (35.5%) and 131 without PVT (64.5%). Our subjects were followed for at least 1 year after treatment with TIPS. Data were collected to estimate the mortality, shunt dysfunction, and complication rates after TIPS creation. Results: During the mean follow-up time of 19.5 ± 12.8 months, 21 (10.3%) patients died, 15 (7.4%) developed shunt dysfunction, and 44 (21.6%) experienced overt hepatic encephalopathy (OHE). No significant differences in mortality (P = 0.134), shunt dysfunction (P = 0.214), or OHE (P = 0.632) were noted between the groups. Age, model for end-stage liver disease (MELD) score, and refractory ascites requiring TIPS were risk factors for mortality. A history of diabetes, percutaneous transhepatic variceal embolization (PTVE), 8-mm diameter stent, and platelet (PLT) increased the risk of shunt dysfunction. The prevalence of variceal bleeding and recurrent ascites was comparable between the two groups (16.7 vs. 16.7% P = 0.998 and 2.7 vs. 3.8% P = 0.678, respectively). Conclusions: Transjugular intrahepatic portosystemic shunts are feasible in the management of cirrhosis with PVT. No significant differences in survival or shunt dysfunction were noted between the PVT and no-PVT groups. The risk of recurrent variceal bleeding, recurrent ascites, and OHE in the PVT group was generally similar to that in the no-PVT group. TIPS represents a potentially feasible treatment option in cirrhosis patients with PVT.
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Affiliation(s)
- Hong-Liang Wang
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Zhejiang Provincial Research Center for Diagnosis and Treatment of Hepatobiliary Diseases, Hangzhou, China
| | - Wei-Jie Lu
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yue-Lin Zhang
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou, China
| | - Chun-Hui Nie
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou, China
| | - Tan-Yang Zhou
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Zhejiang Provincial Research Center for Diagnosis and Treatment of Hepatobiliary Diseases, Hangzhou, China
| | - Guan-Hui Zhou
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Zhejiang Provincial Research Center for Diagnosis and Treatment of Hepatobiliary Diseases, Hangzhou, China
| | - Tong-Yin Zhu
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Zhejiang Provincial Research Center for Diagnosis and Treatment of Hepatobiliary Diseases, Hangzhou, China
| | - Bao-Quan Wang
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Zhejiang Provincial Research Center for Diagnosis and Treatment of Hepatobiliary Diseases, Hangzhou, China
| | - Sheng-Qun Chen
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Zhejiang Provincial Research Center for Diagnosis and Treatment of Hepatobiliary Diseases, Hangzhou, China
| | - Zi-Niu Yu
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Zhejiang Provincial Research Center for Diagnosis and Treatment of Hepatobiliary Diseases, Hangzhou, China
| | - Li Jing
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Zhejiang Provincial Research Center for Diagnosis and Treatment of Hepatobiliary Diseases, Hangzhou, China
| | - Jun-Hui Sun
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Zhejiang Provincial Research Center for Diagnosis and Treatment of Hepatobiliary Diseases, Hangzhou, China.,Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou, China
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19
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Ju C, Li X, Gadani S, Kapoor B, Partovi S. Portal Vein Thrombosis: Diagnosis and Endovascular Management. ROFO-FORTSCHR RONTG 2021; 194:169-180. [PMID: 34649289 DOI: 10.1055/a-1642-0990] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Portal vein thrombosis (PVT) is a rare but severe entity that can cause clinically significant sequela such as worsening portal hypertension or mesenteric ischemia. Those cases refractory to medical management may be referred for endovascular intervention. Several technical considerations have been described in the literature, but a cohesive comparison of these multiple techniques is lacking. METHODS The purpose of this article is to review the diagnosis and endovascular management of PVT, including areas in which further research is warranted. RESULTS Cases of PVT can be readily diagnosed using ultrasound, computed tomography, or magnetic resonance imaging. Treatment often begins with systemic anticoagulation and endovascular interventions may be used in selected cases. Determining the optimal approach to accessing the portal venous system depends on the underlying disease and chronicity of the thrombus and the degree of occlusion. Once access to the portal venous system is established, catheter-directed therapy may be performed to achieve recanalization. CONCLUSION Despite the heterogeneity in patient presentation, cases of PVT can be readily diagnosed across several imaging modalities. Strategizing interventional approaches involves evaluation of the underlying disease and the chronicity of the thrombus. KEY POINTS · This review will enable interventionalists to establish a framework for treating portal vein thrombosis by identifying patient risk factors and thrombus characteristics that determine patient management.. · The unique risks and benefits for transhepatic, transsplenic, and transmesenteric approaches for establishing portal venous access will be discussed.. · Advantages and complications of thrombolysis, thrombectomy, and transjugular intrahepatic portosystemic shunt creation for treating portal vein thrombosis will be reviewed in detail based on our extensive institutional experience.. CITATION FORMAT · Ju C, Li X, Gadani S et al. Portal Vein Thrombosis: Diagnosis and Endovascular Management. Fortschr Röntgenstr 2021; DOI: 10.1055/a-1642-0990.
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Affiliation(s)
- Connie Ju
- Radiology, University of California Los Angeles Health System, Los Angeles, United States
| | - Xin Li
- Radiology, University of Pennsylvania Health System, Philadelphia, United States
| | - Sameer Gadani
- Interventional Radiology, Cleveland Clinic Foundation, Cleveland, United States
| | - Baljendra Kapoor
- Interventional Radiology, Cleveland Clinic Foundation, Cleveland, United States
| | - Sasan Partovi
- Interventional Radiology, Cleveland Clinic Foundation, Cleveland, United States
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20
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Dong S, Qi H, Li Y, Men P, Alifu M, Zhang Y, Li Y, Zhao R. A systematic review and meta-analysis of anticoagulation therapy for portal vein thrombosis in patients with cirrhosis: to treat or not to treat? Hepatol Int 2021; 15:1356-1375. [PMID: 34487316 DOI: 10.1007/s12072-021-10233-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 07/01/2021] [Indexed: 01/01/2023]
Abstract
PURPOSE To date, the optimal treatment for portal vein thrombosis (PVT) in cirrhotic patients has not been established in guidelines or consensus. We conducted a systematic review and meta-analysis to evaluate the effect of anticoagulation therapy in patients with cirrhosis and PVT. METHODS PubMed, Embase, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov were searched (until 31st October 2020) for studies evaluating the effect of anticoagulation therapy on treating PVT in patients with cirrhosis. Odds ratios (ORs) and their 95% confidence intervals (CIs) were pooled using the Mantel-Haenszel method. RESULTS A total of 13 studies were included in the analysis, comprising 6005 patients. Of these, three were prospective cohort studies, nine were retrospective cohort studies and one was case-control study. Compared to no treatment, anticoagulation therapy was associated with higher rates of PVT recanalization (OR 4.29; 95% CI 3.01-6.13). Anticoagulation therapy demonstrated a significant 74% reduction in PVT extension compared to no treatment (OR 0.26; 95% CI 0.14-0.49). Anticoagulation therapy was associated with a nonsignificantly lower risk of death (OR 0.53; 95% CI 0.20-1.40). However, anticoagulation therapy was associated with slightly higher risk of bleeding compared to no treatment (OR 1.16; 95% CI 1.02-1.32). CONCLUSIONS In cirrhotic patients with PVT, anticoagulation therapy helps increase rate of PVT recanalization and improve survival, but may also carry higher risks of bleeding compared to no treatment. Our findings support the use of anticoagulation in cirrhotic patients with PVT.
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Affiliation(s)
- Shujie Dong
- Department of Pharmacy, Peking University Third Hospital, No.49 Huayuan North Road, Beijing, 100191, China
| | - Huihong Qi
- Department of Pharmacy, Tangshan Gongren Hospital, Tangshan, Hebei, China
| | - Yan Li
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Peng Men
- Department of Pharmacy, Peking University Third Hospital, No.49 Huayuan North Road, Beijing, 100191, China
| | - Maiwujudan Alifu
- Department of Pharmacy, The Sixth Affiliated Hospital of Xinjiang Medical University, Ürümqi, China
| | - Yatong Zhang
- Department of Pharmacy, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Yongjun Li
- Department of Vascular Surgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, No.1 Dahua Road, Beijing, 100730, China.
| | - Rongsheng Zhao
- Department of Pharmacy, Peking University Third Hospital, No.49 Huayuan North Road, Beijing, 100191, China.
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21
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Yeoh SW, Kok HK. Transjugular intrahepatic portosystemic shunts in portal vein thrombosis: A review. J Dig Dis 2021; 22:506-519. [PMID: 34323378 DOI: 10.1111/1751-2980.13035] [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] [Received: 04/17/2021] [Revised: 07/16/2021] [Accepted: 07/26/2021] [Indexed: 12/11/2022]
Abstract
The presence of portal vein thrombosis (PVT) has previously been considered a contraindication to the insertion of transjugular intrahepatic portosystemic shunts (TIPSS). However, patients with PVT may have portal hypertension complications and may thus benefit from TIPSS to reduce portal venous pressure. There is an increasing body of literature that discusses the techniques and outcomes of TIPSS in PVT. This review summarizes the techniques, indications and outcomes of TIPSS in PVT in published case reports, case series and comparative trials, especially regarding the reduction in portal hypertensive complications such as variceal bleeding. A comprehensive literature search was conducted using MEDLINE and PubMed databases. Manuscripts published in English between 1 January 1990 and 1 March 2021 were used. Abstracts were screened and data from potentially relevant articles analyzed. TIPSS in PVT has been reported with high levels of technical success, short-term portal vein recanalization and long-term PV patency and TIPSS patency outcomes. Several comparative studies, including randomized controlled trials, have shown favorable outcomes of TIPSS compared with non-TIPSS treatment of PVT complications. Outcomes of TIPSS with PVT appear similar to those in TIPSS without PVT. However, TIPSS may be more technically difficult in the presence of PVT, and such procedures should be performed in expert high-volume centers to mitigate the risk of procedural complications. The presence of PVT should no longer be considered a contraindication to TIPSS. TIPSS for PVT has been acknowledged as a therapeutic strategy in recent international guidelines, although further studies are needed before recommendations can be strengthened. KEY POINTS: Portal vein thrombosis (PVT) is no longer a contraindication to the insertion of transjugular intrahepatic portosystemic shunts (TIPSS) TIPSS often leads to the spontaneous dissolution of PVT, but can be combined with mechanical or pharmacological thrombectomy TIPSS reduces portal hypertensive complications of PVT, such as variceal bleeding, and can also facilitate liver transplantation where PVT may otherwise interfere with vascular anastomoses Studies have shown favorable long-term outcomes of TIPSS compared with TIPSS without PVT; as well as compared with non-TIPSS treatment of PVT complications TIPSS in PVT should be performed in high-volume specialist centers due to technical difficulties.
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Affiliation(s)
- Sern Wei Yeoh
- Department of Gastroenterology, Northern Health, Melbourne, Victoria, Australia.,School of Medical Education, University of Melbourne, Melbourne, Victoria, Australia
| | - Hong Kuan Kok
- Department of Radiology, Northern Health, Melbourne, Victoria, Australia.,School of Medicine, Deakin University, Melbourne, Victoria, Australia
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22
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Ng CH, Tan DJH, Nistala KRY, Syn N, Xiao J, Tan EXX, Woo FZ, Chew NWS, Huang DQ, Dan YY, Sanyal AJ, Muthiah MD. A network meta-analysis of direct oral anticoagulants for portal vein thrombosis in cirrhosis. Hepatol Int 2021; 15:1196-1206. [PMID: 34417718 DOI: 10.1007/s12072-021-10247-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 08/06/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Current guidelines have limited consensus on the approach to portal venous thrombosis (PVT) in cirrhotic patients. While there is rising interest in direct oral anticoagulants (DOACs) use for PVT, current evidence is limited by small sample size and lack of comparisons to traditional anticoagulants. Thus, a network meta-analysis was conducted to compare the use of DOACs with traditional anticoagulants. METHODS Medline and Embase were searched for articles about anticoagulation use in cirrhotic patients with nontumorous PVT for articles on DOACs, warfarin, low-molecular weight heparin (LMWH) or antithrombin III. A network analysis was conducted using risk ratios (RR) with surface under the cumulative ranking curve (SUCRA). A single-arm meta-analysis was used to summarize the outcomes of DOAC treatment. RESULTS A total of 10 articles were included in the study. 79.5% (CI 38.8-95.9) of DOACs patients achieved complete or partial recanalization and 9.80% (CI 4.50-20.0) experienced a bleeding event. DOACs were superior to LMWH (RR 2.299, CI 1.037-5.093, p = 0.040), warfarin (RR 1.762, CI 1.017-3.053, p = 0.043) and no treatment (RR 3.489, CI 1.394-8.733, p = 0.008) in complete recanalization. For partial recanalization, while DOACs were not superior to any treatment, they had the highest probability in achieving partial recanalization in SUCRA analysis. Bleeding risk and mortality were similar compared to other treatments. CONCLUSION The network analysis supports the use of DOACs in cirrhotic patients, with significant rates of complete recanalization compared to other treatments without increasing bleeding risk. DOACs can potentially be considered for nontumorous PVT in cirrhosis.
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Affiliation(s)
- Cheng Han Ng
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore.
| | - Darren Jun Hao Tan
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore
| | | | - Nicholas Syn
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore.,Biostatistics and Modelling Domain, Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Jieling Xiao
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore
| | - Eunice Xiang Xuan Tan
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore.,National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore.,Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Tower Block Level 10, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Felicia Zuying Woo
- Department of Pharmacy, National University Hospital, Singapore, Singapore.,National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
| | - Nicholas W S Chew
- Division of Cardiology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Daniel Q Huang
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore.,National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore.,Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Tower Block Level 10, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Yock Young Dan
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore.,National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore.,Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Tower Block Level 10, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Arun J Sanyal
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Mark D Muthiah
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore. .,National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore. .,Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Tower Block Level 10, 1E Kent Ridge Road, Singapore, 119228, Singapore.
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23
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Efficacy and Safety of Nadroparin Calcium-Warfarin Sequential Anticoagulation in Portal Vein Thrombosis in Cirrhotic Patients: A Randomized Controlled Trial. Clin Transl Gastroenterol 2021; 11:e00228. [PMID: 32858573 PMCID: PMC7455225 DOI: 10.14309/ctg.0000000000000228] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Anticoagulation therapy in portal vein thrombosis (PVT) in patients with cirrhosis is still a matter of debate. Therefore, the aim of this work was to evaluate the efficacy and safety of nadroparin calcium-warfarin sequential (NWS) anticoagulation therapy in cirrhotic patients and to find an optimal anticoagulation strategy.
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24
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Anticoagulation and Transjugular Intrahepatic Portosystemic Shunt for the Management of Portal Vein Thrombosis in Cirrhosis: A Prospective Observational Study. Am J Gastroenterol 2021; 116:1447-1464. [PMID: 33630766 DOI: 10.14309/ajg.0000000000001194] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 01/22/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Current guidelines recommend anticoagulation as the mainstay of portal vein thrombosis (PVT) treatment in cirrhosis. However, because of the heterogeneity of PVT, anticoagulation alone does not always achieve satisfactory results. This study aimed to prospectively evaluate an individualized management algorithm using a wait-and-see strategy (i.e., no treatment), anticoagulation, and transjugular intrahepatic portosystemic shunt (TIPS) to treat PVT in cirrhosis. METHODS Between February 2014 and June 2018, 396 consecutive patients with cirrhosis with nonmalignant PVT were prospectively included in a tertiary care center, of which 48 patients (12.1%) were untreated, 63 patients (15.9%) underwent anticoagulation, 88 patients (22.2%) underwent TIPS, and 197 patients (49.8%) received TIPS plus post-TIPS anticoagulation. The decision of treatment option mainly depends on the stage of liver disease (symptomatic portal hypertension or not) and degree and extension of thrombus. RESULTS During a median 31.7 months of follow-up period, 312 patients (81.3%) achieved partial (n = 25) or complete (n = 287) recanalization, with 9 (3.1%) having rethrombosis, 64 patients (16.2%) developed major bleeding (anticoagulation-related bleeding in 7 [1.8%]), 88 patients (22.2%) developed overt hepatic encephalopathy, and 100 patients (25.3%) died. In multivariate competing risk regression models, TIPS and anticoagulation were associated with a higher probability of recanalization. Long-term anticoagulation using enoxaparin or rivaroxaban rather than warfarin was associated with a decreased risk of rethrombosis and an improved survival, without increasing the risk of bleeding. However, the presence of complete superior mesenteric vein thrombosis was associated with a lower recanalization rate, increased risk of major bleeding, and poor prognosis. DISCUSSION In patients with cirrhosis with PVT, the individualized treatment algorithm achieves a high-probability recanalization, with low rates of portal hypertensive complications and adverse events.
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25
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Yoshiji H, Nagoshi S, Akahane T, Asaoka Y, Ueno Y, Ogawa K, Kawaguchi T, Kurosaki M, Sakaida I, Shimizu M, Taniai M, Terai S, Nishikawa H, Hiasa Y, Hidaka H, Miwa H, Chayama K, Enomoto N, Shimosegawa T, Takehara T, Koike K. Evidence-based clinical practice guidelines for Liver Cirrhosis 2020. J Gastroenterol 2021; 56:593-619. [PMID: 34231046 PMCID: PMC8280040 DOI: 10.1007/s00535-021-01788-x] [Citation(s) in RCA: 127] [Impact Index Per Article: 42.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 02/25/2021] [Indexed: 02/07/2023]
Abstract
The first edition of the clinical practice guidelines for liver cirrhosis was published in 2010, and the second edition was published in 2015 by the Japanese Society of Gastroenterology (JSGE). The revised third edition was recently published in 2020. This version has become a joint guideline by the JSGE and the Japan Society of Hepatology (JSH). In addition to the clinical questions (CQs), background questions (BQs) are new items for basic clinical knowledge, and future research questions (FRQs) are newly added clinically important items. Concerning the clinical treatment of liver cirrhosis, new findings have been reported over the past 5 years since the second edition. In this revision, we decided to match the international standards as much as possible by referring to the latest international guidelines. Newly developed agents for various complications have also made great progress. In comparison with the latest global guidelines, such as the European Association for the Study of the Liver (EASL) and American Association for the Study of Liver Diseases (AASLD), we are introducing data based on the evidence for clinical practice in Japan. The flowchart for nutrition therapy was reviewed to be useful for daily medical care by referring to overseas guidelines. We also explain several clinically important items that have recently received focus and were not mentioned in the last editions. This digest version describes the issues related to the management of liver cirrhosis and several complications in clinical practice. The content begins with a diagnostic algorithm, the revised flowchart for nutritional therapy, and refracted ascites, which are of great importance to patients with cirrhosis. In addition to the updated antiviral therapy for hepatitis B and C liver cirrhosis, the latest treatments for non-viral cirrhosis, such as alcoholic steatohepatitis/non-alcoholic steatohepatitis (ASH/NASH) and autoimmune-related cirrhosis, are also described. It also covers the latest evidence regarding the diagnosis and treatment of liver cirrhosis complications, namely gastrointestinal bleeding, ascites, hepatorenal syndrome and acute kidney injury, hepatic encephalopathy, portal thrombus, sarcopenia, muscle cramp, thrombocytopenia, pruritus, hepatopulmonary syndrome, portopulmonary hypertension, and vitamin D deficiency, including BQ, CQ and FRQ. Finally, this guideline covers prognosis prediction and liver transplantation, especially focusing on several new findings since the last version. Since this revision is a joint guideline by both societies, the same content is published simultaneously in the official English journal of JSGE and JSH.
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Affiliation(s)
- Hitoshi Yoshiji
- Guidelines Committee for Creating and Evaluating the "Evidence-Based Clinical Practice Guidelines for Liver Cirrhosis", The Japanese Society of Gastroenterology / The Japan Society of Hepatology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan.
- Department of Gastroenterology, Nara Medical University, Shijo-cho 840, Kashihara, Nara, 634-8522, Japan.
| | - Sumiko Nagoshi
- Guidelines Committee for Creating and Evaluating the "Evidence-Based Clinical Practice Guidelines for Liver Cirrhosis", The Japanese Society of Gastroenterology / The Japan Society of Hepatology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Takemi Akahane
- Guidelines Committee for Creating and Evaluating the "Evidence-Based Clinical Practice Guidelines for Liver Cirrhosis", The Japanese Society of Gastroenterology / The Japan Society of Hepatology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Yoshinari Asaoka
- Guidelines Committee for Creating and Evaluating the "Evidence-Based Clinical Practice Guidelines for Liver Cirrhosis", The Japanese Society of Gastroenterology / The Japan Society of Hepatology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Yoshiyuki Ueno
- Guidelines Committee for Creating and Evaluating the "Evidence-Based Clinical Practice Guidelines for Liver Cirrhosis", The Japanese Society of Gastroenterology / The Japan Society of Hepatology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Koji Ogawa
- Guidelines Committee for Creating and Evaluating the "Evidence-Based Clinical Practice Guidelines for Liver Cirrhosis", The Japanese Society of Gastroenterology / The Japan Society of Hepatology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Takumi Kawaguchi
- Guidelines Committee for Creating and Evaluating the "Evidence-Based Clinical Practice Guidelines for Liver Cirrhosis", The Japanese Society of Gastroenterology / The Japan Society of Hepatology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Masayuki Kurosaki
- Guidelines Committee for Creating and Evaluating the "Evidence-Based Clinical Practice Guidelines for Liver Cirrhosis", The Japanese Society of Gastroenterology / The Japan Society of Hepatology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Isao Sakaida
- Guidelines Committee for Creating and Evaluating the "Evidence-Based Clinical Practice Guidelines for Liver Cirrhosis", The Japanese Society of Gastroenterology / The Japan Society of Hepatology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Masahito Shimizu
- Guidelines Committee for Creating and Evaluating the "Evidence-Based Clinical Practice Guidelines for Liver Cirrhosis", The Japanese Society of Gastroenterology / The Japan Society of Hepatology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Makiko Taniai
- Guidelines Committee for Creating and Evaluating the "Evidence-Based Clinical Practice Guidelines for Liver Cirrhosis", The Japanese Society of Gastroenterology / The Japan Society of Hepatology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Shuji Terai
- Guidelines Committee for Creating and Evaluating the "Evidence-Based Clinical Practice Guidelines for Liver Cirrhosis", The Japanese Society of Gastroenterology / The Japan Society of Hepatology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Hiroki Nishikawa
- Guidelines Committee for Creating and Evaluating the "Evidence-Based Clinical Practice Guidelines for Liver Cirrhosis", The Japanese Society of Gastroenterology / The Japan Society of Hepatology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Yoichi Hiasa
- Guidelines Committee for Creating and Evaluating the "Evidence-Based Clinical Practice Guidelines for Liver Cirrhosis", The Japanese Society of Gastroenterology / The Japan Society of Hepatology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Hisashi Hidaka
- Guidelines Committee for Creating and Evaluating the "Evidence-Based Clinical Practice Guidelines for Liver Cirrhosis", The Japanese Society of Gastroenterology / The Japan Society of Hepatology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Hiroto Miwa
- Guidelines Committee for Creating and Evaluating the "Evidence-Based Clinical Practice Guidelines for Liver Cirrhosis", The Japanese Society of Gastroenterology / The Japan Society of Hepatology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Kazuaki Chayama
- The Japan Society of Hepatology, Kashiwaya 2 Building 5F, 3-28-10 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Nobuyuki Enomoto
- Guidelines Committee for Creating and Evaluating the "Evidence-Based Clinical Practice Guidelines for Liver Cirrhosis", The Japanese Society of Gastroenterology / The Japan Society of Hepatology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Tooru Shimosegawa
- Guidelines Committee for Creating and Evaluating the "Evidence-Based Clinical Practice Guidelines for Liver Cirrhosis", The Japanese Society of Gastroenterology / The Japan Society of Hepatology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Tetsuo Takehara
- The Japan Society of Hepatology, Kashiwaya 2 Building 5F, 3-28-10 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Kazuhiko Koike
- Guidelines Committee for Creating and Evaluating the "Evidence-Based Clinical Practice Guidelines for Liver Cirrhosis", The Japanese Society of Gastroenterology / The Japan Society of Hepatology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
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Yoshiji H, Nagoshi S, Akahane T, Asaoka Y, Ueno Y, Ogawa K, Kawaguchi T, Kurosaki M, Sakaida I, Shimizu M, Taniai M, Terai S, Nishikawa H, Hiasa Y, Hidaka H, Miwa H, Chayama K, Enomoto N, Shimosegawa T, Takehara T, Koike K. Evidence-based clinical practice guidelines for liver cirrhosis 2020. Hepatol Res 2021; 51:725-749. [PMID: 34228859 DOI: 10.1111/hepr.13678] [Citation(s) in RCA: 87] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 05/26/2021] [Indexed: 12/14/2022]
Abstract
The first edition of the clinical practice guidelines for liver cirrhosis was published in 2010, and the second edition was published in 2015 by the Japanese Society of Gastroenterology (JSGE). The revised third edition was recently published in 2020. This version has become a joint guideline by the JSGE and the Japanese Society of Hepatology (JSH). In addition to the clinical questions (CQs), background questions (BQs) are new items for basic clinical knowledge, and future research questions (FRQs) are newly added clinically important items. Concerning the clinical treatment of liver cirrhosis, new findings have been reported over the past 5 years since the second edition. In this revision, we decided to match the international standards as much as possible by referring to the latest international guidelines. Newly developed agents for various complications have also made great progress. In comparison with the latest global guidelines, such as the European Association for the Study of the Liver (EASL) and American Association for the Study of Liver Diseases (AASLD), we are introducing data based on the evidence for clinical practice in Japan. The flowchart for nutrition therapy was reviewed to be useful for daily medical care by referring to overseas guidelines. We also explain several clinically important items that have recently received focus and were not mentioned in the last editions. This digest version describes the issues related to the management of liver cirrhosis and several complications in clinical practice. The content begins with a diagnostic algorithm, the revised flowchart for nutritional therapy, and refracted ascites, which are of great importance to patients with cirrhosis. In addition to the updated antiviral therapy for hepatitis B and C liver cirrhosis, the latest treatments for non-viral cirrhosis, such as alcoholic steatohepatitis/non-alcoholic steatohepatitis (ASH/NASH) and autoimmune-related cirrhosis, are also described. It also covers the latest evidence regarding the diagnosis and treatment of liver cirrhosis complications, namely gastrointestinal bleeding, ascites, hepatorenal syndrome and acute kidney injury, hepatic encephalopathy, portal thrombus, sarcopenia, muscle cramp, thrombocytopenia, pruritus, hepatopulmonary syndrome, portopulmonary hypertension, and vitamin D deficiency, including BQ, CQ and FRQ. Finally, this guideline covers prognosis prediction and liver transplantation, especially focusing on several new findings since the last version. Since this revision is a joint guideline by both societies, the same content is published simultaneously in the official English journal of JSGE and JSH.
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Affiliation(s)
- Hitoshi Yoshiji
- Guidelines Committee for Creating and Evaluating the Evidence-Based Clinical Practice Guidelines for Liver Cirrhosis, The Japanese Society of Gastroenterology/the Japan Society of hepatology, Tokyo, Japan.,Department of Gastroenterology, Nara Medical University, Nara, Japan
| | - Sumiko Nagoshi
- Guidelines Committee for Creating and Evaluating the Evidence-Based Clinical Practice Guidelines for Liver Cirrhosis, The Japanese Society of Gastroenterology/the Japan Society of hepatology, Tokyo, Japan
| | - Takemi Akahane
- Guidelines Committee for Creating and Evaluating the Evidence-Based Clinical Practice Guidelines for Liver Cirrhosis, The Japanese Society of Gastroenterology/the Japan Society of hepatology, Tokyo, Japan
| | - Yoshinari Asaoka
- Guidelines Committee for Creating and Evaluating the Evidence-Based Clinical Practice Guidelines for Liver Cirrhosis, The Japanese Society of Gastroenterology/the Japan Society of hepatology, Tokyo, Japan
| | - Yoshiyuki Ueno
- Guidelines Committee for Creating and Evaluating the Evidence-Based Clinical Practice Guidelines for Liver Cirrhosis, The Japanese Society of Gastroenterology/the Japan Society of hepatology, Tokyo, Japan
| | - Koji Ogawa
- Guidelines Committee for Creating and Evaluating the Evidence-Based Clinical Practice Guidelines for Liver Cirrhosis, The Japanese Society of Gastroenterology/the Japan Society of hepatology, Tokyo, Japan
| | - Takumi Kawaguchi
- Guidelines Committee for Creating and Evaluating the Evidence-Based Clinical Practice Guidelines for Liver Cirrhosis, The Japanese Society of Gastroenterology/the Japan Society of hepatology, Tokyo, Japan
| | - Masayuki Kurosaki
- Guidelines Committee for Creating and Evaluating the Evidence-Based Clinical Practice Guidelines for Liver Cirrhosis, The Japanese Society of Gastroenterology/the Japan Society of hepatology, Tokyo, Japan
| | - Isao Sakaida
- Guidelines Committee for Creating and Evaluating the Evidence-Based Clinical Practice Guidelines for Liver Cirrhosis, The Japanese Society of Gastroenterology/the Japan Society of hepatology, Tokyo, Japan
| | - Masahito Shimizu
- Guidelines Committee for Creating and Evaluating the Evidence-Based Clinical Practice Guidelines for Liver Cirrhosis, The Japanese Society of Gastroenterology/the Japan Society of hepatology, Tokyo, Japan
| | - Makiko Taniai
- Guidelines Committee for Creating and Evaluating the Evidence-Based Clinical Practice Guidelines for Liver Cirrhosis, The Japanese Society of Gastroenterology/the Japan Society of hepatology, Tokyo, Japan
| | - Shuji Terai
- Guidelines Committee for Creating and Evaluating the Evidence-Based Clinical Practice Guidelines for Liver Cirrhosis, The Japanese Society of Gastroenterology/the Japan Society of hepatology, Tokyo, Japan
| | - Hiroki Nishikawa
- Guidelines Committee for Creating and Evaluating the Evidence-Based Clinical Practice Guidelines for Liver Cirrhosis, The Japanese Society of Gastroenterology/the Japan Society of hepatology, Tokyo, Japan
| | - Yoichi Hiasa
- Guidelines Committee for Creating and Evaluating the Evidence-Based Clinical Practice Guidelines for Liver Cirrhosis, The Japanese Society of Gastroenterology/the Japan Society of hepatology, Tokyo, Japan
| | - Hisashi Hidaka
- Guidelines Committee for Creating and Evaluating the Evidence-Based Clinical Practice Guidelines for Liver Cirrhosis, The Japanese Society of Gastroenterology/the Japan Society of hepatology, Tokyo, Japan
| | - Hiroto Miwa
- Guidelines Committee for Creating and Evaluating the Evidence-Based Clinical Practice Guidelines for Liver Cirrhosis, The Japanese Society of Gastroenterology/the Japan Society of hepatology, Tokyo, Japan
| | | | - Nobuyuki Enomoto
- Guidelines Committee for Creating and Evaluating the Evidence-Based Clinical Practice Guidelines for Liver Cirrhosis, The Japanese Society of Gastroenterology/the Japan Society of hepatology, Tokyo, Japan
| | - Tooru Shimosegawa
- Guidelines Committee for Creating and Evaluating the Evidence-Based Clinical Practice Guidelines for Liver Cirrhosis, The Japanese Society of Gastroenterology/the Japan Society of hepatology, Tokyo, Japan
| | | | - Kazuhiko Koike
- Guidelines Committee for Creating and Evaluating the Evidence-Based Clinical Practice Guidelines for Liver Cirrhosis, The Japanese Society of Gastroenterology/the Japan Society of hepatology, Tokyo, Japan
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27
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Chun HS, Choe AR, Lee M, Cho Y, Kim HY, Yoo K, Kim TH. Treatment of direct oral anticoagulants in patients with liver cirrhosis and portal vein thrombosis. Clin Mol Hepatol 2021; 27:535-552. [PMID: 34130370 PMCID: PMC8524067 DOI: 10.3350/cmh.2021.0109] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 06/06/2021] [Indexed: 11/30/2022] Open
Abstract
Although patients with cirrhosis are known to be in a state of “rebalance” in that pro- and anticoagulant factors increase the risk for both bleeding and thrombosis, the prevalence of portal vein thrombosis (PVT) in patients with cirrhosis can be up to 26%. Therefore, physicians should consider anticoagulation for the prevention and management of PVT in patients with cirrhosis who are at high risk of PVT. Vitamin K antagonist or low molecular weight heparin is suggested as the standard treatment for PVT in cirrhosis. With the advent of new direct-acting oral anticoagulants (DOACs), there is a paradigm shift of switching to DOACs for the treatment of PVT in patients with cirrhosis. However, the safety and efficacy of DOACs in the treatment of PVT was not well-known in patients with cirrhosis. Therefore, this review focused on the current knowledge about the efficacy, safety concerns, and hepatic metabolism of DOACs in patients with cirrhosis and PVT.
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Affiliation(s)
- Ho Soo Chun
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Ewha Womans University Medical Center, Seoul, Korea
| | - A Reum Choe
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Ewha Womans University Medical Center, Seoul, Korea
| | - Minjong Lee
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Ewha Womans University Medical Center, Seoul, Korea
| | - Yuri Cho
- Center for Liver and Pancreatobiliary Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Hwi Young Kim
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Ewha Womans University Medical Center, Seoul, Korea
| | - Kwon Yoo
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Ewha Womans University Medical Center, Seoul, Korea
| | - Tae Hun Kim
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Ewha Womans University Medical Center, Seoul, Korea
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28
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Ilcewicz HN, Martello JL, Piechowski K. Evaluation of the efficacy and safety of direct oral anticoagulants in the treatment of portal vein thrombosis. Eur J Gastroenterol Hepatol 2021; 33:911-916. [PMID: 33079786 PMCID: PMC8371984 DOI: 10.1097/meg.0000000000001958] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the efficacy and safety of direct oral anticoagulants vs. warfarin for portal vein thrombosis treatment. METHODS This was a single-center, retrospective study. Adult patients initiated on a direct oral anticoagulant or warfarin for treatment of a new portal vein thrombosis were included. The primary failure outcome was the absolute difference in recurrent thromboembolic events 90 days following initiation of a direct oral anticoagulant vs. warfarin. The primary safety outcome was the absolute difference in bleeding events 90 days following initiation of a direct oral anticoagulant vs. warfarin. Descriptive statistics, Fisher's exact, and Student's t-tests were utilized as appropriate. RESULTS Thirty-three patients were included. Thirteen (39.4%) patients received direct oral anticoagulants, and 20 (60.6%) received warfarin. None of the patients receiving direct oral anticoagulants experienced a primary failure event compared to four receiving warfarin (P < 0.001). None of the patients receiving direct oral anticoagulants experienced a primary safety event vs. one receiving warfarin (P < 0.001). CONCLUSION Direct oral anticoagulants appear to be effective and safe in the treatment of portal vein thrombosis and in preventing recurrent thromboembolic events. Future studies with larger sample sizes are warranted to confirm direct oral anticoagulants' efficacy in portal vein thrombosis.
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Affiliation(s)
- Haley N. Ilcewicz
- St. Louis College of Pharmacy at University of Health Sciences and Pharmacy in St. Louis, St. Louis, Missouri
| | - Jay L. Martello
- West Virginia University School of Pharmacy, Morgantown, West Virginia, USA
| | - Kara Piechowski
- West Virginia University Medicine, Morgantown, West Virginia, USA
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29
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Zhan C, Prabhu V, Kang SK, Li C, Zhu Y, Kim S, Olsen S, Jacobson IM, Dagher NN, Carney B, Hickey RM, Taslakian B. Comparison of Non-Tumoral Portal Vein Thrombosis Management in Cirrhotic Patients: TIPS Versus Anticoagulation Versus No Treatment. J Clin Med 2021; 10:jcm10112316. [PMID: 34073236 PMCID: PMC8198761 DOI: 10.3390/jcm10112316] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 04/21/2021] [Accepted: 05/11/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND There is a lack of consensus in optimal management of portal vein thrombosis (PVT) in patients with cirrhosis. The purpose of this study is to compare the safety and thrombosis burden change for cirrhotic patients with non-tumoral PVT managed by transjugular intrahepatic portosystemic shunt (TIPS) only, anticoagulation only, or no treatment. METHODS This single-center retrospective study evaluated 52 patients with cirrhosis and non-tumoral PVT managed by TIPS only (14), anticoagulation only (11), or no treatment (27). The demographic, clinical, and imaging data for patients were collected. The portomesenteric thrombosis burden and liver function tests at early follow-up (6-9 months) and late follow-up (9-16 months) were compared to the baseline. Adverse events including bleeding and encephalopathy were recorded. RESULTS The overall portomesenteric thrombosis burden improved in eight (72%) TIPS patients, three (27%) anticoagulated patients, and two (10%) untreated patients at early follow-up (p = 0.001) and in seven (78%) TIPS patients, two (29%) anticoagulated patients, and three (17%) untreated patients in late follow-up (p = 0.007). No bleeding complications attributable to anticoagulation were observed. CONCLUSION TIPS decreased portomesenteric thrombus burden compared to anticoagulation or no treatment for cirrhotic patients with PVT. Both TIPS and anticoagulation were safe therapies.
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Affiliation(s)
- Chenyang Zhan
- Division of Vascular Interventional Radiology, Department of Radiology, NYU Grossman School of Medicine, New York, NY 10016, USA; (C.Z.); (C.L.); (Y.Z.); (R.M.H.)
| | - Vinay Prabhu
- Division of Abdominal Imaging, Department of Radiology, NYU Grossman School of Medicine, New York, NY 10016, USA; (V.P.); (S.K.K.); (S.K.)
| | - Stella K. Kang
- Division of Abdominal Imaging, Department of Radiology, NYU Grossman School of Medicine, New York, NY 10016, USA; (V.P.); (S.K.K.); (S.K.)
- Department of Population Health, NYU Grossman School of Medicine, New York, NY 10016, USA
| | - Clayton Li
- Division of Vascular Interventional Radiology, Department of Radiology, NYU Grossman School of Medicine, New York, NY 10016, USA; (C.Z.); (C.L.); (Y.Z.); (R.M.H.)
| | - Yuli Zhu
- Division of Vascular Interventional Radiology, Department of Radiology, NYU Grossman School of Medicine, New York, NY 10016, USA; (C.Z.); (C.L.); (Y.Z.); (R.M.H.)
| | - Sooah Kim
- Division of Abdominal Imaging, Department of Radiology, NYU Grossman School of Medicine, New York, NY 10016, USA; (V.P.); (S.K.K.); (S.K.)
| | - Sonja Olsen
- Hepatology Section, Division of Gastroenterology, Department of Medicine, NYU Grossman School of Medicine, New York, NY 10016, USA; (S.O.); (I.M.J.)
| | - Ira M. Jacobson
- Hepatology Section, Division of Gastroenterology, Department of Medicine, NYU Grossman School of Medicine, New York, NY 10016, USA; (S.O.); (I.M.J.)
| | - Nabil N. Dagher
- Transplant Institute, Department of Surgery, NYU Grossman School of Medicine, New York, NY 10016, USA;
| | - Brendan Carney
- Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA;
| | - Ryan M. Hickey
- Division of Vascular Interventional Radiology, Department of Radiology, NYU Grossman School of Medicine, New York, NY 10016, USA; (C.Z.); (C.L.); (Y.Z.); (R.M.H.)
| | - Bedros Taslakian
- Division of Vascular Interventional Radiology, Department of Radiology, NYU Grossman School of Medicine, New York, NY 10016, USA; (C.Z.); (C.L.); (Y.Z.); (R.M.H.)
- Correspondence:
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30
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Valeriani E, Di Nisio M, Riva N, Caiano LM, Porreca E, Bang SM, Beyer-Westendorf J, Sartori MT, Barillari G, Santoro R, Kamphuisen PW, Alatri A, Malato A, Vidili G, Oh D, Schulman S, Ageno W. Clinical history of cancer-associated splanchnic vein thrombosis. J Thromb Haemost 2021; 19:983-991. [PMID: 33306241 DOI: 10.1111/jth.15214] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 12/03/2020] [Accepted: 12/07/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Cancer represents a risk factor for splanchnic vein thrombosis (SVT) and usual site venous thromboembolism (VTE). OBJECTIVES To compare characteristics and outcomes of patients with cancer-associated SVT and usual site VTE. PATIENTS/METHODS Patients with solid cancer and SVT were enrolled in an international, prospective registry between May 2008 and January 2012. The comparison cohort included (1:1 ratio) patients with solid cancer and usual site VTE treated at two thrombosis centers who had a minimum of 12 months follow-up at December 2019 or experienced one of the outcomes within 12 months follow-up. Recurrent VTE, major bleeding, and all-cause mortality were evaluated at 12-month follow-up. RESULTS A total of 264 patients (132 in each cohort) were enrolled. Patients with SVT were less likely to have metastatic disease (36.1% vs 72.5%) or receive cancer therapy at thrombosis diagnosis (29.6% vs 64.9%). The most frequent cancer types were hepatobiliary and pancreatic in the SVT cohort and gastrointestinal in the usual site VTE cohort. Fewer patients with SVT received anticoagulation (68.9% vs 99.2%), and treatment duration was shorter (6.0 vs 11.0 months). The cumulative incidence of major bleeding (2.3% vs 4.7%) was nonsignificantly lower in the SVT cohort, whereas recurrent thrombosis (4.7% vs 5.5%) and all-cause mortality (41.7% vs 39.4%) were comparable between the two cohorts. CONCLUSIONS The risk of recurrent thrombosis and bleeding appears to be similar in cancer patients with SVT and cancer patients with usual site VTE, despite some differences in baseline characteristics and anticoagulant treatment. Further prospective studies are warranted to confirm these findings.
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Affiliation(s)
- Emanuele Valeriani
- Department of Medical, Oral and Biotechnological Sciences "G. d'Annunzio" University, Chieti, Italy
- Department of Diagnostic and Therapeutic Medicine, Campus-Bio Medico University, Rome, Italy
| | - Marcello Di Nisio
- Department of Medicine and Ageing Sciences, University G. D'Annunzio, Chieti-Pescara, Italy
| | - Nicoletta Riva
- Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta
| | - Lucia Maria Caiano
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Ettore Porreca
- Department of Medical, Oral and Biotechnological Sciences "G. d'Annunzio" University, Chieti, Italy
| | - Soo-Mee Bang
- Department of Internal Medicine, Seoul National University, Seoul, South Korea
| | - Jan Beyer-Westendorf
- Division of Hematology and Hemostaseology, Department of Medicine I, University Hospital Carl Gustav Carus, Dresden, Germany
| | | | - Giovanni Barillari
- Department of Internal Medicine, Ospedale S. Maria della Misericordia, Udine, Italy
| | - Rita Santoro
- Haemophilia Center, Azienda Ospedaliera Pugliese- Ciaccio, Catanzaro, Italy
| | - Pieter W Kamphuisen
- Department of Vascular Medicine, University of Groningen, Groningen, The Netherlands
| | - Adriano Alatri
- Hemostasis and Thrombosis Center, A.O. Istituti Ospitalieri di Cremona, Cremona, Italy
| | - Alessandra Malato
- Department of Hematology, Policlinico Universitario di Palermo, Palermo, Italy
| | - Gianpaolo Vidili
- Department of Clinical Medicine, University Hospital of Sassari, Sassari, Italy
| | - Doyeun Oh
- Department of Internal Medicine, Pochon CHA University, Seoul, Korea
| | - Sam Schulman
- Department of Medicine, McMaster University and the Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
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31
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Consensus for management of portal vein thrombosis in liver cirrhosis (2020, Shanghai). J Dig Dis 2021; 22:176-186. [PMID: 33470535 PMCID: PMC8252415 DOI: 10.1111/1751-2980.12970] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 01/10/2021] [Accepted: 01/17/2021] [Indexed: 12/11/2022]
Abstract
Portal vein thrombosis (PVT) is a common and severe complication of liver cirrhosis. So far, there have been few consensuses or practice guidelines on the management of PVT in liver cirrhosis. In this expert consensus, we systematically review the epidemiology, risk factors, imaging examinations, diagnosis, assessment of disease severity, and treatment strategy of PVT in liver cirrhosis, based on the most recent evidence and expert opinions, to further standardize the diagnosis and treatment of the disease in clinical practice.
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32
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Anticoagulant Treatment for Splanchnic Vein Thrombosis in Liver Cirrhosis: A Systematic Review and Meta-Analysis. Thromb Haemost 2021; 121:867-876. [PMID: 33525037 DOI: 10.1055/s-0040-1722192] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Splanchnic vein thrombosis (SVT) is a common complication in patients with liver cirrhosis. The aim of this study was to evaluate the efficacy and safety of anticoagulant therapy for SVT in cirrhotic patients. METHODS In this systematic review and meta-analysis, studies reporting on SVT recanalization and progression, recurrent venous thromboembolism (VTE), major bleeding, and overall mortality were searched in MEDLINE, EMBASE, and ClinicalTrial.gov up to December 2019. Pooled proportions and risk ratios (RRs) with corresponding 95% confidence intervals (CIs) were calculated. RESULTS A total of 1,475 patients were included in 26 studies (23 observational and 3 randomized controlled trials). In patients receiving anticoagulant therapy, SVT recanalization occurred in 68% (95% CI, 62-74; 571/842 patients; 22 studies), SVT progression in 6% (95% CI, 4-9; 25/748 patients; 22 studies), recurrent VTE in 10% (95% CI, 4-22; 48/399 patients; 7 studies), major bleeding in 6% (95% CI, 4-10; 58/785 patients; 18 studies), and overall mortality in 9% (95% CI, 6-14; 68/787 patients; 17 studies). Anticoagulant treatment was associated with higher SVT recanalization (RR 3.19; 95% CI, 1.42-7.17), lower thrombosis progression (RR 0.28; 95% CI, 0.15-0.52), major bleeding (RR 0.52; 95% CI, 0.28-0.97), and overall mortality (RR 0.42; 95% CI, 0.24-0.73) compared with no treatment. CONCLUSION Anticoagulant therapy seems to improve vein recanalization and to reduce SVT progression, major bleeding, and overall mortality in cirrhotic patients with SVT. The incidence of recurrent VTE during anticoagulation remains substantial.
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33
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Williams C, Stewart E, Conzen KD, Wolf S, Tran TT. Dabigatran Reversal With Idarucizumab in 2 Patients With Portal Vein Thrombosis Undergoing Orthotopic Liver Transplantation. Semin Cardiothorac Vasc Anesth 2021; 25:200-207. [DOI: 10.1177/1089253220982183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
There are limited data to guide the use of anticoagulation in cirrhotic patients prior to liver transplantation especially when using direct oral anticoagulants. In this article, we present 2 cases. The first is a 42-year-old male with cirrhosis complicated by portal vein thrombosis (PVT) treated with dabigatran who underwent orthotopic liver transplantation without complication. The second case is a 65-year-old man with alcoholic cirrhosis complicated by PVT treated with dabigatran who underwent orthotopic liver transplantation and required reoperation for surgical bleeding. Both patients were treated with dabigatran’s reversal agent idarucizumab prior to incision. In this case series, we discuss the treatment of cirrhotic patients with various anticoagulants, considerations for anticoagulant selection and reversal prior to liver transplant, and questions for future investigation.
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Affiliation(s)
| | - Erin Stewart
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | | | - Scott Wolf
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Timothy T. Tran
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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34
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Wang L, Guo X, Xu X, De Stefano V, Plessier A, Noronha Ferreira C, Qi X. Anticoagulation Favors Thrombus Recanalization and Survival in Patients With Liver Cirrhosis and Portal Vein Thrombosis: Results of a Meta-Analysis. Adv Ther 2021; 38:495-520. [PMID: 33155180 PMCID: PMC7854392 DOI: 10.1007/s12325-020-01550-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 10/23/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Benefit and risk of anticoagulation in cirrhotic patients with portal vein thrombosis (PVT) remain controversial, especially in those with asymptomatic PVT and in non-liver transplant candidates. Furthermore, the predictors of portal vein recanalization and bleeding events after anticoagulation are critical for making clinical decisions, but still unclear. We conducted a meta-analysis to investigate the outcomes of anticoagulation for PVT in liver cirrhosis and explore the predictors of portal vein recanalization and bleeding events after anticoagulation. METHODS All studies regarding anticoagulation for PVT in liver cirrhosis were searched via PubMed, EMBASE, and Cochrane Library databases. Thrombotic outcomes, bleeding events, and survival were compared between anticoagulation and non-anticoagulation groups. Predictors of portal vein recanalization and bleeding events were pooled. Risk ratios (RRs) or mean differences (MDs) with 95% confidence intervals (CIs) were calculated. RESULTS Thirty-three studies including 1696 cirrhotic patients with PVT were included. Anticoagulation significantly increased portal vein recanalization (RR = 2.61; 95% CI 1.99-3.43; P < 0.00001) and overall survival (RR = 1.11; 95% CI 1.03-1.21; P = 0.01) and decreased thrombus progression (RR = 0.26; 95% CI 0.14-0.49; P < 0.0001). Anticoagulation did not significantly influence overall bleeding (RR = 0.78; 95% CI 0.47-1.30; P = 0.34). Early initiation of anticoagulation (RR = 1.58; 95% CI 1.21-2.07; P = 0.0007) significantly increased portal vein recanalization. Child-Pugh class B and C (RR = 0.77; 95% CI 0.62-0.95; P = 0.02) and higher MELD score (MD = - 1.48; 95% CI - 2.20-0.76; P < 0.0001) were significantly associated with decreased portal vein recanalization. No predictor significantly associated with bleeding events was identified. CONCLUSIONS Early initiation of anticoagulation should be supported in liver cirrhosis with PVT. Predictors of portal vein recanalization should be taken into consideration to identify those who may not benefit from anticoagulation. REGISTRATION The work was registered in PROSPERO with registration no. CRD42020157142.
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Affiliation(s)
- Le Wang
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly Called General Hospital of Shenyang Military Area), Shenyang, China
- Postgraduate College, Dalian Medical University, Dalian, China
| | - Xiaozhong Guo
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly Called General Hospital of Shenyang Military Area), Shenyang, China
| | - Xiangbo Xu
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly Called General Hospital of Shenyang Military Area), Shenyang, China
| | - Valerio De Stefano
- Dipartimento Di Diagnostica Per Immagini, Radioterapia Oncologica Ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Aurelie Plessier
- Hôpital Beaujon, AP-HP, DHU Unity, Pôle des Maladies de l'Appareil Digestif, Service d'Hépatologie, Centre de Référence Des Maladies Vasculaires du Foie, Inserm U1149, Centre de Recherche Sur L'Inflammation (CRI), Université Paris 7-Denis-Diderot, ERN Rare Liver Clichy, Paris, France
| | - Carlos Noronha Ferreira
- Serviço de Gastrenterologia E Hepatologia, Hospital de Santa Maria-Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
| | - Xingshun Qi
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly Called General Hospital of Shenyang Military Area), Shenyang, China.
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35
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Rugivarodom M, Charatcharoenwitthaya P. Nontumoral Portal Vein Thrombosis: A Challenging Consequence of Liver Cirrhosis. J Clin Transl Hepatol 2020; 8:432-444. [PMID: 33447527 PMCID: PMC7782107 DOI: 10.14218/jcth.2020.00067] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 09/27/2020] [Accepted: 10/18/2020] [Indexed: 12/13/2022] Open
Abstract
Nontumoral portal vein thrombosis (PVT) is an increasingly recognized complication in patients with cirrhosis. Substantial evidence shows that portal flow stasis, complex thrombophilic disorders, and exogenous factors leading to endothelial dysfunction have emerged as key factors in the pathogenesis of PVT. The contribution of PVT to hepatic decompensation and mortality in cirrhosis is debatable; however, the presence of an advanced PVT increases operative complexity and decreases survival after transplantation. The therapeutic decision for PVT is often determined by the duration and extent of thrombosis, the presence of symptoms, and liver transplant eligibility. Evidence from several cohorts has demonstrated that anticoagulation treatment with vitamin K antagonist or low molecular weight heparin can achieve recanalization of the portal vein, which is associated with a reduction in portal hypertension-related events and improved survival in cirrhotic patients with PVT. Consequently, interest in direct oral anticoagulants for PVT is increasing, but clinical data in cirrhosis are limited. Although the most feared consequence of anticoagulation is bleeding, most studies indicate that anticoagulation therapy for PVT in cirrhosis appears relatively safe. Interestingly, the data showed that transjugular intrahepatic portosystemic shunt represents an effective adjunctive therapy for PVT in cirrhotic patients with symptomatic portal hypertension if anticoagulation is ineffective. Insufficient evidence regarding the optimal timing, modality, and duration of therapy makes nontumoral PVT a challenging consequence of cirrhosis. In this review, we summarize the current literature and provide a potential algorithm for the management of PVT in patients with cirrhosis.
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Affiliation(s)
- Manus Rugivarodom
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Phunchai Charatcharoenwitthaya
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Correspondence to: Phunchai Charatcharoenwitthaya, Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Wang-Lang Road, Bangkoknoi, Bangkok 10700, Thailand. Tel: +662-419-7282, Fax: +662-411-5013, E-mail:
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36
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Ghazaleh S, Beran A, Aburayyan K, Nehme C, Patel D, Khader Y, Sharma S, Aziz M, Abdel-Aziz Y, Hammad T, Nawras A. Efficacy and safety of anticoagulation in non-malignant portal vein thrombosis in patients with liver cirrhosis: a systematic review and meta-analysis. Ann Gastroenterol 2020; 34:104-110. [PMID: 33414629 PMCID: PMC7774659 DOI: 10.20524/aog.2020.0544] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 07/31/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The role of anticoagulation in treating non-malignant portal vein (PV) thrombosis (PVT) in patients with liver cirrhosis remains unclear. In our meta-analysis, we aimed to evaluate the efficacy and safety of anticoagulation for the treatment of non-malignant PVT in these patients. METHODS We conducted a meta-analysis to estimate the effects of anticoagulation on non-malignant PVT in patients with liver cirrhosis. We assessed the rates of PV recanalization, variceal bleeding, and any bleeding. RESULTS We included 9 observational studies which involved 474 patients. The rate of PV recanalization was significantly higher in patients who received anticoagulation compared to those who did not: 65.2% vs. 25.2%; relative risk (RR) 2.31, 95% confidence interval (CI) 1.80-2.96; P<0.00001. Variceal bleeding was significantly lower in patients who received anticoagulation: 0.1% vs. 18.5%; RR 0.15, 95%CI 0.04-0.55; P=0.004. Any bleeding was similar between patients who received anticoagulation and those who did not: 10.3% vs. 22.7%; RR 0.43, 95%CI 0.09-1.99; P=0.28. CONCLUSIONS Anticoagulation use increased the rate of PV recanalization in cirrhotic patients with non-malignant PVT. Anticoagulation decreased the rate of variceal bleeding and did not increase the rate of any bleeding.
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Affiliation(s)
- Sami Ghazaleh
- Department of Internal Medicine, University of Toledo, Toledo, OH (Sami Ghazaleh, Azizullah Beran, Kanana Aburayyan, Christian Nehme, Dipen Patel, Yasmin Khader, Sachit Sharma, Muhammad Aziz)
| | - Azizullah Beran
- Department of Internal Medicine, University of Toledo, Toledo, OH (Sami Ghazaleh, Azizullah Beran, Kanana Aburayyan, Christian Nehme, Dipen Patel, Yasmin Khader, Sachit Sharma, Muhammad Aziz)
| | - Kanana Aburayyan
- Department of Internal Medicine, University of Toledo, Toledo, OH (Sami Ghazaleh, Azizullah Beran, Kanana Aburayyan, Christian Nehme, Dipen Patel, Yasmin Khader, Sachit Sharma, Muhammad Aziz)
| | - Christian Nehme
- Department of Internal Medicine, University of Toledo, Toledo, OH (Sami Ghazaleh, Azizullah Beran, Kanana Aburayyan, Christian Nehme, Dipen Patel, Yasmin Khader, Sachit Sharma, Muhammad Aziz)
| | - Dipen Patel
- Department of Internal Medicine, University of Toledo, Toledo, OH (Sami Ghazaleh, Azizullah Beran, Kanana Aburayyan, Christian Nehme, Dipen Patel, Yasmin Khader, Sachit Sharma, Muhammad Aziz)
| | - Yasmin Khader
- Department of Internal Medicine, University of Toledo, Toledo, OH (Sami Ghazaleh, Azizullah Beran, Kanana Aburayyan, Christian Nehme, Dipen Patel, Yasmin Khader, Sachit Sharma, Muhammad Aziz)
| | - Sachit Sharma
- Department of Internal Medicine, University of Toledo, Toledo, OH (Sami Ghazaleh, Azizullah Beran, Kanana Aburayyan, Christian Nehme, Dipen Patel, Yasmin Khader, Sachit Sharma, Muhammad Aziz)
| | - Muhammad Aziz
- Department of Internal Medicine, University of Toledo, Toledo, OH (Sami Ghazaleh, Azizullah Beran, Kanana Aburayyan, Christian Nehme, Dipen Patel, Yasmin Khader, Sachit Sharma, Muhammad Aziz)
| | - Yousef Abdel-Aziz
- Department of Gastroenterology and Hepatology, University of Tennessee, Memphis, TN (Yousef Abdel-Aziz)
| | - Tariq Hammad
- Department of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX (Tariq Hammad)
| | - Ali Nawras
- Department of Gastroenterology and Hepatology, University of Toledo, Toledo, OH (Ali Nawras), USA
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Xu X, Guo X, Wang R, Wang L, Li Q, Yi F, Li H, Qi X. Low-molecular-weight heparin followed by rivaroxaban for acute occlusive portomesenteric vein thrombosis in a cirrhotic patient treated with multiple endoscopic variceal procedures. Ann Hepatol 2020; 19:573-577. [PMID: 31521463 DOI: 10.1016/j.aohep.2019.08.002] [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: 05/08/2019] [Revised: 07/09/2019] [Accepted: 08/20/2019] [Indexed: 02/07/2023]
Abstract
Acute portomesenteric vein thrombosis is potentially lethal. In the present paper, a cirrhotic patient with a previous history of esophageal variceal bleeding presented with acute occlusive portomesenteric vein thrombosis, but achieved complete recanalization by low-molecular-weight heparin followed by rivaroxaban. Notably, no bleeding episode occurred during anticoagulation therapy. This case supported early initiation of anticoagulation in such patients.
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Affiliation(s)
- Xiangbo Xu
- Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, PR China; Postgraduate College, Shenyang Pharmaceutical University, Shenyang 110016, PR China
| | - Xiaozhong Guo
- Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, PR China.
| | - Ran Wang
- Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, PR China
| | - Le Wang
- Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, PR China
| | - Qianqian Li
- Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, PR China
| | - Fangfang Yi
- Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, PR China
| | - Hongyu Li
- Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, PR China
| | - Xingshun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, PR China.
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38
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Nicoară-Farcău O, Soy G, Magaz M, Baiges A, Turon F, Garcia-Criado A, Barrufet M, Burrel M, Hernández-Gea V, García-Pagán JC. New Insights into the Pathogenesis, Risk Factors, and Treatment of Portal Vein Thrombosis in Patients with Cirrhosis. Semin Thromb Hemost 2020; 46:673-681. [PMID: 32820481 DOI: 10.1055/s-0040-1715473] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Portal vein thrombosis (PVT) is a frequent event in patients with cirrhosis regardless of etiology. Notwithstanding the commonality of the problem, the pathophysiology and risk factors for PVT in cirrhosis are largely unknown. The clinical impact of PVT in the natural history of cirrhosis is unclear, indications for PVT treatment are not well defined, and treatment recommendations are based on experts' opinion and consensus only. Therefore, this review aims to summarize current knowledge of mechanisms and risk factors for PVT development and assess the current evidence of PVT management, with a special focus on strategies of anticoagulation and transjugular intrahepatic portosystemic shunt placement.
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Affiliation(s)
- Oana Nicoară-Farcău
- Department of Hepatology, Regional Institute of Gastroenterology and Hepatology "Octavian Fodor," "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania.,Liver Unit, Barcelona Hepatic Hemodynamic Laboratory, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi I i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Guillem Soy
- Liver Unit, Barcelona Hepatic Hemodynamic Laboratory, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi I i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.,Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver)
| | - Marta Magaz
- Liver Unit, Barcelona Hepatic Hemodynamic Laboratory, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi I i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.,Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver)
| | - Anna Baiges
- Liver Unit, Barcelona Hepatic Hemodynamic Laboratory, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi I i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.,Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver)
| | - Fanny Turon
- Liver Unit, Barcelona Hepatic Hemodynamic Laboratory, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi I i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.,Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver)
| | - Angeles Garcia-Criado
- Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver).,Department of Radiology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Marta Barrufet
- Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver).,Department of Radiology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Marta Burrel
- Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver).,Department of Radiology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Virginia Hernández-Gea
- Liver Unit, Barcelona Hepatic Hemodynamic Laboratory, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi I i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.,Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver)
| | - Juan Carlos García-Pagán
- Liver Unit, Barcelona Hepatic Hemodynamic Laboratory, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi I i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.,Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver)
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Mohan BP, Aravamudan VM, Khan SR, Ponnada S, Asokkumar R, Adler DG. Treatment response and bleeding events associated with anticoagulant therapy of portal vein thrombosis in cirrhotic patients: Systematic review and meta-analysis. Ann Gastroenterol 2020; 33:521-527. [PMID: 32879600 PMCID: PMC7406805 DOI: 10.20524/aog.2020.0503] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 04/21/2020] [Indexed: 12/14/2022] Open
Abstract
Background Well-defined guidelines for the treatment of portal vein thrombosis (PVT) in patients with cirrhosis are lacking, given the paucity of robust data. Among the available treatment options the best choice is unknown. Methods We conducted a comprehensive search of multiple electronic databases and conference proceedings (through December 2019) to identify studies that reported on the use of anticoagulants in the treatment of PVT in patients with cirrhosis. Our goals were to evaluate the pooled odds ratio (OR) and pooled rate of treatment responders and bleeding events. Results A total of 17 studies were included: 648 patients were treated with anticoagulation and 96 were controls. Pooled OR for treatment responders was 5.1 (95% confidence interval [CI] 2.5-10.2, P = 0.001) and pooled OR for bleeding was 0.4 (95%CI 0.1-1.5, P = 0.2) for anticoagulation treatment versus control. Pooled rate of treatment responders with anticoagulation was 66.7% (95%CI 58.3-74.1) compared to 26% (95%CI 14.2-42.7) for the control group. Pooled rate of bleeding seemed comparable (7.8%, 95%CI 4.5-13.3, and 15.4%, 95%CI 4.3-42.7). On subgroup analysis, pooled rates of treatment responders and bleeding events seemed similar between low molecular weight heparin, vitamin K antagonists, and direct oral anticoagulants. Conclusions Our study demonstrated that anticoagulation is effective and safe in the treatment of PVT in patients with cirrhosis. Owing to the comparable outcomes, direct oral anticoagulants may be considered as first-line treatment, depending on patient preferences.
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Affiliation(s)
- Babu P Mohan
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | | | - Shahab Rasool Khan
- Section of Gastroenterology, Rush University Medical Center, Chicago, Illinois, USA
| | - Suresh Ponnada
- Internal Medicine, Carilion Roanoke Memorial Hospital, Roanoke, Virginia, USA
| | - Ravishankar Asokkumar
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Douglas G Adler
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, UT, USA
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40
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Acute Portal Vein Thrombosis Treated with Recombinant Human Soluble Thrombomodulin Combined with Antithrombin III. Case Rep Med 2020; 2020:8268016. [PMID: 32328109 PMCID: PMC7174955 DOI: 10.1155/2020/8268016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 03/23/2020] [Indexed: 11/18/2022] Open
Abstract
Portal vein thrombosis is a major complication associated with liver cirrhosis. In cirrhotic patients, a decrease in procoagulant and anticoagulant factors and an unstable balance between them is observed, and a relative decrease in the activation of anticoagulant drivers is one of the main causes of portal vein thrombosis (PVT). Herein, we report a case of acute portal thrombosis associated with liver cirrhosis and treated with a recombinant form of soluble thrombomodulin (thrombomodulin alpha, TM-α) in combination with antithrombin III. TM-α was administered in accordance with the dosage and route of administration for disseminated intravascular coagulation therapy and resulted in dissolution of PVT with a gradual decrease in D-dimer levels. No adverse events were observed during the course of treatment. In the future, in addition to conventional anticoagulation therapy using heparin or antivitamin K drugs, novel therapies targeting protein C activation using a recombinant form of soluble thrombomodulin may play an important role in the treatment of acute PVT.
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41
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Xu X, Xu S, Primignani M, De Stefano V, He Y, Yi F, Guo X, Valla D, Qi X. Nonselective β-Blockers May Progress the Thrombosis of Portal Venous System in Cirrhotic Patients: A Retrospective Observational Study. Adv Ther 2020; 37:1452-1463. [PMID: 32076942 PMCID: PMC7140745 DOI: 10.1007/s12325-020-01250-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Occlusive portal venous system thrombosis (PVT) is significantly associated with poor outcomes in cirrhotic patients. Nonselective β-blockers (NSBBs) may be associated with the development of PVT. However, the role of NSBBs in progressing thrombosis remains unclear. METHODS Forty-three patients on whom contrast-enhanced computed tomography or magnetic resonance imaging was performed twice, and for whom there was detailed information regarding NSBBs, were eligible in this study, including 16 in the NSBBs group and 27 in the no NSBBs group. A composite endpoint of progressing thrombosis included the development of PVT in patients without PVT and aggravation of PVT in patients with PVT. Logistic regression analysis was employed to identify the effect of NSBBs on the progression of PVT. RESULTS At the last admission, 13 patients had progressing thrombosis. The incidence of progressing thrombosis was significantly higher in the NSBBs group than in the no NSBBs group [50.0% (8/16) vs. 18.5% (5/27), P = 0.030]. The use of NSBBs (odds ratio 4.400, 95% confidence interval 1.107-17.482, P = 0.035) was significantly associated with progressing thrombosis in univariate logistic regression analyses, but not significant (odds ratio 4.084, 95% confidence interval 0.488-34.158, P = 0.194) in multivariate logistic regression analyses. CONCLUSIONS NSBBs may play a role in the progression of PVT in liver cirrhosis. The benefits and risks of NSBBs in the management of liver cirrhosis should be fully weighed.
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Affiliation(s)
- Xiangbo Xu
- Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, China
- Postgraduate College, Shenyang Pharmaceutical University, Shenyang, China
| | - Shixue Xu
- Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, China
| | - Massimo Primignani
- CRC "A.M. e A. Migliavacca" Center for the Study of Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico Università degli Studi di Milano, Via F. Sforza 35, 20122, Milan, Italy
| | - Valerio De Stefano
- Fondazione Policlinico A. Gemelli IRCCS, Istituto di Ematologia, Università Cattolica, Rome, Italy
| | - Yanglan He
- Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, China
| | - Fangfang Yi
- Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, China
| | - Xiaozhong Guo
- Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, China
| | - Dominique Valla
- Service d'Hépatologie, Hôpital Beaujon, APHP, Clichy-la-Garenne, France
- CRI, UMR1149, Inserm and Université de Paris, Paris, France
| | - Xingshun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, China.
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Proietti M, Marzona I, Vannini T, Colacioppo P, Tettamanti M, Foresta A, Fortino I, Merlino L, Lip GYH, Roncaglioni MC. Impact of liver disease on oral anticoagulant prescription and major adverse events in patients with atrial fibrillation: analysis from a population-based cohort study. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 7:f84-f92. [PMID: 32129845 DOI: 10.1093/ehjcvp/pvaa015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 11/29/2019] [Accepted: 02/28/2020] [Indexed: 12/19/2022]
Abstract
AIMS Data on the impact of liver disease (LD) in patients with atrial fibrillation (AF) and the role of oral anticoagulant (OAC) drugs for stroke prevention are limited. METHODS AND RESULTS A retrospective observational population-based cohort study on the administrative health databases of Lombardy region Italy. All AF patients ≥40 years admitted to hospital from 2000 to 2018 were considered. Atrial fibrillation and LD diagnosis were established using ICD9-CM codes. Use of OAC was determined with Anatomical Therapeutic Chemical codes. Primary study outcomes were stroke, major bleeding, and all-cause death. Among 393 507 AF patients, 16 168 (4.1%) had concomitant LD. Liver disease AF patients were significantly less treated with OAC. Concomitant LD was associated with an increased risk in all the study outcomes [hazard ratio (HR): 1.18, 95% confidence interval (CI): 1.11-1.25 for stroke; HR: 1.57, 95% CI: 1.47-1.66 for major bleeding; HR: 1.41, 95% CI: 1.39-1.44 for all-cause death]. Use of OAC in patients with AF and LD resulted in a reduction in stroke (HR: 0.80, 95% CI: 0.70-0.92), major bleeding (HR: 0.86, 95% CI: 0.74-0.99), and all-cause death (HR: 0.77, 95% CI: 0.73-0.80), with similar results according to subgroups. A net clinical benefit (NCB) analysis suggested a positive benefit/risk ratio in using OAC in AF patients with LD (NCB: 0.408, 95% CI: 0.375-0.472). CONCLUSION In AF patients, concomitant LD carries a significantly higher risk for all clinical outcomes. Use of OAC in AF patients with LD was associated with a significant favourable benefit/risk ratio, even in high-risk patient subgroups.
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Affiliation(s)
- Marco Proietti
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Geriatric Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy.,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Irene Marzona
- Department of Cardiovascular Medicine, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, 20156 Milan, Italy
| | - Tommaso Vannini
- Department of Cardiovascular Medicine, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, 20156 Milan, Italy
| | - Pierluca Colacioppo
- Department of Cardiovascular Medicine, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, 20156 Milan, Italy
| | - Mauro Tettamanti
- Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Andreana Foresta
- Department of Cardiovascular Medicine, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, 20156 Milan, Italy
| | - Ida Fortino
- Regional Health Ministry, Lombardy Region, Milan, Italy
| | - Luca Merlino
- Regional Health Ministry, Lombardy Region, Milan, Italy
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Maria Carla Roncaglioni
- Department of Cardiovascular Medicine, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, 20156 Milan, Italy
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Safety of variceal band ligation in patients with cirrhosis and portal vein thrombosis treated with anticoagulant therapy: A retrospective study. Eur J Gastroenterol Hepatol 2020; 32:395-400. [PMID: 31464780 DOI: 10.1097/meg.0000000000001522] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Anticoagulant therapy has been recommended in patients with cirrhosis and portal vein thrombosis especially in candidates for liver transplantation. These patients are also likely to need variceal band ligation. This study aimed to assess the incidence of upper gastrointestinal bleeding after elective variceal band ligation in patients with cirrhosis receiving anticoagulant therapy for portal vein thrombosis. METHODS Patients with cirrhosis and nontumoral portal vein thrombosis treated with anticoagulant therapy undergoing elective variceal band ligation were retrospectively included. We recorded upper gastrointestinal bleeding events occurring within two weeks after variceal band ligation. Postvariceal band ligation bleeding was defined as active bleeding on at least one site of previous ligation at endoscopy. RESULTS Between 2014 and 2017, 32 patients with cirrhosis had scheduled variceal band ligations while on anticoagulant therapy [men 75%; median age 59 years; aetiology of cirrhosis: alcohol (50%), viral (34%), alcohol and viral (16%); and Child-Pugh score: A (31%), B (44%), and C (25%)]. Three (9%) patients presented postvariceal band ligation bleeding during the follow-up. None of these events led to haemorrhagic shock or death. Factors associated with postvariceal band ligation bleeding included variceal band ligation performed as secondary prophylaxis (P = 0.05) and previous decompensation of cirrhosis (P = 0.03). CONCLUSION In this small group of patients under anticoagulation therapy undergoing variceal band ligation, only a minority presented postendoscopic bleeding of minor importance. Nevertheless, particular attention should be paid to patients with previous decompensation of cirrhosis.
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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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Zhang L, Huan H, Tong H, Wei B, Wang Z, Liu C, Wu H. Warfarin prevented de novo portal vein thrombosis after transjugular intrahepatic portosystemic shunt: A retrospective study. Medicine (Baltimore) 2020; 99:e18737. [PMID: 31914090 PMCID: PMC6959952 DOI: 10.1097/md.0000000000018737] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Portal vein thrombosis (PVT) might impair the prognosis of cirrhotic patients. However, formation of de novo PVT after transjugular intrahepatic portosystemic shunt (TIPS) in cirrhotic patients without preexisting PVT was rarely reported. Moreover, it is not known whether warfarin is efficient in preventing de novo PVT after TIPS. The current study aimed to investigate retrospectively the incidence and location of de novo PVT, and preventive effects of warfarin on de novo PVT after TIPS for cirrhotic patients. Patients who received TIPS placement between March 1, 2015 and March 1, 2016 in our hospital were screened retrospectively. Patients without preexisting PVT before TIPS and those who were followed up for at least 12 months were included. There were 2 groups: 1 group received warfarin (warfarin group) post-TIPS, while another group (control group) did not receive prophylactic drug to prevent PVT. Their baseline characteristics and follow-up data were retrieved. The occurrence of PVT, adverse events due to warfarin, difference in stent patency and clinical complications such as stent dysfunction, hepatic encephalopathy, mortality, liver cancer, variceal bleeding, infection, and liver failure, and results of follow-up biochemical examination were compared. Eighty-three patients without preexisting PVT were included. There were 56 patients in the control group and 27 in the warfarin group. The incidence of PVT in the warfarin group was 14.8% (4/27), whereas the incidence in the control group was 42.9% (24/56, P = .013). The location of de novo PVT was mainly at left portal vein. Adverse events due to warfarin was mostly mild, such as hemorrhinia and gingival hemorrhage. No significant difference regarding to stent patency and clinical complications between the 2 groups was found. At 24-month after-TIPS, for the remaining patients in both groups, the total bilirubin was significantly increased while the red blood cell count was significantly decreased in control group compared with those in warfarin group (P < .05). PVT could commonly occur after TIPS in patients without preexisting PVT. Warfarin could prevent PVT in these patients, and might improve patient's liver function.
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Affiliation(s)
- Linhao Zhang
- Department of Gastroenterology
- Laboratory of Gastroenterology and Hepatology, West China Hospital, Sichuan University
| | - Hui Huan
- Department of Gastroenterology
- Department of Gastroenterology, Hospital of Chengdu Office of People's Government of Tibetan autonomous Region, Sichuan, China
| | | | - Bo Wei
- Department of Gastroenterology
| | | | - Chao Liu
- Department of Gastroenterology, Hospital of Chengdu Office of People's Government of Tibetan autonomous Region, Sichuan, China
| | - Hao Wu
- Department of Gastroenterology
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Zheng K, Yoshida EM, Tacke F, Li Y, Guo X, Qi X. Risk of Stroke in Liver Cirrhosis: A Systematic Review and Meta-Analysis. J Clin Gastroenterol 2020; 54:96-105. [PMID: 30882537 DOI: 10.1097/mcg.0000000000001201] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Liver cirrhosis can lead to abnormal coagulation, rendering patients at risk for bleeding but also thrombotic complications. We conducted a systematic review and meta-analysis to explore the epidemiology of stroke in liver cirrhosis and the potential association between them. MATERIALS AND METHODS Studies were searched through the PubMed, EMBASE, and Cochrane Library databases. Incidence and prevalence of unspecific stroke, hemorrhagic stroke, intracranial hemorrhage, subarachnoid hemorrhage, and ischemic stroke were pooled by using a random-effect model. Meta-regression analyses were employed to explore the sources of heterogeneity. As for the cohort studies, hazard ratios (HRs) with 95% CIs were pooled to evaluate the association between liver cirrhosis and stroke. RESULTS Twenty-seven studies with 93,191 cirrhotic patients were included, of which 23 explored the incidence and 10 explored the prevalence. The pooled incidence of unspecific stroke, hemorrhagic stroke, intracranial hemorrhage, and ischemic stroke was 4.1%, 1.3%, 2.0%, and 3.7%, respectively. The pooled prevalence of unspecific and ischemic stroke was 9.0% and 2.6%, respectively. Heterogeneity among studies was significant in most of meta-analyses. Meta-regression analyses indicated that the sample size might explain the potential source of heterogeneity (P=0.018). Liver cirrhosis significantly increased the risk of subarachnoid (HR=2.36; 95% CI, 1.80-3.09; P=0.000) and intracranial hemorrhage (HR=1.48; 95% CI, 1.06-2.05; P=0.020), but not unspecific (HR=1.02; 95% CI, 0.49-2.14; P=0.960), ischemic (HR=0.79; 95% CI, 0.46-1.35; P=0.380), or hemorrhagic stroke (HR=1.88; 95% CI, 0.52-6.81; P=0.335). CONCLUSIONS Stroke is uncommon in cirrhotic patients. However, considering a positive relationship of liver cirrhosis with subarachnoid and intracranial hemorrhage, the prophylactic strategy may be selectively adopted in cirrhotic patients.
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Affiliation(s)
- Kexin Zheng
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang
- Postgraduate College, Jinzhou Medical University, Jinzhou, Liaoning Province, China
| | - Eric M Yoshida
- Division of Gastroenterology, University of British Columbia, Diamond Health Care Centre, Vancouver General Hospital, Vancouver, BC, Canada
| | - Frank Tacke
- Department of Gastroenterology, Metabolic Diseases and Intensive Care Medicine, University Hospital Aachen, Aachen, Germany
| | - Yingying Li
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang
- Postgraduate College, Jinzhou Medical University, Jinzhou, Liaoning Province, China
| | - Xiaozhong Guo
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang
| | - Xingshun Qi
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang
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Hayashi T, Takatori H, Horii R, Nio K, Terashima T, Iida N, Kitahara M, Shimakami T, Arai K, Kitamura K, Kawaguchi K, Yamashita T, Sakai Y, Yamashita T, Mizukoshi E, Honda M, Toyama T, Okumura K, Kozaka K, Kaneko S. Danaparoid sodium-based anticoagulation therapy for portal vein thrombosis in cirrhosis patients. BMC Gastroenterol 2019; 19:217. [PMID: 31842768 PMCID: PMC6915942 DOI: 10.1186/s12876-019-1140-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 12/09/2019] [Indexed: 01/15/2023] Open
Abstract
Background Portal vein thrombosis (PVT) is a common complication of cirrhosis. However, in patients with PVT and cirrhosis, there is no clear evidence supporting effective treatment modalities. In this study, we examined the effectiveness and safety of anticoagulation therapy using danaparoid sodium for PVT in patients with cirrhosis. Methods This retrospective study assessed 52 cirrhotic patients with PVT treated with danaparoid sodium for 2 weeks between November 2008 and September 2018. The primary outcome measure was the post-treatment status of PVT assessed by reduction in thrombus volume and safety of the therapeutic intervention. PVT status was evaluated with contrast-enhanced computed tomography (CECT). All patients received 1250 units of danaparoid sodium twice daily by intravenous injection for 14 days. Patients on antithrombin III (AT-III) combination therapy were additionally administered 1500 units of AT-III on days 1–5 and days 8–12. Effectiveness was evaluated by CECT from between days 13 and 18. The secondary outcome measure was the prognosis of PVT. Results All patients showed reduction in PVT volume without complications. Return of plasma AT-III level to > 70% during the treatment period contributes to ≥75% reduction of PVT volume. The prognosis in PVT patients depends on hepatic reserve capacity. When limited to Child-Pugh B and C liver cirrhosis patients, a ≥ 75% reduction of PVT volume improved the prognosis. Conclusions Danaparoid sodium-based anticoagulation therapy was effective and safe for PVT in patients with cirrhosis. Return of plasma AT-III level to the normal range during the treatment period contributes to reduction of PVT volume. A reduction of ≥75% in PVT volume may improve the prognosis of Child-Pugh B and C decompensated cirrhosis patients with PVT.
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Affiliation(s)
- Takehiro Hayashi
- Department of Gastroenterology, Kanazawa University Graduate School of Medical Science, Kanazawa, Ishikawa, Japan.,Department of Gastroenterology, Yawata Medical Center, Komatsu, Ishikawa, Japan
| | - Hajime Takatori
- Department of Gastroenterology, Kanazawa University Graduate School of Medical Science, Kanazawa, Ishikawa, Japan.
| | - Rika Horii
- Department of Gastroenterology, Kanazawa University Graduate School of Medical Science, Kanazawa, Ishikawa, Japan
| | - Kouki Nio
- Department of Gastroenterology, Kanazawa University Graduate School of Medical Science, Kanazawa, Ishikawa, Japan
| | - Takeshi Terashima
- Department of Gastroenterology, Kanazawa University Graduate School of Medical Science, Kanazawa, Ishikawa, Japan
| | - Noriho Iida
- Department of Gastroenterology, Kanazawa University Graduate School of Medical Science, Kanazawa, Ishikawa, Japan
| | - Masaaki Kitahara
- Department of Gastroenterology, Kanazawa University Graduate School of Medical Science, Kanazawa, Ishikawa, Japan
| | - Tetsuro Shimakami
- Department of Gastroenterology, Kanazawa University Graduate School of Medical Science, Kanazawa, Ishikawa, Japan
| | - Kuniaki Arai
- Department of Gastroenterology, Kanazawa University Graduate School of Medical Science, Kanazawa, Ishikawa, Japan
| | - Kazuya Kitamura
- Department of Gastroenterology, Kanazawa University Graduate School of Medical Science, Kanazawa, Ishikawa, Japan
| | - Kazunori Kawaguchi
- Department of Gastroenterology, Kanazawa University Graduate School of Medical Science, Kanazawa, Ishikawa, Japan
| | - Taro Yamashita
- Department of Gastroenterology, Kanazawa University Graduate School of Medical Science, Kanazawa, Ishikawa, Japan
| | - Yoshio Sakai
- Department of Gastroenterology, Kanazawa University Graduate School of Medical Science, Kanazawa, Ishikawa, Japan
| | - Tatsuya Yamashita
- Department of Gastroenterology, Kanazawa University Graduate School of Medical Science, Kanazawa, Ishikawa, Japan
| | - Eishiro Mizukoshi
- Department of Gastroenterology, Kanazawa University Graduate School of Medical Science, Kanazawa, Ishikawa, Japan
| | - Masao Honda
- Department of Gastroenterology, Kanazawa University Graduate School of Medical Science, Kanazawa, Ishikawa, Japan
| | - Tadashi Toyama
- Department of Nephrology, Kanazawa University Graduate School of Medical Science, Kanazawa, Ishikawa, Japan
| | - Kenichiro Okumura
- Department of Radiology, Kanazawa University Graduate School of Medical Science, Kanazawa, Ishikawa, Japan
| | - Kazuto Kozaka
- Department of Radiology, Kanazawa University Graduate School of Medical Science, Kanazawa, Ishikawa, Japan
| | - Shuichi Kaneko
- Department of Gastroenterology, Kanazawa University Graduate School of Medical Science, Kanazawa, Ishikawa, Japan
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Summers KL, Davis KA, Nisly SA. Bleeding Risk of Therapeutic Unfractionated Heparin and Low Molecular Weight Heparin in Patients with Cirrhosis. Clin Drug Investig 2019; 40:191-196. [PMID: 31755014 DOI: 10.1007/s40261-019-00875-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND OBJECTIVE Patients with cirrhosis are simultaneously at an increased risk of bleeding and thrombosis. Studies comparing the safety of parenteral anticoagulants in this population are lacking. This study evaluated the safety of therapeutic unfractionated heparin versus low molecular weight heparin in patients with cirrhosis. METHODS This system-wide, retrospective cohort study included adults with cirrhosis receiving unfractionated heparin or low molecular weight heparin for the treatment of acute venous thromboembolism. The primary endpoint was the incidence of major bleeding. RESULTS Eighty-two patients were included in this study, with 52 receiving unfractionated heparin and 30 receiving low molecular weight heparin. More major bleeding occurred in the unfractionated heparin arm compared to the low molecular weight heparin arm (19.2% vs 0%, p = 0.010). CONCLUSIONS Low molecular weight heparin may be a safer option in patients with cirrhosis treated for acute venous thromboembolism, but future studies should confirm these findings.
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Affiliation(s)
| | - Kyle A Davis
- Department of Pharmacy, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Sarah A Nisly
- Department of Pharmacy, Wake Forest Baptist Health, Winston-Salem, NC, USA. .,School of Pharmacy, Wingate University, Wingate, NC, USA.
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49
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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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50
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Faccia M, Ainora ME, Ponziani FR, Riccardi L, Garcovich M, Gasbarrini A, Pompili M, Zocco MA. Portal vein thrombosis in cirrhosis: Why a well-known complication is still matter of debate. World J Gastroenterol 2019; 25:4437-4451. [PMID: 31496623 PMCID: PMC6710174 DOI: 10.3748/wjg.v25.i31.4437] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 07/08/2019] [Accepted: 07/19/2019] [Indexed: 02/06/2023] Open
Abstract
Portal vein thrombosis (PVT) represents a well-known complication during the natural course of liver cirrhosis (LC), ranging from asymptomatic cases to life-threating conditions related to portal hypertension and hepatic decompensation. Portal flow stasis, complex acquired hypercoagulable disorders and exogenous factors leading to endothelial dysfunction have emerged as key factors for PVT development. However, PVT occurrence remains unpredictable and many issues regarding its natural history, prognostic significance and treatment are still elusive. In particular although spontaneous resolution or disease stability occur in most cases of PVT, factors predisposing to disease progression or recurrence after spontaneous recanalization are not clarified as yet. Moreover, PVT impact on LC outcome is still debated, as PVT may represent itself a consequence of liver fibrosis and hepatic dysfunction progression. Anticoagulation and transjugular intrahepatic portosystemic shunt are considered safe and effective in this setting and are recommended in selected cases, even if the safer therapeutic option and the optimal therapy duration are still unknown. Nevertheless, their impact on mortality rates should be addressed more extensively. In this review we present the most debated questions regarding PVT, whose answers should come from prospective cohort studies and large sample-size randomized trials.
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Affiliation(s)
- Mariella Faccia
- Department of Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome 00168, Italy
| | - Maria Elena Ainora
- Department of Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome 00168, Italy
| | - Francesca Romana Ponziani
- Department of Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome 00168, Italy
| | - Laura Riccardi
- Department of Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome 00168, Italy
| | - Matteo Garcovich
- Department of Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome 00168, Italy
| | - Antonio Gasbarrini
- Department of Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome 00168, Italy
| | - Maurizio Pompili
- Department of Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome 00168, Italy
| | - Maria Assunta Zocco
- Department of Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome 00168, Italy
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