1
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Ma J, Chalasani NP, Schwantes-An L, Björnsson ES. Review article: the safety of anticoagulants and antiplatelet agents in patients with cirrhosis. Aliment Pharmacol Ther 2023; 57:52-71. [PMID: 36373544 DOI: 10.1111/apt.17297] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 07/26/2022] [Accepted: 10/27/2022] [Indexed: 11/16/2022]
Abstract
Patients with cirrhosis were long thought to be coagulopathic. However, this paradigm has changed in recent years and currently, cirrhosis is recognised as a prothrombotic state. Due to the increasing incidence of cirrhosis from nonalcoholic steatohepatitis which is closely associated with cardiac disease, patients with cirrhosis increasingly require therapy with anticoagulants and antiplatelet agents. However, their potential for causing catastrophic and life-threatening bleeding in patients with cirrhosis leads to hesitancy about their use in patients with cirrhosis. Overall, traditional anticoagulation is safe for all Child-Pugh classes while newer direct oral anticoagulants (DOACs) are mostly safe in Child-Pugh class A/B and contraindicated in severe hepatic impairment. For different indications, published data to date suggest that anticoagulation is overall safe for patients with cirrhosis who have venous thromboembolism, atrial fibrillation and portal vein thrombosis, and does not increase the risk of variceal bleeding. Moreover, DOACs appear to have similar safety profiles as traditional anticoagulants. Finally, most studies suggest that antiplatelet agents are also safe to use in patients with cirrhosis although they are mostly contraindicated in severe hepatic impairment. For both anticoagulants and antiplatelet agents, severe thrombocytopaenia presents a relative contraindication to their use. More prospective trials and large cohort studies are needed to advance our understanding of the safety and nuances of DOACs and antiplatelet agents in patients with advanced cirrhosis.
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Affiliation(s)
- Jiayi Ma
- Indiana University School of Medicine and Indiana University Health, Indianapolis, Indiana, USA
| | - Naga P Chalasani
- Indiana University School of Medicine and Indiana University Health, Indianapolis, Indiana, USA
| | - Linus Schwantes-An
- Indiana University School of Medicine, Medical & Molecular Genetics, Indianapolis, Indiana, USA
| | - Einar Stefán Björnsson
- Department of Gastroenterology, Landspitali University Hospital, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
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2
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Peng B, Lu J, Guo H, Liu J, Li A. Regional citrate anticoagulation for replacement therapy in patients with liver failure: A systematic review and meta-analysis. Front Nutr 2023; 10:1031796. [PMID: 36875829 PMCID: PMC9977825 DOI: 10.3389/fnut.2023.1031796] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 01/09/2023] [Indexed: 02/18/2023] Open
Abstract
Background Citrate refers to an anticoagulant agent commonly used in extracorporeal organ support. Its application is limited in patients with liver failure (LF) due to the increased risk of citrate accumulation induced by liver metabolic dysfunction. This systematic review aims to assess the efficacy and safety of regional citrate anticoagulation in extracorporeal circulation for patients with liver failure. Methods PubMed, Web of Science, Embase, and Cochrane Library were searched. Studies regarding extracorporeal organ support therapy for LF were included to assess the efficacy and safety of regional citrate anticoagulation. Methodological quality of included studies were assessed using the Methodological Index for Non-randomized Studies (MINORS). Meta-analysis was performed using R software (version 4.2.0). Results There were 19 eligible studies included, involving 1026 participants. Random-effect model showed an in-hospital mortality of 42.2% [95%CI (27.2, 57.9)] in LF patients receiving extracorporeal organ support. The during-treatment incidence of filter coagulation, citrate accumulation, and bleeding were 4.4% [95%CI (1.6-8.3)], 6.7% [95%CI (1.5-14.4)], and 5.0% [95%CI (1.9-9.3)], respectively. The total bilirubin(TBIL), alanine transaminase (ALT), aspartate transaminase(AST), serum creatinine(SCr), blood urea nitrogen(BUN), and lactate(LA) decreased, compared with those before the treatment, and the total calcium/ionized calcium ratio, platelet(PLT), activated partial thromboplastin time(APTT), serum potential of hydrogen(pH), buffer base(BB), and base excess(BE) increased. Conclusion Regional citrate anticoagulation might be effective and safe in LF extracorporeal organ support. Closely monitoring and timely adjusting during the process could reduce the risk for complications. More prospective clinical trials of considerable quality are needed to further support our findings. Systematic review registration https://www.crd.york.ac.uk/prospero/, identifier CRD42022337767.
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Affiliation(s)
- Bo Peng
- Beijing Ditan Hospital, Capital Medical University, Beijing, China.,Beijing Fengtai Hospital, Beijing, China
| | - Jiaqi Lu
- Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Hebing Guo
- Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Jingyuan Liu
- Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Ang Li
- Beijing Ditan Hospital, Capital Medical University, Beijing, China
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3
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Bissonnette J, Riescher‐Tuczkiewicz A, Gigante E, Bourdin C, Boudaoud L, Soliman H, Durand F, Ronot M, Valla D, Vilgrain V, de Raucourt E, Rautou P. Predicting bleeding after liver biopsy using comprehensive clinical and laboratory investigations: A prospective analysis of 302 procedures. J Thromb Haemost 2022; 20:2786-2796. [PMID: 36128757 PMCID: PMC9828241 DOI: 10.1111/jth.15888] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 08/05/2022] [Accepted: 09/15/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND Liver biopsy carries a small risk of bleeding complications. No validated clinical or laboratory tool helps predict liver biopsy-related bleeding. OBJECTIVES To determine whether global hemostasis tests and/or a clinical questionnaire could identify patients at risk of liver biopsy-related bleeding. PATIENTS/METHODS Consecutive patients scheduled for liver biopsy with an overnight hospital stay were prospectively included. Before liver biopsy, routine hemostasis tests, Platelet Function Analyzer 100, thromboelastometry, thrombin generation assay, plasma clot lysis time, and a clinical questionnaire were performed. Bleeding was defined as a liver hematoma or new free fluid on a systematic ultrasound performed 24 h after liver biopsy or a decrease in hemoglobin level of 2 g/dL or more in patients with pre-existing free fluid in the abdominal cavity. RESULTS Three hundred two patients were included: 173 underwent percutaneous and 129 transjugular liver biopsy. There were 21 bleeding episodes (7%); 20 based on ultrasonographic criteria, 1 on laboratory criteria. None of the hemostasis tests and no item of the clinical questionnaire were associated with liver biopsy-related bleeding in the overall study group. Same results were obtained in subgroup analyses focusing on patients who underwent percutaneous liver biopsy, transjugular liver biopsy, or on patients with cirrhosis. Pain 2 h after liver biopsy was more frequent in patients with liver biopsy-related bleeding (55% vs. 23% p = .002). CONCLUSIONS An extensive hemostasis workup, including global hemostasis assays, does not improve prediction of liver biopsy-related bleeding. Pain 2 h after liver biopsy should alert the clinician to the possibility of procedure-related bleeding.
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Affiliation(s)
- Julien Bissonnette
- AP‐HP, Hôpital Beaujon, Service d’Hépatologie, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE‐LIVER, Centre de recherche sur l’inflammation, Inserm, UMR1149Université Paris CitéParisFrance
| | - Alix Riescher‐Tuczkiewicz
- AP‐HP, Hôpital Beaujon, Service d’Hépatologie, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE‐LIVER, Centre de recherche sur l’inflammation, Inserm, UMR1149Université Paris CitéParisFrance
| | - Elia Gigante
- AP‐HP, Hôpital Beaujon, Service d’Hépatologie, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE‐LIVER, Centre de recherche sur l’inflammation, Inserm, UMR1149Université Paris CitéParisFrance
| | - Carole Bourdin
- Service d’hématologie biologiqueHôpital BeaujonClichyFrance
| | - Larbi Boudaoud
- Service d’hématologie biologiqueHôpital BeaujonClichyFrance
| | - Heithem Soliman
- AP‐HP, Hôpital Beaujon, Service d’Hépatologie, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE‐LIVER, Centre de recherche sur l’inflammation, Inserm, UMR1149Université Paris CitéParisFrance
| | - François Durand
- AP‐HP, Hôpital Beaujon, Service d’Hépatologie, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE‐LIVER, Centre de recherche sur l’inflammation, Inserm, UMR1149Université Paris CitéParisFrance
| | - Maxime Ronot
- 'AP‐HP, Hôpital Beaujon, Service de Radiologie', 'Centre de recherche sur l’inflammation, Inserm, UMR1149'Université Paris CitéParisFrance
| | - Dominique Valla
- AP‐HP, Hôpital Beaujon, Service d’Hépatologie, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE‐LIVER, Centre de recherche sur l’inflammation, Inserm, UMR1149Université Paris CitéParisFrance
| | - Valérie Vilgrain
- 'AP‐HP, Hôpital Beaujon, Service de Radiologie', 'Centre de recherche sur l’inflammation, Inserm, UMR1149'Université Paris CitéParisFrance
| | | | - Pierre‐Emmanuel Rautou
- AP‐HP, Hôpital Beaujon, Service d’Hépatologie, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE‐LIVER, Centre de recherche sur l’inflammation, Inserm, UMR1149Université Paris CitéParisFrance
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4
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Garcia-Saenz-de-Sicilia M, Al-Obaid L, Hughes DL, Duarte-Rojo A. Mastering Core Recommendations during HEPAtology ROUNDS in Patients with Advanced Chronic Liver Disease. Semin Liver Dis 2022; 42:341-361. [PMID: 35764316 DOI: 10.1055/a-1886-5909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Efficient and thorough care of hospitalized patients with advanced chronic liver disease is of utter importance to improve outcomes and optimize quality of life. This requires understanding current evidence and best practices. To facilitate focus on up-to-date knowledge and a practical approach, we have created the HEPA-ROUNDS mnemonic while outlining a practical review of the literature with critical appraisal for the busy clinician. The HEPA-ROUNDS mnemonic provides a structured approach that incorporates critical concepts in terms of prevention, management, and prognostication of the most common complications frequently encountered in patients with advanced chronic liver disease. In addition, implementing the HEPA-ROUNDS mnemonic can facilitate education for trainees and staff caring for patients with advanced chronic liver disease.
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Affiliation(s)
| | - Lolwa Al-Obaid
- Division of Gastroenterology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Dempsey L Hughes
- Division of Gastroenterology, Hepatology and Nutrition, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Andrés Duarte-Rojo
- Division of Gastroenterology, Hepatology and Nutrition, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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5
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Hsu LI, Chen JW, Lin DT, Wei ST, Hou SM. The continued decline of plasma transfusions in Taiwan: An 11-year population-based study. Vox Sang 2021; 117:535-544. [PMID: 34905221 DOI: 10.1111/vox.13222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 10/12/2021] [Accepted: 10/25/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND OBJECTIVES In Taiwan, plasma use per capita ranks among the highest in the world. We aimed to describe the trends in usage after the introduction of new hospital accreditation standards that evaluate compliance with institutional plasma transfusion guidelines. MATERIALS AND METHODS We identified hospitalizations receiving plasma between 2007 and 2017 from the national health insurance database. We estimated plasma transfusions per thousand capita. The risk ratio of transfusion rates among hospitalizations in 2017 compared to 2007 was estimated using logistic regression. RESULTS The total number of plasma transfusions declined from 964,408 in 2007 to 659,828 in 2017, yielding a rate of 28.00 per thousand capita. The proportion of hospitalizations receiving plasma declined by 38%, from 3.89% (95% confidence interval: 3.86%-3.91%) to 2.62% (2.61%-2.64%). Gastroenterology (16.4%) and general surgery (15.3%) accounted for the largest proportions of plasma usage. Within these two services, liver diseases were the top diagnoses needing plasma use. For hospitalized patients with liver diseases, approximately 40% of plasma units were administered to patients with neither noticeable bleeding nor red blood cells transfusions. Among these patients, almost 50% received plasma with an international normalized ratio trigger of less than 1.50. The use of potential alternative therapies or anticoagulants remained quite low during this period. CONCLUSION Plasma utilization rates during hospitalizations continuously declined over 11 years. However, inappropriate plasma use remained high, while the use of alternative therapies remained low in services such as gastroenterology. To improve the appropriateness of plasma transfusions, patient blood management should be implemented in the near future.
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Affiliation(s)
- Ling-I Hsu
- Department of Research, Taiwan Blood Services Foundation, Taipei, Taiwan, ROC
| | - Jen-Wen Chen
- Department of Research, Taiwan Blood Services Foundation, Taipei, Taiwan, ROC
| | - Dong-Tsamn Lin
- Department of Research, Taiwan Blood Services Foundation, Taipei, Taiwan, ROC
| | - Sheng-Tang Wei
- Department of Research, Taiwan Blood Services Foundation, Taipei, Taiwan, ROC
| | - Sheng-Mou Hou
- Department of Research, Taiwan Blood Services Foundation, Taipei, Taiwan, ROC.,The Director's Office, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan, ROC
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Mesenchymal stromal cells mitigate liver damage after extended resection in the pig by modulating thrombospondin-1/TGF-β. NPJ Regen Med 2021; 6:84. [PMID: 34862411 PMCID: PMC8642541 DOI: 10.1038/s41536-021-00194-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 11/01/2021] [Indexed: 12/13/2022] Open
Abstract
Post-surgery liver failure is a serious complication for patients after extended partial hepatectomies (ePHx). Previously, we demonstrated in the pig model that transplantation of mesenchymal stromal cells (MSC) improved circulatory maintenance and supported multi-organ functions after 70% liver resection. Mechanisms behind the beneficial MSC effects remained unknown. Here we performed 70% liver resection in pigs with and without MSC treatment, and animals were monitored for 24 h post surgery. Gene expression profiles were determined in the lung and liver. Bioinformatics analysis predicted organ-independent MSC targets, importantly a role for thrombospondin-1 linked to transforming growth factor-β (TGF-β) and downstream signaling towards providing epithelial plasticity and epithelial-mesenchymal transition (EMT). This prediction was supported histologically and mechanistically, the latter with primary hepatocyte cell cultures. MSC attenuated the surgery-induced increase of tissue damage, of thrombospondin-1 and TGF-β, as well as of epithelial plasticity in both the liver and lung. This suggests that MSC ameliorated surgery-induced hepatocellular stress and EMT, thus supporting epithelial integrity and facilitating regeneration. MSC-derived soluble factor(s) did not directly interfere with intracellular TGF-β signaling, but inhibited thrombospondin-1 secretion from thrombocytes and non-parenchymal liver cells, therewith obviously reducing the availability of active TGF-β.
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7
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Ye Y, Li X, Zhu L, Yang C, Tan YW. Establishment of a risk assessment score for deep vein thrombosis after artificial liver support system treatment. World J Clin Cases 2021; 9:9406-9416. [PMID: 34877276 PMCID: PMC8610855 DOI: 10.12998/wjcc.v9.i31.9406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 06/13/2021] [Accepted: 09/23/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The artificial liver support system (ALSS) is an effective treatment method for liver failure, but it requires deep venous intubation and long-term indwelling catheterization. However, the coagulation mechanism disorder of basic liver failure diseases, and deep venous thrombosis (DVT) often occur.
AIM To evaluate the risk factors for DVT following use of an ALSS and establish a risk assessment score.
METHODS This study was divided into three stages. In the first stage, the risk factors for DVT were screened and the patient data were collected, including ALSS treatment information; biochemical indices; coagulation and hematology indices; complications; procoagulant use therapy status; and a total of 24 indicators. In the second stage, a risk assessment score for DVT after ALSS treatment was developed. In the third stage, the DVT risk assessment score was validated.
RESULTS A total of 232 patients with liver failure treated with ALSS were enrolled in the first stage, including 12 with lower limb DVT. Logistic regression analysis showed that age [odds ratio (OR), 1.734; P = 0.01], successful catheterization time (OR, 1.667; P = 0.005), activity status (strict bed rest) (OR, 3.049; P = 0.005), and D-dimer level (≥ 500 ng/mL) (OR, 5.532; P < 0.001) were independent risk factors for DVT. We then established a scoring system for risk factors. In the validation group, a total of 213 patients with liver failure were treated with ALSS, including 14 with lower limb DVT. When the cutoff value of risk assessment was 3, the specificity and sensitivity of the risk assessment score were 88.9% and 85.7%, respectively.
CONCLUSION A simple risk assessment scoring system was established for DVT patients with liver failure treated with ALSS and was verified to have good sensitivity and specificity.
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Affiliation(s)
- Yun Ye
- Department of Hepatology, The Third Hospital of Zhenjiang Affiliated Jiangsu University, Zhenjiang 212000, Jiangsu Province, China
| | - Xiang Li
- Department of Hepatology, The Third Hospital of Zhenjiang Affiliated Jiangsu University, Zhenjiang 212000, Jiangsu Province, China
| | - Li Zhu
- Department of Hepatology, The Third Hospital of Zhenjiang Affiliated Jiangsu University, Zhenjiang 212000, Jiangsu Province, China
| | - Cong Yang
- Department of Hepatology, The Third Hospital of Zhenjiang Affiliated Jiangsu University, Zhenjiang 212000, Jiangsu Province, China
| | - You-Wen Tan
- Department of Hepatology, The Third Hospital of Zhenjiang Affiliated Jiangsu University, Zhenjiang 212000, Jiangsu Province, China
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8
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Jepsen P, Tapper EB, Deleuran T, Kazankov K, Askgaard G, Sørensen HT, Vilstrup H, West J. Risk and Outcome of Venous and Arterial Thrombosis in Patients With Cirrhosis: A Danish Nation-wide Cohort Study. Hepatology 2021; 74:2725-2734. [PMID: 34137045 PMCID: PMC8542589 DOI: 10.1002/hep.32019] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 06/06/2021] [Accepted: 06/13/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Cirrhosis affects hemostasis, but its effects across the spectrum of thromboses remain poorly understood. We examined risks and outcomes of venous and arterial thrombosis. APPROACH AND RESULTS We used nation-wide Danish health care registries to identify outpatients with cirrhosis and a sex- and age-matched comparison cohort without cirrhosis from the general population. Patients with cirrhosis and comparators were followed until they had a venous thromboembolism (VTE), acute myocardial infarction (AMI), or ischemic stroke (IS) or died. We computed absolute risks and HRs of thrombosis and compared outcomes after thrombosis. We included 5,854 patients with cirrhosis (median Model for End-Stage Liver Disease score, 9; interquartile range, 7-13), and their risk of any of the thrombotic events was 0.8% after 1 year and 6.3% after 10 years. They were more likely than the 23,870 matched comparators to have a VTE (adjusted hazard ratio [aHR], 2.0; 95% CI, 1.5-2.6) or IS (aHR, 1.7; 95% CI, 1.3-2.3), but not AMI (aHR, 0.7; 95% CI, 0.5-0.9). Among patients with cirrhosis, decompensation increased the risk of AMI, but not the other thromboses. Following thrombosis, patients with cirrhosis had higher 90-day mortality than comparators (after VTE: 17% vs. 7%; after AMI: 27% vs. 5%; after IS: 10% vs. 7%) and were less likely to receive antithrombotic treatment. CONCLUSIONS Patients with cirrhosis had an increased risk of VTE and IS, but not AMI. Among patients with cirrhosis, decompensation increased the risk of AMI, exclusively. Mortality after thrombosis was higher in patients with cirrhosis than in other patients. These findings are relevant for decisions about antithrombotic prophylaxis in patients with cirrhosis.
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Affiliation(s)
- Peter Jepsen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark,Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Elliot B. Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor USA
| | - Thomas Deleuran
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Konstantin Kazankov
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark,Liver Failure Group, Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, United Kingdom
| | - Gro Askgaard
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Hendrik Vilstrup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Joe West
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, United Kingdom,NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, United Kingdom
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Calvert P, Gupta D, Lip GY. Antithrombotic therapy in chronic liver disease: to clot or not to clot. THE LANCET REGIONAL HEALTH. EUROPE 2021; 10:100226. [PMID: 34647111 PMCID: PMC8495095 DOI: 10.1016/j.lanepe.2021.100226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Peter Calvert
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital Liverpool, UK
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital Liverpool, UK
| | - Gregory Y.H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Denmark
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10
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Li L, Chen L, Wang H, Li P, Wang D, Zhang W, Mi L, Lin F, Qin Y, Zhou Y. Clinical correlation between coagulation disorders and sepsis in patients with liver failure. Clin Hemorheol Microcirc 2021; 80:219-231. [PMID: 34719481 DOI: 10.3233/ch-211113] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE This study aimed to explore the clinical detection and prognosis of coagulation function in patients with liver failure and sepsis. METHODS The plasma fibrinogen (FIB), factor II, factor VII, factor V, factor IV, antithrombin III (ATIII), platelet (PLT), mean PLT volume (MPV), D-dimer, prothrombin activity (PTA), and fibrin degradation product (FDP) levels and thromboelastogram values were detected in patients with liver failure complicated with sepsis and compared with those in the liver failure and liver cirrhosis groups. The patients with liver failure complicated with sepsis were analyzed by univariate and multivariate logistic regression, and the regression equation was established. RESULTS The levels of FIB, factor II, factor VII, factor V, ATIII, PLT, MPV, D-dimer, and FDP in the patients with liver failure complicated with sepsis were compared with those in the control group patients, and the differences were statistically significant (p < 0.05). Among the thromboelastography parameters in the patients with liver failure and sepsis, the differences in the K-value, R-value, angle, maximum amplitude, and coagulation index values compared with those of the control group were statistically significant (p < 0.05). The logistic regression model obtained was as follows: p = 1/(1 + e [-0.128×X1-0.058×X2 + 0.211×X3 + 0.2×X4 + 0.25]). The specificity, sensitivity, and accuracy values of the regression equation in determining the prognosis were 92%, 93.9%, and 92.8%, respectively. Among the 11 factors, factor VII, PLT, FDP, and D-dimer were included in the regression equation. CONCLUSION Coagulation disorder is exacerbated in patients with liver failure and sepsis. Among the 11 coagulation-related factors, factor VII, PLT, FDP, and D-dimer may be the independent factors influencing the prognosis of patients with acute liver failure and sepsis.
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Affiliation(s)
- Lei Li
- Department of Emergency, Fifth Medical Center of Chinese PLA Hospital, Beijing, China
| | - Ling Chen
- Department of Emergency, Fifth Medical Center of Chinese PLA Hospital, Beijing, China
| | - Han Wang
- Department of Blood Transfusion, Fifth Medical Center of Chinese PLA Hospital, Beijing, China
| | - Peiran Li
- Department of Clinical Laboratory, Fifth Medical Center of Chinese PLA Hospital, Beijing, China
| | - Dan Wang
- Department of Emergency, Fifth Medical Center of Chinese PLA Hospital, Beijing, China
| | - Wei Zhang
- Department of Emergency, Fifth Medical Center of Chinese PLA Hospital, Beijing, China
| | - Lai Mi
- Department of Emergency, Fifth Medical Center of Chinese PLA Hospital, Beijing, China
| | - Fang Lin
- Department of Critical Care Medicine, Fifth Medical Center of Chinese PLA Hospital, Beijing, China
| | - Yuling Qin
- Department of Emergency, Fifth Medical Center of Chinese PLA Hospital, Beijing, China
| | - Yuesu Zhou
- Department of Emergency, Fifth Medical Center of Chinese PLA Hospital, Beijing, China
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11
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Martinez S, Garcia I, Ruiz A, Tàssies D, Reverter JC, Colmenero J, Beltran J, Fondevila C, Blasi A. Is antivitamin K reversal required in patients with cirrhosis undergoing liver transplantation? Transfusion 2021; 61:3008-3016. [PMID: 34358342 DOI: 10.1111/trf.16607] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 06/13/2021] [Accepted: 07/05/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Antivitamin K agent (AVK) reversal in patients with cirrhosis awaiting liver transplantation (LT) is not defined in guidelines. We investigated the effect of reversion with prothrombin complex concentrate (PCC) on intraoperative transfusion, bleeding, and safety in LT patients on AVK. STUDY DESIGN AND METHODS In 511 patients undergoing LT, we identified 25 patients treated with AVK (AVK group) and 13 patients with incidental portal vein thrombosis (PVT) without AVK (incidental PVT group). Fifty patients who underwent LT without PVT or AVK matched by age, model for end stage of liver disease (MELD), body mass index (BMI), and cirrhosis etiology were selected as the control group. RESULTS There were no significant differences between the three groups in intraoperative blood loss, transfusion, and postoperative bleeding. In the AVK group, there were no differences between patients who received PCC and those who did not in intraoperative blood loss, red blood cells, fibrinogen, and platelet transfusion, or postoperative bleeding. PCC use had no effect on RBC transfusion in patients who had international normalized ratio or clotting time above versus below median values of the two parameters at baseline (2.3 and 103 s, respectively). No thrombotic events were detected in patients who received PCC. DISCUSSION These data suggest that systematic administration of PCC to revert AVK prior to LT should be reconsidered.
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Affiliation(s)
- Samira Martinez
- Anesthesia Department, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Isabel Garcia
- Anesthesia Department, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Angel Ruiz
- Donation and Transplantation Coordination Unit, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Dolors Tàssies
- Hemostasis Department, IDIBAPS, Hospital Clinic de Barcelona, Barcelona, Spain
| | | | - Jordi Colmenero
- Hepatology Department, Hospital Clinic Barcelona IDIBAPS, Barcelona, Spain
| | - Joan Beltran
- Anesthesia Department, Hospital Clinic de Barcelona, Barcelona, Spain
| | | | - Annabel Blasi
- Anesthesia Department, Hospital Clinic de Barcelona, IDIBAPS, Barcelona, Spain
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12
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Stevens CA, Yau BC, Lai NC, Huang WT, Cang WC, Bushway A, Derry KL. The use of four-factor prothrombin complex concentrate in patients with liver disease on warfarin therapy. Thromb Res 2021; 204:123-125. [PMID: 34182230 DOI: 10.1016/j.thromres.2021.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 06/08/2021] [Accepted: 06/14/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Craig A Stevens
- Department of Pharmacy, UC San Diego Health, San Diego, CA, USA
| | - Benny C Yau
- Department of Pharmacy, Stanford Health Care, Stanford, CA, USA
| | - Ngan C Lai
- Department of Pharmacy, Sutter Health Care, Oakland, CA, USA
| | - Wan-Ting Huang
- Department of Pharmacy, UC San Diego Health, San Diego, CA, USA
| | - William C Cang
- Department of Pharmacy, UC San Diego Health, San Diego, CA, USA
| | - Audrey Bushway
- Department of Pharmacy, UC San Diego Health, San Diego, CA, USA
| | - Katrina L Derry
- Department of Pharmacy, UC San Diego Health, San Diego, CA, USA.
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13
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Terrier J, Daali Y, Fontana P, Csajka C, Reny JL. Towards Personalized Antithrombotic Treatments: Focus on P2Y 12 Inhibitors and Direct Oral Anticoagulants. Clin Pharmacokinet 2020; 58:1517-1532. [PMID: 31250210 DOI: 10.1007/s40262-019-00792-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Oral anticoagulants and antiplatelet drugs are commonly prescribed to lower the risk of cardiovascular diseases, such as venous and arterial thrombosis, which represent the leading causes of mortality worldwide. A significant percentage of patients taking antithrombotics will nevertheless experience bleeding or recurrent ischemic events, and this represents a major public health issue. Cardiovascular medicine is now questioning the one-size-fits-all policy, and more personalized approaches are increasingly being considered. However, the available tools are currently limited and they are only moderately able to predict clinical events or have a significant impact on clinical outcomes. Predicting concentrations of antithrombotics in blood could be an effective means of personalization as they have been associated with bleeding and recurrent ischemia. Target concentration interventions could take advantage of physiologically based pharmacokinetic (PBPK) and population-based pharmacokinetic (POPPK) models, which are increasingly used in clinical settings and have attracted the interest of governmental regulatory agencies, to propose dosages adapted to specific population characteristics. These models have the benefit of combining parameters from different sources, such as experimental in vitro data and patients' demographic, genetic, and physiological in vivo data, to characterize the dose-concentration relationships of compounds of interest. As such, they can be used to predict individual drug exposure. In the near future, these models could therefore be a valuable means of predicting personalized antithrombotic blood concentrations and, hopefully, of preventing clinical non-response or bleeding in a given patient. Existing approaches for personalization of antithrombotic prescriptions will be reviewed using practical examples for P2Y12 inhibitors and direct oral anticoagulants. The review will additionally focus on the existing PBPK and POPPK models for these two categories of drugs. Lastly, we address potential scenarios for their implementation in clinics, along with the main limitations and challenges.
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Affiliation(s)
- Jean Terrier
- Division of General Internal Medicine, Geneva University Hospitals, Geneva, Switzerland.,Geneva Platelet Group, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Youssef Daali
- Geneva Platelet Group, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland.,Clinical Pharmacology and Toxicology Service, Anesthesiology, Pharmacology and Intensive Care Department, Geneva University Hospitals, Geneva, Switzerland
| | - Pierre Fontana
- Geneva Platelet Group, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Division of Angiology and Haemostasis, Geneva University Hospitals, Geneva, Switzerland
| | - Chantal Csajka
- School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
| | - Jean-Luc Reny
- Division of General Internal Medicine, Geneva University Hospitals, Geneva, Switzerland. .,Geneva Platelet Group, Faculty of Medicine, University of Geneva, Geneva, Switzerland. .,Division of Internal Medicine and Rehabilitation, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1205, Geneva, Switzerland.
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14
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Huang ZC, Li CQ, Liu XY, Cao ZC, Jia HY, Dong Y, Liu TL, Sun JJ. Efficacy and Safety of Direct Oral Anticoagulants in Patients with Atrial Fibrillation and Liver Disease: a Meta-Analysis and Systematic Review. Cardiovasc Drugs Ther 2020; 35:1205-1215. [PMID: 32880804 DOI: 10.1007/s10557-020-07065-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/27/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND Liver disease is associated with increased bleeding risk. The efficacy and safety of direct oral anticoagulants (DOACs) is a subject of contention in atrial fibrillation (AF) patients with liver disease. METHODS Electronic databases (PubMed, Embase, and Cochrane Library) were searched to retrieve studies on the efficacy and safety of DOACs versus warfarin in AF patients with liver disease from January 1980 to April 2020. A meta-analysis was conducted using a random-effects model. RESULTS Six studies involving 41,859 patients were included. Compared with warfarin, DOACs demonstrated significant reduction in ischemic stroke (HR, 0.68; 95% CI (0.54-0.86)), major bleeding (0.74 (0.59-0.92)), and intracranial hemorrhage (ICH) (0.48 (0.40-0.58)), with no significant effect on gastrointestinal bleeding (P = 0.893) in AF patients with liver disease. Similar results were observed in regular-dose, reduced-dose, and active liver disease subgroups, albeit Asian patients had a slight reduction in major bleeding (P = 0.055). Furthermore, the pooled estimates of individual DOAC subgroups indicated that dabigatran and apixaban led to greater safety in major bleeding (P < 0.001), ICH (P < 0.001), and gastrointestinal bleeding (P < 0.005) in these patients. The same trends were observed in AF patients with cirrhosis. CONCLUSIONS Our findings suggest that DOACs significantly reduce the risk of ischemic stroke, major bleeding, and ICH, with no significant effect on the risk of gastrointestinal bleeding in AF patients with liver disease compared with warfarin.
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Affiliation(s)
- Zhi-Chun Huang
- Department of Cardiology, Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
| | - Chang-Qing Li
- Department of Cardiology, Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
| | - Xiao-Yu Liu
- Department of Cardiology, Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
| | - Zhong-Chao Cao
- Department of Cardiology, Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
| | - Hai-Yu Jia
- Department of Cardiology, Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
| | - Ying Dong
- Department of Pharmacy, Affiliated Hospital of Inner Mongolia Medical University, 1 Tong Dao North Street, Hohhot, Inner Mongolia, 010059, People's Republic of China
| | - Tian-Long Liu
- Department of Pharmacy, Affiliated Hospital of Inner Mongolia Medical University, 1 Tong Dao North Street, Hohhot, Inner Mongolia, 010059, People's Republic of China
| | - Jian-Jun Sun
- Department of Pharmacy, Affiliated Hospital of Inner Mongolia Medical University, 1 Tong Dao North Street, Hohhot, Inner Mongolia, 010059, People's Republic of China.
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15
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Ollivier-Hourmand I, Nguyen N, De Gottardi A, Valla D, Hillaire S, Dutheil D, Bureau C, Hernandez-Gea V, De Raucourt E, Plessier A. Management of anticoagulation in adult patients with chronic parenchymal or vascular liver disease: Vascular liver diseases: Position papers from the francophone network for vascular liver diseases, the French Association for the Study of the Liver (AFEF), and ERN-rare liver. Clin Res Hepatol Gastroenterol 2020; 44:438-446. [PMID: 32278777 DOI: 10.1016/j.clinre.2020.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 03/03/2020] [Indexed: 02/04/2023]
Affiliation(s)
- Isabelle Ollivier-Hourmand
- Department of gastroenterology and hepatology, university hospital of Caen, Côte de la Nacre hospital, avenue de la Côte de Nacre, 14033 Caen cedex 9, France; French Network for Rare Liver Diseases (FILFOIE), Saint-Antoine hospital, AP-HP, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France.
| | - Nga Nguyen
- Department of gastroenterology and hepatology, university hospital of Caen, Côte de la Nacre hospital, avenue de la Côte de Nacre, 14033 Caen cedex 9, France; French Network for Rare Liver Diseases (FILFOIE), Saint-Antoine hospital, AP-HP, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France
| | - Andrea De Gottardi
- Department of gastroenterology and hepatology, Cantonal Hospital Authority, Direzione generale, Viale Officina 3, 6500 Bellinzona, Switzerland
| | - Dominique Valla
- French Network for Rare Liver Diseases (FILFOIE), Saint-Antoine hospital, AP-HP, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France; Department of hepatology, Beaujon hospital AP-HP, 100, boulevard du Général Leclerc, 92118 Clichy, France; Reference center of vascular liver diseases, European Reference Network (ERN) "Rare-Liver", Clichy, France
| | - Sophie Hillaire
- Department of internal medicine, Foch hospital, 40, rue Worth, 92150 Suresnes, France
| | - Danielle Dutheil
- French Network for Rare Liver Diseases (FILFOIE), Saint-Antoine hospital, AP-HP, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France; Department of hepatology, Association of patients with vascular liver diseases (AMVF), Beaujon hospital, 100, boulevard du Général Leclerc, 92118 Clichy, France
| | - Christophe Bureau
- French Network for Rare Liver Diseases (FILFOIE), Saint-Antoine hospital, AP-HP, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France; Department of gastroenterology and hepatology, university hospital of Toulouse, Rangueil hospital, 1, avenue du Professeur Jean-Poulhès, 31400 Toulouse, France
| | - Virginia Hernandez-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona. Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd). Health Care Provider of the European Reference Network onRare Liver Disorders (ERN-Liver), Spain
| | - Emmanuelle De Raucourt
- French Network for Rare Liver Diseases (FILFOIE), Saint-Antoine hospital, AP-HP, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France; Department of laboratory hematology, Beaujon hospital AP-HP, 100, boulevard du Général Leclerc, 92118 Clichy, France; Reference center of vascular liver diseases, European Reference Network (ERN) "Rare-Liver", Clichy, France
| | - Aurélie Plessier
- French Network for Rare Liver Diseases (FILFOIE), Saint-Antoine hospital, AP-HP, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France; Department of hepatology, Beaujon hospital AP-HP, 100, boulevard du Général Leclerc, 92118 Clichy, France; Reference center of vascular liver diseases, European Reference Network (ERN) "Rare-Liver", Clichy, France
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16
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Lee HF, Chan YH, Chang SH, Tu HT, Chen SW, Yeh YH, Wu LS, Kuo CF, Kuo CT, See LC. Effectiveness and Safety of Non-Vitamin K Antagonist Oral Anticoagulant and Warfarin in Cirrhotic Patients With Nonvalvular Atrial Fibrillation. J Am Heart Assoc 2020; 8:e011112. [PMID: 30834802 PMCID: PMC6474939 DOI: 10.1161/jaha.118.011112] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background Liver cirrhotic patients with nonvalvular atrial fibrillation have been excluded from randomized clinical studies regarding oral anticoagulants for stroke prevention. Whether non–vitamin K antagonist oral anticoagulants (NOACs) are superior to warfarin for these patients remains unclear. Methods and Results This nationwide retrospective cohort study, with data collected from the Taiwan National Health Insurance Research Database, enrolled 2428 liver cirrhotic patients with nonvalvular atrial fibrillation taking apixaban (n=171), dabigatran (n=535), rivaroxaban (n=732), or warfarin (n=990) from June 1, 2012, to December 31, 2016. We used propensity score–based stabilized weights to balance covariates across study groups. Patients were followed until the occurrence of an event or the end date of study. The NOAC group (n=1438) showed risk of ischemic stroke/systemic embolism and intracranial hemorrhage comparable to that of the warfarin group (n=990) after adjustment. The NOAC group showed significantly lower risk of gastrointestinal bleeding (hazard ratio: 0.51 [95% CI, 0.32–0.79]; P=0.0030) and all major bleeding (hazard ratio: 0.51 [95% CI, 0.32–0.74]; P=0.0003) compared with warfarin group. Overall, 90% (n=1290) of patients were taking a low‐dose NOAC (apixaban 2.5 mg twice daily, rivaroxaban 10–15 mg daily, or dabigatran 110 mg twice daily). The subgroup analysis indicated that both dabigatran and rivaroxaban showed lower risk of all major bleeding than warfarin. The advantage of lower gastrointestinal and all major bleeding with NOACs over warfarin is contributed by those subgroups with either nonalcoholic or nonadvanced liver cirrhosis. Conclusions NOACs have a risk of thromboembolism comparable to that of warfarin and a lower risk of major bleeding among liver cirrhotic Asian patients with nonvalvular atrial fibrillation. Consequently, thromboprophylaxis with low‐dose NOACs may be considered for such patients. See Editorial by Gallagher et al
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Affiliation(s)
- Hsin-Fu Lee
- 1 Cardiovascular Department Chang Gung Memorial Hospital Linkou, Taoyuan Taiwan.,6 College of Medicine Chang Gung University Taoyuan Taiwan.,7 Graduate Institute of Clinical Medical Sciences College of Medicine Chang Gung University Taoyuan Taiwan
| | - Yi-Hsin Chan
- 1 Cardiovascular Department Chang Gung Memorial Hospital Linkou, Taoyuan Taiwan.,2 Microscopy Core Laboratory Chang Gung Memorial Hospital Linkou, Taoyuan Taiwan.,6 College of Medicine Chang Gung University Taoyuan Taiwan
| | - Shang-Hung Chang
- 1 Cardiovascular Department Chang Gung Memorial Hospital Linkou, Taoyuan Taiwan.,3 Center for Big Data Analytics and Statistics Chang Gung Memorial Hospital Linkou, Taoyuan Taiwan.,6 College of Medicine Chang Gung University Taoyuan Taiwan
| | - Hui-Tzu Tu
- 3 Center for Big Data Analytics and Statistics Chang Gung Memorial Hospital Linkou, Taoyuan Taiwan.,8 Department of Public Health College of Medicine Chang Gung University Taoyuan Taiwan
| | - Shao-Wei Chen
- 1 Cardiovascular Department Chang Gung Memorial Hospital Linkou, Taoyuan Taiwan.,4 Division of Thoracic and Cardiovascular Surgery Department of Surgery Chang Gung Memorial Hospital Linkou, Taoyuan Taiwan.,6 College of Medicine Chang Gung University Taoyuan Taiwan
| | - Yung-Hsin Yeh
- 1 Cardiovascular Department Chang Gung Memorial Hospital Linkou, Taoyuan Taiwan.,6 College of Medicine Chang Gung University Taoyuan Taiwan
| | - Lung-Sheng Wu
- 1 Cardiovascular Department Chang Gung Memorial Hospital Linkou, Taoyuan Taiwan.,6 College of Medicine Chang Gung University Taoyuan Taiwan
| | - Chang-Fu Kuo
- 3 Center for Big Data Analytics and Statistics Chang Gung Memorial Hospital Linkou, Taoyuan Taiwan.,5 Division of Rheumatology, Allergy and Immunology Department of Internal Medicine Chang Gung Memorial Hospital Linkou, Taoyuan Taiwan.,6 College of Medicine Chang Gung University Taoyuan Taiwan
| | - Chi-Tai Kuo
- 1 Cardiovascular Department Chang Gung Memorial Hospital Linkou, Taoyuan Taiwan.,6 College of Medicine Chang Gung University Taoyuan Taiwan
| | - Lai-Chu See
- 3 Center for Big Data Analytics and Statistics Chang Gung Memorial Hospital Linkou, Taoyuan Taiwan.,5 Division of Rheumatology, Allergy and Immunology Department of Internal Medicine Chang Gung Memorial Hospital Linkou, Taoyuan Taiwan.,8 Department of Public Health College of Medicine Chang Gung University Taoyuan Taiwan.,9 Biostatistics Core Laboratory Molecular Medicine Research Center Chang Gung University Taoyuan Taiwan
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17
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Abdel-Bakky MS, Helal GK, El-Sayed EM, Alhowail AH, Mansour AM, Alharbi KS, Amin E, Allam S, Salama SA, Saad AS. Silencing of tissue factor by antisense deoxyoligonucleotide mitigates thioacetamide-induced liver injury. Naunyn Schmiedebergs Arch Pharmacol 2020; 393:1887-1898. [PMID: 32430618 DOI: 10.1007/s00210-020-01896-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 05/01/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Retinoid receptors (RRs), RAR-α and RXR-α, work as transcription factors that regulate cell growth, differentiation, survival, and death. Hepatic stellate cells (HSCs) store retinoid and release its RRs as lipid droplets upon their activation. PURPOSE We test the hypothesis that loss of retinoid receptors RAR-α and RXR-α from HSCs is dependent on tissue factor (TF) during thioacetamide (TAA)-induced liver injury. METHODS Liver toxicity markers, TF, fibrin, cleaved caspase-3, and cyclin D1 as well as histopathology were investigated. RESULTS Increased TF, fibrin, cleaved caspase-3, and cyclin D1 protein expression is seen in zone of central vein after TAA injection compared with vehicle-treated mice. A strong downregulation of RAR-α and RXR-α is seen in TAA-induced liver injury. In addition, histopathological obliteration and pericentral expression of cleaved caspase 3 and cyclin D1 are observed after TAA injection compared with the normal vehicle-treated mice. No changes have been seen in TAA/TF-sense (SC) in whole parameters compared with TAA-treated animals. TAA/TF-antisense (AS)-treated mice show normal expression of all parameters and normal histopathological features when compared with the control mice. In conclusion, this study declares that the strong downregulation of RAR-α and RXR-α may cause liver injury and particularly activation of HSCs in TAA-induced toxicity. TF-AS treatment not only downregulates TF protein expression but also alleviates loss of liver RAR-α and RXR-α and suppresses the activated apoptosis signals in TAA-induced liver toxicity. Finally, TF and RAR-α/RXR-α are important regulatory molecules in TAA induced acute liver injury.
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Affiliation(s)
- M S Abdel-Bakky
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Al-Azhar University, Cairo, 11751, Egypt. .,Department of Pharmacology and Toxicology, College of Pharmacy, Qassim University, Buraydah, 51452, Kingdom of Saudi Arabia.
| | - G K Helal
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Al-Azhar University, Cairo, 11751, Egypt.,Department of Pharmacology and Toxicology, Faculty of Pharmacy, Heliopolis University, Cairo, Egypt
| | - E M El-Sayed
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Al-Azhar University, Cairo, 11751, Egypt
| | - A H Alhowail
- Department of Pharmacology and Toxicology, College of Pharmacy, Qassim University, Buraydah, 51452, Kingdom of Saudi Arabia
| | - A M Mansour
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Al-Azhar University, Cairo, 11751, Egypt
| | - K S Alharbi
- Department of Pharmacology, College of Pharmacy, Jouf University, Sakakah, 72341, Kingdom of Saudi Arabia
| | - Elham Amin
- Department of Pharmacognosy, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, 62514, Egypt.,Department of Medicinal Chemistry and Pharmacognosy, College of Pharmacy, Qassim University, Buraydah, 52471, Kingdom of Saudi Arabia
| | - S Allam
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Kafralsheikh University, Kafralsheikh, Egypt
| | - S A Salama
- Department of Biochemistry, Faculty of Pharmacy, Al-Azhar University, Cairo, 11751, Egypt.,Division of Biochemistry, Department of Pharmacology and GTMR Unit, College of Clinical Pharmacy, Taif University, Taif, 21974, Saudi Arabia
| | - A S Saad
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Port Said University, Port Said, Egypt
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18
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Chiabotto G, Camussi G, Bruno S. Role of ncRNAs in modulation of liver fibrosis by extracellular vesicles. ACTA ACUST UNITED AC 2020. [DOI: 10.1186/s41544-020-00050-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
AbstractExtracellular vesicles (EVs) are small membrane vesicles carrying bioactive lipids, proteins and nucleic acids of the cell of origin. In particular, EVs carry non-coding RNAs (ncRNAs) and the vesicle membrane may protect them from degradation. Once released within the extracellular space, EVs can transfer their cargo, including ncRNAs, to neighboring or distant cells, thus inducing phenotypical and functional changes that may be relevant in several physio-pathological conditions. This review provides an overview of the role of EV-carried ncRNAs in the modulation of liver fibrosis. In particular, we focused on EV-associated microRNAs (miRNAs) and long non-coding RNAs (lncRNAs) involved into the development of liver fibrosis and on the potential use of EV-associated ncRNAs as diagnostic and prognostic biomarkers of liver fibrosis.
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19
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Ballestri S, Capitelli M, Fontana MC, Arioli D, Romagnoli E, Graziosi C, Lonardo A, Marietta M, Dentali F, Cioni G. Direct Oral Anticoagulants in Patients with Liver Disease in the Era of Non-Alcoholic Fatty Liver Disease Global Epidemic: A Narrative Review. Adv Ther 2020; 37:1910-1932. [PMID: 32285340 PMCID: PMC7467481 DOI: 10.1007/s12325-020-01307-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Indexed: 12/15/2022]
Abstract
Atrial fibrillation (AF) and venous thromboembolism (VTE) are highly prevalent and relevant healthcare issues. Direct oral anticoagulants (DOACs) are now the first-choice for anticoagulant treatment of these conditions displaying a better efficacy/safety profile than vitamin-K antagonists, mainly due to significantly reduced risk of major bleeding, especially of intracranial haemorrhage. Nonalcoholic fatty liver disease (NAFLD) is the most common liver disease in developed countries showing a continuously growing prevalence. Nonalcoholic steatohepatitis (NASH), its evolutive form, will be the leading cause for liver transplantation by 2020. NAFLD is independently associated with an increased risk of abnormalities of cardiac structure and function, including cardiac rhythm disorders (mainly AF). Moreover, data suggest an increased risk of unprovoked VTE associated with NAFLD/NASH. Therefore, a growing number of patients with chronic liver disease (CLD) will be candidate for anticoagulant therapy in the near future. Cirrhosis of any etiology is characterized by an unstable thrombosis/bleeding haemostatic balance, making anticoagulant therapy particularly challenging in this condition. Given that patients with significant active liver disease and cirrhosis were excluded from all pivotal randomized controlled trials on DOACs, this comprehensive review aims at critically discussing real-world evidence, including the latest population studies, regarding the use of DOACs in patients with CLD/cirrhosis.
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Affiliation(s)
- Stefano Ballestri
- Internal Medicine Unit, Pavullo Hospital, Azienda USL, Modena, Italy.
| | - Mariano Capitelli
- Internal Medicine Unit, Pavullo Hospital, Azienda USL, Modena, Italy
| | | | - Dimitriy Arioli
- Internal Medicine and Critical Care Unit, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Elisa Romagnoli
- Internal Medicine and Critical Care Unit, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Catia Graziosi
- Internal Medicine Unit, Pavullo Hospital, Azienda USL, Modena, Italy
| | - Amedeo Lonardo
- Metabolic Syndrome Unit, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Marco Marietta
- Hematology Unit, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Francesco Dentali
- Department of Clinical and Experimental Medicine, Insubria University, Varese, Italy
| | - Giorgio Cioni
- Internal Medicine Unit, Pavullo Hospital, Azienda USL, Modena, Italy
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20
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Han H, Qin Y, Yu Y, Wei X, Guo H, Ruan Y, Cao Y, He J. Atrial fibrillation in hospitalized patients with end-stage liver disease: temporal trends in prevalence and outcomes. Liver Int 2020; 40:674-684. [PMID: 31705572 DOI: 10.1111/liv.14291] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 10/29/2019] [Accepted: 10/31/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND & AIMS End-stage liver disease (ESLD) happens due to the development and progression of chronic liver disease. This study aims to investigate the temporal trend, patient characteristics and outcomes of atrial fibrillation (AF) in hospitalized ESLD patients across the United States. METHODS Nationwide Inpatient Sample from 2003 to 2014 was utilized to retrospectively study the weighted prevalence of AF in hospitalized ESLD patients. Multivariable regression models were used to assess the association between AF with clinical factors, in-hospital mortality, length of stay (LOS) and cost. RESULTS 639 345 hospitalizations associated with ESLD were identified, of which 47 710 (7.48%) were diagnosed with AF. The prevalence of AF increased from 5.73% in 2003 to 9.75% in 2014 in ESLD and varied by age, race, income, insurance type and hospital characteristics. Factors associated with AF included advancing age, male, white race, high income and urban teaching hospital. AF presence was associated with significant higher in-hospital mortality (odds ratio, 1.40; 95% confidence interval, 1.35-1.45), 21% longer LOS and 22% higher cost. In addition, a significant decreasing trend in in-hospital mortality was observed (from 16.70% to 10.63% in patients with AF and from 10.74% to 7.50% in patients without AF). CONCLUSIONS The prevalence of AF in hospitalized ESLD patients has continued to increase from 2003 through 2014. AF is associated with poor prognosis and higher health resource utilization. Innovative anticoagulation strategies through improved collaboration between cardiologists and hepatologists are required for better management of hospitalized ESLD patients comorbid with AF.
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Affiliation(s)
- Hedong Han
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Yingyi Qin
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Yamei Yu
- Department of Cardiology, Shanghai Tong Ren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xin Wei
- Department of Cardiology, Virginia Commonwealth University, Richmond, VA, USA
| | - Honglei Guo
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Yiming Ruan
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Jia He
- Department of Health Statistics, Second Military Medical University, Shanghai, China.,Tongji University School of Medicine, Shanghai, China
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21
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Zafar MI. Suitability of APINCH high-risk medications use in diabetes mellitus. Eur J Pharmacol 2020; 867:172845. [DOI: 10.1016/j.ejphar.2019.172845] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 11/15/2019] [Accepted: 12/03/2019] [Indexed: 12/17/2022]
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22
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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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Valeriani E, Riva N, Di Nisio M, Ageno W. Splanchnic Vein Thrombosis: Current Perspectives. Vasc Health Risk Manag 2019; 15:449-461. [PMID: 31695400 PMCID: PMC6815215 DOI: 10.2147/vhrm.s197732] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 10/02/2019] [Indexed: 12/14/2022] Open
Abstract
Splanchnic vein thrombosis (SVT) including portal, mesenteric, splenic vein thrombosis and the Budd-Chiari syndrome, is a manifestation of unusual site venous thromboembolism. SVT presents with a lower incidence than deep vein thrombosis of the lower limbs and pulmonary embolism, with portal vein thrombosis and Budd-Chiari syndrome being respectively the most and the least common presentations of SVT. SVT is classified as provoked if secondary to a local or systemic risk factor, or unprovoked if the causative trigger cannot be identified. Diagnostic evaluation is often affected by the lack of specificity of clinical manifestations: the presence of one or more risk factors in a patient with a high clinical suspicion may suggest the execution of diagnostic tests. Doppler ultrasonography represents the first line diagnostic tool because of its accuracy and wide availability. Further investigations, such as computed tomography and magnetic resonance angiography, should be executed in case of suspected thrombosis of the mesenteric veins, suspicion of SVT-related complications, or to complete information after Doppler ultrasonography. Once SVT diagnosis is established, a careful patient evaluation should be performed in order to assess the risks and benefits of the anticoagulant therapy and to drive the optimal treatment intensity. Due to the low quality and large heterogeneity of published data, guidance documents and expert opinion could direct therapeutic decision, suggesting which patients to treat, which anticoagulant to use and the duration of treatment.
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Affiliation(s)
- Emanuele Valeriani
- 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
| | - Marcello Di Nisio
- Department of Medicine and Ageing Sciences, University G. D'Annunzio, Chieti-Pescara, Italy
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
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24
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O'Leary JG, Greenberg CS, Patton HM, Caldwell SH. AGA Clinical Practice Update: Coagulation in Cirrhosis. Gastroenterology 2019; 157:34-43.e1. [PMID: 30986390 DOI: 10.1053/j.gastro.2019.03.070] [Citation(s) in RCA: 243] [Impact Index Per Article: 48.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 03/19/2019] [Accepted: 03/22/2019] [Indexed: 12/12/2022]
Abstract
DESCRIPTION This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership. The intent is to evaluate the current data on mechanism of altered coagulation in patients with cirrhosis, provide guidance on the use of currently available testing of the coagulation cascade, and help practitioners use anticoagulation and pro-coagulants appropriately in patients with cirrhosis. METHODS This review is framed around the best practice points, which were derived from the most impactful publications in the area of coagulation in cirrhosis and agreed to by all authors. BEST PRACTICE ADVICE 1: Global tests of clot formation, such as rotational thromboelastometry, thromboelastography, sonorheometry, and thrombin generation, may eventually have a role in the evaluation of clotting in patients with cirrhosis, but currently lack validated target levels. BEST PRACTICE ADVICE 2: In general, clinicians should not routinely correct thrombocytopenia and coagulopathy before low-risk therapeutic paracentesis, thoracentesis, and routine upper endoscopy for variceal ligation in patients with hepatic synthetic dysfunction-induced coagulation abnormalities. BEST PRACTICE ADVICE 3: Blood products should be used sparingly because they increase portal pressure and carry a risk of transfusion-associated circulatory overload, transfusion-related acute lung injury, infection transmission, alloimmunization, and/or transfusion reactions. BEST PRACTICE ADVICE 4: The following transfusion thresholds for management of active bleeding or high-risk procedures may optimize clot formation in advanced liver disease: hematocrit ≥25%, platelet count >50,000, and fibrinogen >120 mg/dL. Commonly utilized thresholds for international normalized ratio correction are not supported by evidence. BEST PRACTICE ADVICE 5: Thrombopoietin agonists are a good alternative to platelet transfusion, but require time (about 10 days) to elevate platelet levels. BEST PRACTICE ADVICE 6: The large volume of fresh frozen plasma required to reach an arbitrary international normalized ratio target, limitations of the usual target, minimal effect on thrombin generation, and adverse effects on portal pressure limit the utility of this agent significantly. BEST PRACTICE ADVICE 7: The 4-factor prothrombin complex concentrate contains both pro- and anticoagulant factors that offer an attractive low-volume therapeutic to rebalance a disturbed hemostatic system. However, dosage is, in part, based on international normalized ratio, which is problematic in cirrhosis, and published experience in liver disease is limited. BEST PRACTICE ADVICE 8: Anti-fibrinolytic therapy may be considered in patients with persistent bleeding from mucosal oozing or puncture wound bleeding consistent with impaired clot integrity. Both ε-aminocaproic acid and tranexamic acid inhibit clot dissolution. Neither is believed to generate a hypercoagulable state, although both may exacerbate pre-existing thrombi. BEST PRACTICE ADVICE 9: Desmopressin releases von Willebrand factor as its primary hemostatic mechanism. As this factor is usually elevated in cirrhosis, the agent lacks a sound evidence-based foundation, but may be useful in patients with concomitant renal failure. BEST PRACTICE ADVICE 10: Systemic heparin infusion is recommended for symptomatic deep vein thrombosis and portal and mesenteric vein thrombosis, but there are unresolved issues regarding monitoring with both the anti-Xa assay and the partial thromboplastin time due to cirrhosis-related antithrombin deficiency (heparin cofactor). BEST PRACTICE ADVICE 11: Treatment of incidental portal and mesenteric vein thrombosis depends on estimated impact on transplantation surgical complexity vs risks of bleeding and falls. Therapy with low-molecular-weight heparin, vitamin K antagonists, and direct-acting anticoagulants improve portal vein repermeation vs observation alone. BEST PRACTICE ADVICE 12: Direct-acting anticoagulants, such as the factor Xa and thrombin inhibitors, are relatively safe and effective in stable cirrhotic patients, but are in need of further study in patients with more advanced liver disease.
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Affiliation(s)
| | | | - Heather M Patton
- Southern California Permanente Medical Group-San Diego, San Diego, California
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25
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Anticoagulation in Patients with Liver Cirrhosis (Literature Review). ACTA BIOMEDICA SCIENTIFICA 2019. [DOI: 10.29413/abs.2019-4.2.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Liver cirrhosis is accompanied by complex hemostatic disorders with an increase in the risk of both hemorrhagic and thrombotic complications. Reduced coagulation protein synthesis, such as factors II, VII, IX, X and thrombocytopenia are associated with an increased risk of bleeding. Reducing the synthesis of such anticoagulants as protein C, protein S, antithrombin III is accompanied by increased generation of thrombin, which leads to procoagulant status, increased risk of venous thrombosis, pulmonary embolism, and portal vein thrombosis. Activation of the coagulation cascade increases the risk of thrombosis, and also plays an important role in liver damage, contributing to the progression of fibrosis. Cirrhosis increases the risk of thromboembolic complications of atrial fibrillation.Anticoagulants are necessary for the prevention of thrombosis and thromboembolic complications. However, there are no large prospective studies. There is insufficient data on the safety of anticoagulant therapy in cirrhosis. There are difficulties in monitoring anticoagulation in the application of vitamin K antagonists and low molecular weight heparins.The review presents the available data on the use of warfarin, unfractionated heparin, low molecular weight heparins and direct oral anticoagulants in patients with liver cirrhosis, indicating the need for prevention of venous thrombosis in patients with risk factors, the possibility of preventing decompensation of cirrhosis, reducing the frequency of cardioembolic strokes in patients with atrial fibrillation.
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26
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Steuber TD, Howard ML, Nisly SA. Direct Oral Anticoagulants in Chronic Liver Disease. Ann Pharmacother 2019; 53:1042-1049. [PMID: 30947523 DOI: 10.1177/1060028019841582] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Objective: To review the use of direct oral anticoagulants (DOACs) in patients with chronic liver disease (CLD). Data Sources: A MEDLINE literature search was performed from 1964 through February 2019 using the following search terms: cirrhosis, chronic liver disease, direct oral anticoagulant, and the individual DOACs. Study Selection and Data Extraction: All English-language human trials and reports that examined DOACs for treatment or prevention of venous thromboembolic (VTE) events in patients with CLD were included. Data Synthesis: A total of 6 clinical trials examining the use of DOACs in patients with CLD were identified. All DOACs have been utilized in patients with CLD, with the exception of betrixaban, for prevention of stroke in atrial fibrillation or treatment of VTE (except for treatment of pulmonary embolism). The studies primarily evaluated patients with mild to moderate liver disease (Child-Turcotte-Pugh class A and B). The DOACs had similar rates of bleeding compared with traditional anticoagulants. Relevance to Patient Care and Clinical Practice: This review evaluates and summarizes the available evidence on DOACs in the setting of CLD. These agents may be more appealing in this population because monitoring or administration may be difficult with traditional anticoagulants (warfarin or low-molecular-weight heparins). Conclusion: Early data suggest that DOACs may be safe in patients with mild to moderate CLD. Should a DOAC be selected as an alternative to traditional anticoagulants, more frequent monitoring should be used because hepatotoxicity may be a concern. Larger clinical trials are needed to address efficacy outcomes as well as differences among individual DOACs in this population.
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Affiliation(s)
- Taylor D Steuber
- 1 Auburn University Harrison School of Pharmacy, Huntsville, AL, USA
| | - Meredith L Howard
- 2 University of North Texas System College of Pharmacy, Fort Worth, TX, USA
| | - Sarah A Nisly
- 3 Wingate University School of Pharmacy, Wingate, NC, USA
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27
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Use of prothrombin complex concentrates in patients with decompensated liver cirrhosis is associated with thromboembolic events. J Hepatol 2019; 70:800-801. [PMID: 30630599 DOI: 10.1016/j.jhep.2018.11.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 11/15/2018] [Accepted: 11/21/2018] [Indexed: 01/02/2023]
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28
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Kockerling D, Nathwani R, Forlano R, Manousou P, Mullish BH, Dhar A. Current and future pharmacological therapies for managing cirrhosis and its complications. World J Gastroenterol 2019; 25:888-908. [PMID: 30833797 PMCID: PMC6397723 DOI: 10.3748/wjg.v25.i8.888] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 01/17/2019] [Accepted: 01/26/2019] [Indexed: 02/06/2023] Open
Abstract
Due to the restrictions of liver transplantation, complication-guided pharmacological therapy has become the mainstay of long-term management of cirrhosis. This article aims to provide a complete overview of pharmacotherapy options that may be commenced in the outpatient setting which are available for managing cirrhosis and its complications, together with discussion of current controversies and potential future directions. PubMed/Medline/Cochrane Library were electronically searched up to December 2018 to identify studies evaluating safety, efficacy and therapeutic mechanisms of pharmacological agents in cirrhotic adults and animal models of cirrhosis. Non-selective beta-blockers effectively reduce variceal re-bleeding risk in cirrhotic patients with moderate/large varices, but appear ineffective for primary prevention of variceal development and may compromise renal function and haemodynamic stability in advanced decompensation. Recent observational studies suggest protective, haemodynamically-independent effects of beta-blockers relating to reduced bacterial translocation. The gut-selective antibiotic rifaximin is effective for secondary prophylaxis of hepatic encephalopathy; recent small trials also indicate its potential superiority to norfloxacin for secondary prevention of spontaneous bacterial peritonitis. Diuretics remain the mainstay of uncomplicated ascites treatment, and early trials suggest alpha-adrenergic receptor agonists may improve diuretic response in refractory ascites. Vaptans have not demonstrated clinical effectiveness in treating refractory ascites and may cause detrimental complications. Despite initial hepatotoxicity concerns, safety of statin administration has been demonstrated in compensated cirrhosis. Furthermore, statins are suggested to have protective effects upon fibrosis progression, decompensation and mortality. Evidence as to whether proton pump inhibitors cause gut-liver-brain axis dysfunction is conflicting. Emerging evidence indicates that anticoagulation therapy reduces incidence and increases recanalisation rates of non-malignant portal vein thrombosis, and may impede hepatic fibrogenesis and decompensation. Pharmacotherapy for cirrhosis should be implemented in accordance with up-to-date guidelines and in conjunction with aetiology management, nutritional optimisation and patient education.
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Affiliation(s)
- David Kockerling
- Liver Unit/Division of Integrative Systems Medicine and Digestive Disease, Imperial College London, London W2 1NY, United Kingdom
| | - Rooshi Nathwani
- Liver Unit/Division of Integrative Systems Medicine and Digestive Disease, Imperial College London, London W2 1NY, United Kingdom
| | - Roberta Forlano
- Liver Unit/Division of Integrative Systems Medicine and Digestive Disease, Imperial College London, London W2 1NY, United Kingdom
| | - Pinelopi Manousou
- Liver Unit/Division of Integrative Systems Medicine and Digestive Disease, Imperial College London, London W2 1NY, United Kingdom
| | - Benjamin H Mullish
- Liver Unit/Division of Integrative Systems Medicine and Digestive Disease, Imperial College London, London W2 1NY, United Kingdom
| | - Ameet Dhar
- Liver Unit/Division of Integrative Systems Medicine and Digestive Disease, Imperial College London, London W2 1NY, United Kingdom
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29
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Luyendyk JP, Schoenecker JG, Flick MJ. The multifaceted role of fibrinogen in tissue injury and inflammation. Blood 2019; 133:511-520. [PMID: 30523120 PMCID: PMC6367649 DOI: 10.1182/blood-2018-07-818211] [Citation(s) in RCA: 280] [Impact Index Per Article: 56.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 11/26/2018] [Indexed: 02/08/2023] Open
Abstract
The canonical role of the hemostatic and fibrinolytic systems is to maintain vascular integrity. Perturbations in either system can prompt primary pathological end points of hemorrhage or thrombosis with vessel occlusion. However, fibrin(ogen) and proteases controlling its deposition and clearance, including (pro)thrombin and plasmin(ogen), have powerful roles in driving acute and reparative inflammatory pathways that affect the spectrum of tissue injury, remodeling, and repair. Indeed, fibrin(ogen) deposits are a near-universal feature of tissue injury, regardless of the nature of the inciting event, including injuries driven by mechanical insult, infection, or immunological derangements. Fibrin can modify multiple aspects of inflammatory cell function by engaging leukocytes through a variety of cellular receptors and mechanisms. Studies on the role of coagulation system activation and fibrin(ogen) deposition in models of inflammatory disease and tissue injury have revealed points of commonality, as well as context-dependent contributions of coagulation and fibrinolytic factors. However, there remains a critical need to define the precise temporal and spatial mechanisms by which fibrinogen-directed inflammatory events may dictate the severity of tissue injury and coordinate the remodeling and repair events essential to restore normal organ function. Current research trends suggest that future studies will give way to the identification of novel hemostatic factor-targeted therapies for a range of tissue injuries and disease.
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Affiliation(s)
- James P Luyendyk
- Department of Pathobiology and Diagnostic Investigation
- Department of Pharmacology and Toxicology, and
- Institute for Integrative Toxicology, Michigan State University, East Lansing, MI
| | - Jonathan G Schoenecker
- Department of Orthopaedics
- Department of Pharmacology
- Department of Pediatrics, and
- Department of Pathology, Vanderbilt University Medical Center, Nashville, TN; and
| | - Matthew J Flick
- Division of Experimental Hematology and Cancer Biology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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30
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Fortea JI, Puente Á, Ezcurra I, Cuadrado A, Arias-Loste MT, Cabezas J, Llerena S, Iruzubieta P, Rodríguez-Lope C, Huelin P, Casafont F, Fábrega E, Crespo J. Management of haemostatic alterations and associated disorders in cirrhosis in Spain: A national survey. Dig Liver Dis 2019; 51:95-103. [PMID: 29960901 DOI: 10.1016/j.dld.2018.06.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Revised: 05/17/2018] [Accepted: 06/01/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Knowledge of haematological abnormalities in cirrhosis has greatly improved in recent years. AIMS To evaluate how Spanish Digestive Disease specialists manage haemostatic alterations and associated disorders in patients with cirrhosis. METHODS All members of the Spanish Association for the Study of the Liver and Spanish Society of Digestive Pathology were invited to fill in a web-based questionnaire. RESULTS 135 professionals, 93 hepatologists and 42 non-hepatologists responded to the survey. The concept of rebalanced haemostasis was known by 74.8% of them. Most specialists corrected the INR and thrombocytopenia before invasive procedures with moderate risk of bleeding or major surgery and in severe gastrointestinal bleeding. The threshold of platelets and, especially, INR used to administer blood products varied greatly. Pharmacological prophylaxis of venous thromboembolism prevailed, but it was highly dependent on the INR and platelet figures. Most participants initiated anticoagulation regardless of the degree of portal vein thrombosis, even in patients ineligible for transplantation. In potential candidates, only 56% maintained it indefinitely or until liver transplantation. No major differences between hepatologists and non-hepatologists were found. CONCLUSIONS A significant variability and certain deviation from current guidelines was observed among Spanish Digestive Disease specialists regarding management of haemostatic alterations and associated disorders in cirrhosis.
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Affiliation(s)
- José Ignacio Fortea
- Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander, Spain; Marqués de Valdecilla Research Institute (IDIVAL), Santander, Spain; CIBER of Hepatic and Digestive Diseases (CIBERehd), Madrid, Spain.
| | - Ángela Puente
- Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander, Spain; Marqués de Valdecilla Research Institute (IDIVAL), Santander, Spain; CIBER of Hepatic and Digestive Diseases (CIBERehd), Madrid, Spain
| | - Iranzu Ezcurra
- Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander, Spain
| | - Antonio Cuadrado
- Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander, Spain; Marqués de Valdecilla Research Institute (IDIVAL), Santander, Spain; CIBER of Hepatic and Digestive Diseases (CIBERehd), Madrid, Spain
| | - María Teresa Arias-Loste
- Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander, Spain; Marqués de Valdecilla Research Institute (IDIVAL), Santander, Spain; CIBER of Hepatic and Digestive Diseases (CIBERehd), Madrid, Spain
| | - Joaquín Cabezas
- Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander, Spain; Marqués de Valdecilla Research Institute (IDIVAL), Santander, Spain; CIBER of Hepatic and Digestive Diseases (CIBERehd), Madrid, Spain
| | - Susana Llerena
- Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander, Spain; Marqués de Valdecilla Research Institute (IDIVAL), Santander, Spain; CIBER of Hepatic and Digestive Diseases (CIBERehd), Madrid, Spain
| | - Paula Iruzubieta
- Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander, Spain; Marqués de Valdecilla Research Institute (IDIVAL), Santander, Spain; CIBER of Hepatic and Digestive Diseases (CIBERehd), Madrid, Spain
| | - Carlos Rodríguez-Lope
- Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander, Spain; Marqués de Valdecilla Research Institute (IDIVAL), Santander, Spain; CIBER of Hepatic and Digestive Diseases (CIBERehd), Madrid, Spain
| | - Patricia Huelin
- Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander, Spain; Marqués de Valdecilla Research Institute (IDIVAL), Santander, Spain; CIBER of Hepatic and Digestive Diseases (CIBERehd), Madrid, Spain
| | - Fernando Casafont
- Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander, Spain; Marqués de Valdecilla Research Institute (IDIVAL), Santander, Spain; CIBER of Hepatic and Digestive Diseases (CIBERehd), Madrid, Spain
| | - Emilio Fábrega
- Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander, Spain; Marqués de Valdecilla Research Institute (IDIVAL), Santander, Spain; CIBER of Hepatic and Digestive Diseases (CIBERehd), Madrid, Spain
| | - Javier Crespo
- Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander, Spain; Marqués de Valdecilla Research Institute (IDIVAL), Santander, Spain; CIBER of Hepatic and Digestive Diseases (CIBERehd), Madrid, Spain
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Lv Y, Qi X, He C, Wang Z, Yin Z, Niu J, Guo W, Bai W, Zhang H, Xie H, Yao L, Wang J, Li T, Wang Q, Chen H, Liu H, Wang E, Xia D, Luo B, Li X, Yuan J, Han N, Zhu Y, Xia J, Cai H, Yang Z, Wu K, Fan D, Han G. Covered TIPS versus endoscopic band ligation plus propranolol for the prevention of variceal rebleeding in cirrhotic patients with portal vein thrombosis: a randomised controlled trial. Gut 2018; 67:2156-2168. [PMID: 28970291 DOI: 10.1136/gutjnl-2017-314634] [Citation(s) in RCA: 112] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 08/18/2017] [Accepted: 08/21/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Limited data are available on the prevention of variceal rebleeding in cirrhotic patients with portal vein thrombosis (PVT). This study aimed to compare transjugular intrahepatic portosystemic shunt (TIPS) with covered stents versus endoscopic band ligation (EBL) plus propranolol for the prevention of variceal rebleeding among patients with cirrhosis and PVT. DESIGN Consecutive cirrhotic patients (94% Child-Pugh class A or B) with PVT who had variceal bleeding in the past 6 weeks were randomly assigned to TIPS group (n=24) or EBL plus propranolol group (EBL+drug, n=25), respectively. Primary endpoint was variceal rebleeding. Secondary endpoints included survival, overt hepatic encephalopathy (OHE), portal vein recanalisation and rethrombosis, other complications of portal hypertension and adverse events. RESULTS During a median follow-up of 30 months in both groups, variceal rebleeding was significantly less frequent in the TIPS group (15% vs 45% at 1 year and 25% vs 50% at 2 years, respectively; HR=0.28, 95% CI 0.10 to 0.76, p=0.008), with a significantly higher portal vein recanalisation rate (95% vs 70%; p=0.03) and a relatively lower rethrombosis rate (5% vs 33%; p=0.06) compared with the EBL+drug group. There were no statistically significant differences in survival (67% vs 84%; p=0.152), OHE (25% vs 16%; p=0.440), other complications of portal hypertension and adverse events between groups. CONCLUSION Covered TIPS placement in patients with PVT and moderately decompensated cirrhosis was more effective than EBL combined with propranolol for the prevention of rebleeding, with a higher probability of PVT resolution without increasing the risk of OHE and adverse effects, but this benefit did not translate into improved survival. TRIAL REGISTRATION NUMBER ClinicalTrials.gov: NCT01326949.
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Affiliation(s)
- Yong Lv
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Xingshun Qi
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Chuangye He
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Zhengyu Wang
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Zhanxin Yin
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | | | - Wengang Guo
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Wei Bai
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Hongbo Zhang
- Department of Digestive Endoscopy, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Huahong Xie
- Department of Digestive Endoscopy, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Liping Yao
- Department of Digestive Endoscopy, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Jianhong Wang
- Department of Ultrasound, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Tao Li
- Department of Ultrasound, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Qiuhe Wang
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Hui Chen
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Haibo Liu
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Enxing Wang
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Dongdong Xia
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Bohan Luo
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Xiaomei Li
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Jie Yuan
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Na Han
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Ying Zhu
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Jielai Xia
- Department of Medical Statistics, Fourth Military Medical University, Xi'an, China
| | - Hongwei Cai
- Department of Medical Statistics, Fourth Military Medical University, Xi'an, China
| | - Zhiping Yang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Kaichun Wu
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Daiming Fan
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Guohong Han
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
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Intagliata NM, Argo CK, Stine JG, Lisman T, Caldwell SH, Violi F. Concepts and Controversies in Haemostasis and Thrombosis Associated with Liver Disease: Proceedings of the 7th International Coagulation in Liver Disease Conference. Thromb Haemost 2018; 118:1491-1506. [PMID: 30060258 PMCID: PMC6202935 DOI: 10.1055/s-0038-1666861] [Citation(s) in RCA: 117] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 05/17/2018] [Indexed: 12/12/2022]
Affiliation(s)
- N. M. Intagliata
- Department of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, United States
| | - C. K. Argo
- Department of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, United States
| | - J. G. Stine
- Department of Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, United States
| | - T. Lisman
- Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - S. H. Caldwell
- Department of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, United States
| | - F. Violi
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
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33
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Pant A, Kopec AK, Luyendyk JP. Role of the blood coagulation cascade in hepatic fibrosis. Am J Physiol Gastrointest Liver Physiol 2018; 315:G171-G176. [PMID: 29723040 PMCID: PMC6139645 DOI: 10.1152/ajpgi.00402.2017] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 04/19/2018] [Accepted: 04/24/2018] [Indexed: 02/07/2023]
Abstract
Liver is the primary source of numerous proteins that are critical for normal function of the blood coagulation cascade. Because of this, diseases of the liver, particularly when affiliated with severe complications like cirrhosis, are associated with abnormalities of blood clotting. Although conventional interpretation has inferred cirrhosis as a disorder of uniform bleeding risk, it is now increasingly appreciated as a disease wherein the coagulation cascade is precariously rebalanced. Moreover, prothrombotic risk factors are also associated with a more rapid progression of fibrosis in humans, suggesting that coagulation proteases participate in disease pathogenesis. Indeed, strong evidence drawn from experimental animal studies indicates that components of the coagulation cascade, particularly coagulation factor Xa and thrombin, drive profibrogenic events, leading to hepatic fibrosis. Here, we concisely review the evidence supporting a pathologic role for coagulation in the development of liver fibrosis and the potential mechanisms involved. Further, we highlight how studies in experimental animals may shed light on emerging clinical evidence, suggesting that beneficial effects of anticoagulation could extend beyond preventing thrombotic complications to include reducing pathologies like fibrosis.
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Affiliation(s)
- Asmita Pant
- Department of Pathobiology and Diagnostic Investigation, Michigan State University , East Lansing, Michigan
- Institute for Integrative Toxicology, Michigan State University , East Lansing, Michigan
| | - Anna K Kopec
- Department of Pathobiology and Diagnostic Investigation, Michigan State University , East Lansing, Michigan
- Institute for Integrative Toxicology, Michigan State University , East Lansing, Michigan
| | - James P Luyendyk
- Department of Pathobiology and Diagnostic Investigation, Michigan State University , East Lansing, Michigan
- Institute for Integrative Toxicology, Michigan State University , East Lansing, Michigan
- Department of Pharmacology and Toxicology, Michigan State University , East Lansing, Michigan
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34
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Artaza T, Lopes M, Romero M, Gómez AZ, de la Cruz G, Sánchez JJ, González C, Gómez R. Efficacy and safety of anticoagulation in non-malignant portal vein thrombosis in patients with liver cirrhosis. GASTROENTEROLOGIA Y HEPATOLOGIA 2018; 41:611-617. [PMID: 30049580 DOI: 10.1016/j.gastrohep.2018.06.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 05/12/2018] [Accepted: 06/04/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND AIM Treatment for portal vein thrombosis (PVT) is not well established. Nevertheless, anticoagulation therapy can seemingly be used as first-line therapy. However, there are limited data on the role of this treatment in patients with PVT and cirrhosis. We sought to assess the safety and efficacy of anticoagulation therapy in a series of patients with non-malignant PVT and liver cirrhosis. METHODS We analyzed the data of 32 patients with cirrhosis and PVT between March 2009 and September 2015. All patients received anticoagulation treatment. PVT was diagnosed within the context of biannual hepatocellular carcinoma screening in these patients. RESULTS Recanalisation was achieved in 23 patients: complete in 17 patients (53.1%) and partial in 6 patients (18.7%). The median time for achieving a complete response was 7 months (95% CI: 6-8). We did not discover any risk factors associated with repermeation (partial or complete). None of the patients presented with thrombosis progression while receiving anticoagulation. Nine patients who achieved complete recanalisation and stopped anticoagulation therapy suffered rethrombosis (52%). There were no differences between the patients who achieved complete or partial recanalisation (35%) and those who did not (33%) in relation to the onset of hepatic events during follow-up. Three patients (9%) presented with bleeding complications: two variceal bleeding episodes and one brain hemorrhage. CONCLUSIONS In cirrhotic patients with non-malignant PVT, anticoagulation therapy led to partial or complete recanalisation in 70% of patients, with a broad safety profile. Due to the existing rethrombosis rate, long-term anticoagulation should be considered.
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Affiliation(s)
- Tomas Artaza
- Department of Gastroenterology, Hospital Virgen de la Salud, Toledo, Spain.
| | - Miriam Lopes
- Department of Gastroenterology, Hospital Virgen de la Salud, Toledo, Spain
| | - Marta Romero
- Department of Gastroenterology, Hospital Virgen de la Salud, Toledo, Spain
| | - Ana-Zaida Gómez
- Department of Gastroenterology, Hospital Virgen de la Salud, Toledo, Spain
| | - Gema de la Cruz
- Department of Gastroenterology, Hospital Virgen de la Salud, Toledo, Spain
| | - Juan José Sánchez
- Department of Gastroenterology, Hospital Virgen de la Salud, Toledo, Spain
| | | | - Rafael Gómez
- Department of Gastroenterology, Hospital Virgen de la Salud, Toledo, Spain
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35
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Guillaume M, Bureau C, Plessier A. Is there evidence for stopping anticoagulation therapy before endoscopic variceal ligation? Liver Int 2018; 38:1175-1176. [PMID: 29932511 DOI: 10.1111/liv.13749] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Maeva Guillaume
- Service d'Hépatologie et Gastro-entérologie, Hôpital Purpan Centre Hospitalier Universitaire de Toulouse, Toulouse, France.,Université Paul Sabatier Toulouse III, Toulouse, France.,Institut CARDIOMET, Toulouse, France
| | - Christophe Bureau
- Service d'Hépatologie et Gastro-entérologie, Hôpital Purpan Centre Hospitalier Universitaire de Toulouse, Toulouse, France.,Université Paul Sabatier Toulouse III, Toulouse, France.,Institut CARDIOMET, Toulouse, France
| | - Aurélie Plessier
- Service d'Hépatologie, Hôpital Beaujon, Assistance Publique des Hôpitaux de Paris, Clichy, France
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36
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Yang J, Li C, Zhang L, Wang X. Extracellular Vesicles as Carriers of Non-coding RNAs in Liver Diseases. Front Pharmacol 2018; 9:415. [PMID: 29740327 PMCID: PMC5928552 DOI: 10.3389/fphar.2018.00415] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 04/10/2018] [Indexed: 12/12/2022] Open
Abstract
Extracellular vesicles (EVs) are small membranous vesicles secreted from normal, diseased, and transformed cells in vitro and in vivo. EVs have been found to play a critical role in cell-to-cell communication by transferring non-coding RNAs (ncRNAs) including microRNAs (miRNAs), long ncRNAs (lncRNAs) and so on. Emerging evidence shows that transferring biological information through EVs to neighboring cells in intercellular communication not only keep physiological functions, but also participate in the pathogenesis of liver diseases. Liver diseases often promote release of EVs and/or in different cargo sorting into these EVs. Either of these modifications can promote disease pathogenesis. Given this fact, EV-associated ncRNAs, such as miR-192, miR-122 and lncRNA-ROR and so on, can serve as new diagnostic biomarkers and new therapeutic targets for liver disease, because altered EV-associated ncRNAs may reflect the underlying liver disease condition. In this review, we focus on understanding the emerging role of EV-associated ncRNAs in viral hepatitis, liver fibrosis, alcoholic hepatitis (AH), non-alcoholic steatohepatitis (NASH) and hepatocellular carcinoma (HCC) and discuss their utility in biomarker discovery and therapeutics. A better understanding of this multifaceted pattern of communication between different type cells in liver may contribute to developing novel approaches for personalized diagnostics and therapeutics.
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Affiliation(s)
- Junfa Yang
- School of Pharmacy, Anhui Medical University, Hefei, China.,Anhui Province Key Laboratory of Major Autoimmune Diseases, Anhui Institute of Innovative Drugs, Hefei, China.,The Key Laboratory of Anti-inflammatory and Immune Medicines, Ministry of Education, Anhui Medical University, Hefei, China
| | - Changyao Li
- School of Pharmacy, Anhui Medical University, Hefei, China.,Anhui Province Key Laboratory of Major Autoimmune Diseases, Anhui Institute of Innovative Drugs, Hefei, China.,The Key Laboratory of Anti-inflammatory and Immune Medicines, Ministry of Education, Anhui Medical University, Hefei, China
| | - Lei Zhang
- School of Pharmacy, Anhui Medical University, Hefei, China.,Anhui Province Key Laboratory of Major Autoimmune Diseases, Anhui Institute of Innovative Drugs, Hefei, China.,The Key Laboratory of Anti-inflammatory and Immune Medicines, Ministry of Education, Anhui Medical University, Hefei, China
| | - Xiao Wang
- Department of Radiology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
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