Protein C and D-dimer are related to portal vein thrombosis in patients with liver cirrhosis

Risk factors for hepatic hydrothorax in patients with cirrhosis: a clinical retrospective study

Aims and background

Hepatic hydrothorax, which presents as an unexplained pleural effusion, is one of the important complications in patients with end-stage cirrhosis. It has a significant correlation with prognosis and mortality. The aim of this clinical study was to detect the risk factors for hepatic hydrothorax in patients with cirrhosis and to better understand potentially life-threatening complications.

Methods

Retrospectively, 978 cirrhotic patients who were hospitalized at the Shandong Public Health Clinical Center from 2013 to 2021 were involved in this study. They were divided into the observation group and the control group based on the presence of hepatic hydrothorax. The epidemiological, clinical, laboratory, and radiological characteristics of the patients were collected and analyzed. ROC curves were used to evaluate the forecasting ability of the candidate model. Furthermore, 487 cases in the experimental group were divided into left, right, and bilateral groups, and the data were analyzed.

Results

The patients in the observation group had a higher proportion of upper gastrointestinal bleeding (UGIB), a history of spleen surgery, and a higher model for end-stage liver disease (MELD) scores compared with the control group. The width of the portal vein (PVW) (P = 0.022), prothrombin activity (PTA) (P = 0.012), D-dimer (P = 0.010), immunoglobulin G (IgG) (P = 0.007), high-density lipoprotein cholesterol (HDL) (P = 0.022), and the MELD score were significantly associated with the occurrence of the hepatic hydrothorax. The AUC of the candidate model was 0.805 (P < 0.001, 95% CI = 0.758-0.851). Portal vein thrombosis was more common in bilateral pleural effusion compared with the left and right sides (P = 0.018).

Conclusion

The occurrence of hepatic hydrothorax has a close relationship with lower HDL, PTA, and higher PVW, D-dimer, IgG, and MELD scores. Portal vein thrombosis is more common in cirrhotic patients with bilateral pleural effusion compared to those with unilateral pleural effusion.

Potential utility of a multi-component coagulation factor panel to calculate MELD scores and assess the risk of portal vein thrombosis in chronic liver disease

BACKGROUND

Current quantitative approaches to assess chronic liver disease (CLD) severity have limitations. Further, portal vein thrombosis (PVT) pre-liver transplant (LT) is a major contributor to morbidity in CLD; the means of detecting and/or predicting PVT are limited. We sought to explore whether plasma coagulation factor activity levels can serve as a substitute for prothrombin time/international normalized ratio (PT/INR) in the Model for End-stage Liver Disease (MELD), and/or help assess the risk of PVT.

METHODS

Plasma activity levels of Factor V (FV), Factor VIII (FVIII), Protein C (PC), and Protein S (PS) and the concentrations of D-dimer, sP-selectin, and asTF were assessed in two cohorts of CLD patients (ambulatory, n = 42; LT, n = 43).

RESULTS

FV and PC activity levels strongly correlated with MELD scores, which enabled the development of a novel scoring system based on multiple linear regressions of the correlations of FV and PC activity with MELD-Na that substitutes PT/INR. Six-month and 1-year follow-up revealed that our novel approach was non-inferior to MELD-Na at predicting mortality. A significant inverse correlation between FVIII activity levels and PVT was found in the LT cohort (p = 0.010); FV and PS activity levels were in-trend (p = 0.069, p = 0.064). We developed a logistic regression-based compensation score to identify patients at risk of PVT.

CONCLUSIONS

We demonstrate that FV and PC activity levels may be used to replace PT/INR in MELD scoring. We also show the potential of using the combination of FV, FVIII, and PS activity levels to assess the risk of PVT in CLD.

Analysis of related factors of portal vein thrombosis in liver cirrhosis

BACKGROUND AND AIMS

To investigate the usefulness of interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), protein C (PC), and thromboelastography (TEG) to serve as a predictor of portal vein thrombosis (PVT) in patients with liver cirrhosis. Additionally, we examined the clinical significance of the above indicators in terms of disease progression.

METHODS

A total of 123 patients with liver cirrhosis were recruited from May 2021 to December 2021, according to the imaging findings. They were divided into the PVT group (n = 52) and the non-PVT group (n = 71). Furthermore, patients with PVT were divided into plasma transfusion groups (n = 13) and non-plasma transfusion groups (n = 39). The basic general information, past medical history, laboratory, and imaging examination data were collected and analyzed.

RESULTS

In univariate analysis, there was no significant difference between the two groups in IL-6, PC, reaction time (R), alpha angle (Angle), maximum amplitude, or coagulation index (CI) (P > 0.05). TNF-α in the PVT group was significantly lower than that in the non-PVT group (P = 0.001). K-time (K) in the PVT group was significantly higher than that in the non-PVT group (P = 0.031). There was no significant difference in IL-6, TNF-α, PC, or TEG between different Child-Pugh classification groups (P > 0.05). There were no significant differences in TEG between the plasma transfusion group and the non-plasma transfusion group. In Binary logistic regression analysis, TNF-α (OR = 0.9881, 95%CI = 0.971, 0.990, P < 0.001), K(OR = 1.28, 95% = 1.053, 1.569, P = 0.014), activate partial thromboplastin time (APTT) (OR = 0.753, 95%CI = 0.656, 0.865, P < 0.001), portal vein diameter (OR = 1.310, 95%CI = 1.108, 1.549, P = 0.002)and the history of splenectomy or embolism (OR = 7.565, 95%CI = 1.514, 37.799, P = 0.014)were related to the formation of PVT.

CONCLUSIONS

TNF-α, K, APTT, portal vein diameter, and splenectomy or embolism history were associated with PVT formation, but IL-6 was not.

Epidemiology of portal vein thrombosis in liver cirrhosis: A systematic review and meta-analysis

BACKGROUND

Portal vein thrombosis (PVT) may be associated with negative outcomes in patients with liver cirrhosis. However, the prevalence and incidence of PVT in liver cirrhosis are heterogeneous among studies and have not been sufficiently determined yet.

METHODS

The PubMed, EMBASE, and Cochrane Library databases were searched. Eligible studies would explore the prevalence and/or incidence of PVT in liver cirrhosis without hepatocellular carcinoma or abdominal surgery. Pooled proportion with 95% confidence interval (CI) was calculated using a random-effect model. Factors associated with the presence/occurrence of PVT were also extracted.

RESULTS

Among the 8549 papers initially identified, 74 were included. Fifty-four studies explored the prevalence of PVT in liver cirrhosis with a pooled prevalence of 13.92% (95%CI=11.18-16.91%). Based on cross-sectional data, Child-Pugh class B/C, higher D-dimer, ascites, and use of non-selective beta-blockers (NSBBs) were associated with the presence of PVT in liver cirrhosis. Twenty-three studies explored the incidence of PVT in liver cirrhosis with a pooled incidence of 10.42% (95%CI=8.16-12.92%). Based on cohort data, Child-Pugh class B/C, higher model of end-stage liver disease score, higher D-dimer, lower platelets count, decreased portal flow velocity, ascites, use of NSBBs, and moderate or high-risk esophageal varices could predict the occurrence of PVT in liver cirrhosis.

CONCLUSION

Approximately one seventh of cirrhotic patients have PVT, and one tenth will develop PVT. Progression of liver cirrhosis and portal hypertension seems to be in parallel with the risk of PVT. Prospective studies with detailed information about classification and extension of PVT in liver cirrhosis are needed.

Liver Cirrhosis Patients Homozygous for MTHFR C677T Develop Portal Vein Thrombosis 8 Years Earlier Than Wild Type

BACKGROUND AND AIM

Age at portal vein thrombosis (PVT) in liver cirrhosis (LC) carriers of the methylene tetrahydrofolate reductase (MTHFR) rs1801133 (C → T667 transition) polymorphism has never been addressed; we compared age at PVT in LC patients genotyped for the MTHFR and explored the interrelated clinical and laboratory factors predicting age at PVT.

APPROACH AND RESULTS

Retrospective cross-sectional cohort study. PVT participants: MTHFR CC n = 36, MTHFR CT n = 53, MTHFR TT n = 19; age, sex, age at PVT, Child-Pugh score, rs1799963 PT polymorphisms (G → A 20,210 transition), plasma HC and natural anticoagulants available for all participants. Age at PVT was lower in MTHFR TT than CT and CC (56 ± 13 vs. 57 ± 13 vs. 64 ± 9 years, p = 0.001); median (IQR) plasma HC was higher in MTHFR TT than in the other groups [(17 (9.4, 23.3) vs 13 (8,14.7) vs 11 (8.9, 12.7) μmol/l, p = 0.03)]. MTHFR TT, male gender and protein C predicted age at PVT (p = 0.02, p = 0.04 and p = 0.08); MTHFR TT and Child-Pugh score predicted plasma HC (p = 0.005 and p = 0.01) as well as low plasma protein C (p < 0.0001 and p = 0.0002). Plasma HC inversely related to protein C in the MTHFR TT group (p < 0.0001). Compound MTHFR TT with PT GA had lower age at PVT compared to MTHFR TT alone (49 ± 18 vs 58 ± 12 years).

CONCLUSIONS

MTHFR TT anticipates PVT associated with LC by an average of 8 years; MTHFR TT associates with severity of liver disease and to high plasma HC; the latter may contribute to the prematurity of PVT by interfering with the anticoagulant activity of protein C.

Narrative review of portal vein thrombosis in cirrhosis: pathophysiology, diagnosis, and management from an interventional radiology perspective

OBJECTIVE

This paper examines the incidence, clinical presentation, and pathophysiology of portal vein thrombosis (PVT) in cirrhosis. Additionally, we have reviewed the literature regarding the current status of medical and interventional radiology management of PVT and have proposed a novel algorithm for the management given different clinical scenarios. Lastly two representative cases displaying endovascular treatment options are provided.

BACKGROUND

Portal vein thrombus in the setting of cirrhosis is an increasingly recognized clinical issue with debate on its pathophysiology, natural course, and optimal treatment. Approximately one-third of patients are asymptomatic, and detection of the thrombus is an incidental finding on imaging performed for other reasons. In 30% to 50% of patients, PVT resolves spontaneously. However, there is increased post-transplant mortality in patients with completely occlusive PVT, therefore effective early revascularization strategies are needed for patients with complete PVT who are expected to undergo liver transplant. Additionally, no consensus has been reached regarding PVT treatment in terms of timing and type of interventions as well as type and duration of anticoagulation.

METHODS

Computerized literature search as well as discussion with experts in the field.

CONCLUSIONS

Management of PVT is complex, as many variables affect which treatments can be used. Anticoagulation appears to be the optimal first-line treatment in patients with acute PVT but without bleeding varices or mesenteric ischemia. Minimally invasive treatments include various methods of mechanical thrombectomy, chemical thrombolysis, and transjugular intrahepatic portosystemic shunt (TIPS) placement with or without variceal embolization. Definitive recommendations are difficult due to lack of high quality data and continued research is needed to evaluate the efficacy of different anticoagulants as well as the timing and use of various minimally invasive therapies in specific circumstances.

Diagnostic accuracy of D-dimer in patients at high-risk for splanchnic vein thrombosis: A systematic review and meta-analysis

BACKGROUND

D-dimer is included in the diagnostic algorithm for deep vein thrombosis and pulmonary embolism. However, its role in the diagnosis of splanchnic vein thrombosis (SVT) is still controversial. The aim of this study was to evaluate the diagnostic accuracy of D-dimer for SVT.

METHODS

We performed a systematic review of the literature with meta-analysis (PROSPERO protocol registration number: CRD42020184300). The electronic databases MEDLINE, EMBASE, and CENTRAL were searched from inception to March 2021 week 4. Studies which evaluated D-dimer accuracy for SVT in any category of patients were selected. The index test was any D-dimer assay; the reference standard was any radiological imaging. The QUADAS-2 checklist was used for the risk of bias assessment. A bivariate random-effects regression model was used to calculate summary estimates of sensitivity and specificity.

RESULTS

12 studies (with a total of 1298 patients) evaluating the accuracy of D-dimer in patients at high risk of SVT (surgical patients, patients with liver cirrhosis or hepatocellular carcinoma) were included. None of the included studies was at low risk of bias. The weighted mean prevalence of SVT was 33.4% (95% CI, 22.5-45.2%, I2 = 94.8%). D-dimer accuracy was expressed by sensitivity 96% (95% CI, 72-100%); specificity 25% (95% CI, 5-67%); positive likelihood ratio 1.3 (95% CI, 0.9-1.9); negative likelihood ratio 0.16 (95% CI, 0.03-0.84); area under the ROC curve 0.80 (95% CI, 0.76-0.83).

CONCLUSIONS

D-dimer seems to have high sensitivity in the diagnosis of patients at high-risk for SVT. However, there is a strong need for more robust evidence on this topic.

Mechanism, diagnosis, and treatment of portal vein thrombosis in cirrhosis

Portal vein thrombosis (PVT) is one of the common complications of cirrhosis. Its formation is influenced by many factors, such as liver function grade, blood coagulation state, portal vein pressure, and blood flow velocity. The treatment of patients with PVT is more difficult than that of patients without PVT, and the prognosis is poor. However, the presence of PVT is usually asymptomatic, thus early detection and intervention are important. Currently, there are different views on the mechanism of PVT. This review will discuss the mechanism of PVT and summarize its pathogenesis, diagnosis, and treatment, with an aim to provide evidence for clinical practice.

Prediction of portal vein thrombosis after hepatectomy for hepatocellular carcinoma

PURPOSE

Portal vein thrombosis (PVT) following hepatectomy is potentially life-threatening. We aimed to evaluate the incidence of PVT after hepatectomy for hepatocellular carcinoma and identify coagulation and fibrinolytic factors that could predict early-stage postoperative PVT.

METHODS

A retrospective analysis was conducted on 65 hepatocellular carcinoma patients who underwent radical hepatectomy. The risk factors for postoperative PVT were identified based on univariate and multivariate analyses, and the levels of coagulation and fibrinolytic factors were measured during the perioperative period.

RESULTS

The incidence of PVT after hepatectomy was 20.0%. The patients were divided into two groups: those with PVT (n=13; PVT group) and those without PVT (n=52; no-PVT group). The frequency of the use of the Pringle maneuver during surgery was higher in the PVT group than in the no-PVT group, and the postoperative/preoperative ratios of thrombin-antithrombin III complex (TAT) and of D-dimer were significantly higher in the PVT group.

CONCLUSION

A high incidence of PVT was found in hepatocellular carcinoma patients after hepatectomy. The frequency of the Pringle maneuver is a potential risk factor for postoperative PVT, and the postoperative/preoperative TAT and D-dimer ratios may be used as early predictors of PVT after hepatectomy for hepatocellular carcinoma.

Blood microRNA Signatures Serve as Potential Diagnostic Biomarkers for Hepatic Sinusoidal Obstruction Syndrome Caused by Gynura japonica Containing Pyrrolizidine Alkaloids

Background and Aims: The Gynura japonica-induced hepatic sinusoidal obstruction syndrome (HSOS) is closely related to pyrrolizidine alkaloids (PAs), and its prevalence has been increasing worldwide in recent years. However, no effective therapy for PA-induced HSOS in clinics is available, partially due to the failure of quick diagnosis. This study aims to identify blood microRNA (miRNA) signatures as potential biomarkers for PA-induced HSOS in clinics.

Methods: The microarray-based miRNA profiling was performed on blood samples of the discovery cohort, which consisted of nine patients with HSOS and nine healthy donors. Differentially expressed miRNAs were further confirmed using a validation cohort, which consisted of 20 independent patients with HSOS. In addition, the rat model was established through the oral administration of the total alkaloid extract from G. japonica to investigate the association of miRNA biomarkers with the progression of HSOS. Bioinformatic analyses, including GO and KEGG enrichment, receiver operating characteristics curve, and correlation analyses were conducted to evaluate the accuracy of the potential miRNA biomarkers.

Results: Three miRNAs, namely miR-148a-3p, miR-362-5p, and miR-194-5p, were overexpressed in patients and rats with PA-induced HSOS. These miRNAs were positively related to the severity of liver injury and displayed considerable diagnostic accuracy for patients with HSOS with areas under the curve over 0.87.

Conclusion: In summary, this study demonstrated that three miRNAs, hsa-miR-148a-3p, hsa-miR-362-5p, and hsa-miR-194-5p, might serve as potential biomarkers for PA-induced HSOS in clinics.

Serum Lipoprotein (a) on Postoperative Day 3: A Strong Predictor of Portal and/or Splenic Vein Thrombosis in Cirrhotic Patients With Splenectomy

Elevated lipoprotein (a) [Lp(a)] is related to the incidence of lower limb deep vein thrombosis and pulmonary embolism. Its role in portal and/or splenic vein thrombosis (PSVT) is not established. A total of 77 consecutive patients who underwent splenectomy for cirrhotic portal hypertension were prospectively studied between 2014 and 2017. The impact of Lp(a) on preoperative day 1 and postoperative days (PODs) 1, 3, 5, 7, and 14 was analyzed. Color Doppler ultrasound examination was performed for the diagnosis of PSVT. The median interval between surgery and postoperative PSVT was 6 days (range: 2-13 days). The levels of Lp(a) were highly increased in patients with PSVT and significant intergroup differences (vs non-PSVT) were found until day 3 and day 5 after operation, respectively. On POD 3, at a threshold of 309.06 mg/L, Lp(a) was a better predictor of PSVT (area under the curve [AUC] = 0.872) compared to the levels on PODs 1, 5, and 7 (AUC = 0.775, 0.796, and 0.791, respectively). The median Lp(a) values peaked at 382.5 mg/L on POD 5 for patients without PSVT. After POD 5, the Lp(a) decreased with values at 347.4 mg/L on POD 7 and 150.7 mg/L on POD 14. For the first time, Lp(a) was shown to be abnormal in patients with PSVT following splenectomy. Monitoring of serum Lp(a) levels on POD 3 might represent a valuable tool to predict early PSVT after splenectomy in cirrhotic patients.

Increased portal vein diameter is predictive of portal vein thrombosis development in patients with liver cirrhosis

Background

Cirrhotic patients with portal vein thrombosis (PVT) may have a high risk of hepatic decompensation and increased mortality. This study aimed to investigate if increased portal vein diameter is associated with PVT development.

Methods

A total of 174 cirrhotic patients were enrolled between February 1 and August 31, 2017. All participants were divided into PVT (n=62) and non-PVT (n=112) groups based on the thrombus that was detected by ultrasonography and confirmed by computed tomography angiography (CTA).

Results

The study participants, aged 54.7±10.5 years (PVT) and 55.8±11.6 years (non-PVT), were included in this analysis. The Child-Pugh score of PVT or non-PVT was 6.6±1.3 and 5.8±0.9, respectively. Hepatitis B virus (HBV) is the primary etiological agent of cirrhosis. Logistic regression, receiver operating characteristic (ROC), and nomograph analysis designated portal diameter as the strongest independent risk factor for predicting PVT development [odds ratio (OR): 3.96, area under the ROC curve (AUC): 0.88; P<0.01], and the cutoff with predictive value for PVT development was >12.5 mm. No differences were observed in the overall survival (OS) in cirrhosis with or without PVT or stratifying on portal diameter based on the cutoff value.

Conclusions

Increased portal diameter is associated with an increased risk of PVT development. Patients with cirrhosis and increased portal diameter are a high-risk subgroup that may need thromboprophylaxis.

Risk factors and impact of portal vein thrombosis in liver transplantation

INTRODUCTION

portal vein thrombosis is a relatively common complication of advanced cirrhosis that increases perioperative risk in liver transplant recipients. This condition was characterized in a cohort of patients, including risk factors and their influence on survival.

MATERIAL AND METHODS

a retrospective study of liver transplant recipients at the Clínica Universidad de Navarra was performed between 2000 and 2015. Differences in clinical and biological characteristics and survival were analyzed in subjects with and without portal vein thrombosis. A predictive index was also developed.

RESULTS

a total of 288 patients were included in the study, portal vein thrombosis was recorded in 46 (16%) cases and seven (15.2%) had stage 3/4 disease according to Yerdel's classification. Factors associated with the presence of esophageal/gastric varices (OR = 3.7; p = 0.03) included variceal ligation or sclerotherapy (OR = 2.3; p = 0.01), being overweight/obesity (OR = 2.1; p = 0.04) and thrombocytopenia (OR = 3.6; p = 0.04). There were no significant differences between the groups with and without portal vein thrombosis in terms of survival according to Kaplan-Meier curve analysis (p = 0.7). However, the mortality rate was higher for Yerdel stages 3-4 (p < 0.01). A predictive index was developed that included varices, body mass index (BMI), thrombocytopenia and activated partial thromboplastin time (APTT). This index had a sensitivity of 76.1% and a specificity of 53.7% for the development of portal thrombosis.

CONCLUSIONS

the presence of esophageal/gastric varices, variceal ligation/sclerotherapy, thrombocytopenia and being overweight/obesity was associated with a higher rate of portal vein thrombosis. Advanced stages had an impact on survival.

Acute Portal Vein Thrombosis Treated with Recombinant Human Soluble Thrombomodulin Combined with Antithrombin III

Portal vein thrombosis is a major complication associated with liver cirrhosis. In cirrhotic patients, a decrease in procoagulant and anticoagulant factors and an unstable balance between them is observed, and a relative decrease in the activation of anticoagulant drivers is one of the main causes of portal vein thrombosis (PVT). Herein, we report a case of acute portal thrombosis associated with liver cirrhosis and treated with a recombinant form of soluble thrombomodulin (thrombomodulin alpha, TM-α) in combination with antithrombin III. TM-α was administered in accordance with the dosage and route of administration for disseminated intravascular coagulation therapy and resulted in dissolution of PVT with a gradual decrease in D-dimer levels. No adverse events were observed during the course of treatment. In the future, in addition to conventional anticoagulation therapy using heparin or antivitamin K drugs, novel therapies targeting protein C activation using a recombinant form of soluble thrombomodulin may play an important role in the treatment of acute PVT.

Predictive value of D-dimer testing for the diagnosis of venous thrombosis in unusual locations: A systematic review

BACKGROUND

The value of D-dimer testing for the diagnosis of thrombosis in unusual sites is not properly established and evidence is scarce. We performed a systematic review of the literature.

METHODS

The search was conducted in MEDLINE and Cochrane Library for papers published in the last 10 years including different presentations of thrombosis in unusual sites. Twenty-three articles were included, from January 1, 2008, to December 31, 2018, comprising 3378 patients with thrombosis in unusual sites (upper extremity deep vein thrombosis, cerebral vein thrombosis and splanchnic vein thrombosis). The Newcastle-Ottawa scale was used to assess the quality of the studies.

RESULTS

Two articles were related to upper extremity thrombosis, showing a high sensitivity and negative predictive value for D-dimer testing. Twelve articles concerned cerebral vein thrombosis, concluding that the timing of D-dimer testing was important, and that patients with a shorter duration of symptoms showed higher D-dimer levels. Sensitivity and specificity in these patients ranged from 58% to 97% and from 77% to 97.5%, respectively. Nine articles were related to splanchnic vein thrombosis. One described a population of patients with mesenteric venous thrombosis, and the rest included patients with portal vein thrombosis. The D-dimer testing methods and the proposed cut-off levels were remarkably different among the included studies.

CONCLUSION

D-dimer testing should not be currently recommended for the diagnosis of thrombosis in unusual sites as a first line diagnostic tool. The development of algorithms combining biomarkers such as D-dimer and clinical decision tools could improve the diagnosis.

Heparin-like Effect Associated With Risk of Bleeding, Sepsis, and Death in Patients With Severe Alcohol-Associated Hepatitis

BACKGROUND & AIMS

Endogenous heparinoids or heparin-like effects (HLEs) can cause coagulation failure in patients with cirrhosis and sepsis. We performed a prospective study of the association between HLE and bleeding events, sepsis, and outcomes of patients with severe alcohol-associated hepatitis.

METHODS

Our final analysis comprised 78 patients with severe alcohol-associated hepatitis (44.3 ± 11.7 years; all male; discriminant function >32) who presented without sepsis at a single center in India from August 2015 through August 2016. Blood samples were collected at days 0, 3, and 7 after presentation and assessed by a global coagulation assay; by SONOCLOT (global and heparinase treated); and in assays for factor VIII, von Willebrand factor, protein C, and antithrombin. Patients were followed for sepsis, bleeding and outcome. The primary outcome was association of HLE with survival 28 days after presentation.

RESULTS

HLEs were observed in 32 patients (41%) at day 0, 27 patients (34.6%) at day 3, and 28 patients (35.9%) patients at day 7. Factors associated with mortality at day 0 were factor VIII activity >160% (hazard ratio [HR], 3.1; 95% CI, 1.4-9.5; P = .026), level of protein C <34% (HR, 0.7; 95% CI, 0.5-0.8; P = .037), antithrombin activity <28% (HR, 0.7; 95% CI, 0.3-1.1; P = .008) and international normalized ratio >2.6 (HR, 2.3; 95% CI, 1.8-9.7; P = .010). In multivariate analyses, only factor VIII activity (HR, 2.3; 95% CI, 1.6-7.8; P = .046), international normalized ratio (1.9; 95% CI, 1.2-4.3; P = .039), level of protein C (HR, 0.9; 95% CI, 0.7-1.1; P = .052) and model for end-stage liver disease score (HR, 3.2; 95% CI, 1.9-10.2; P = .042) were associated with mortality. Episodes of epistaxis, hemorrhoid bleeding, hemoperitoneum, and pulmonary hemorrhage occurred in 10.2%, 12.3%, 3.4%, and 4.5% of patients respectively. The presence of HLE at day 0 increased the risk of sepsis (HR, 2.5; 95% CI, 2.2-4.3; P = .002), bleeding (HR, 1.4; 95% CI, 1.2-5.3; P = .004) and death (HR, 1.2; 95% CI, 1.4-1.7; P = .044).

CONCLUSIONS

In a prospective study of patients with severe alcohol-associated hepatitis, we associated HLE with coagulation abnormalities, risk of sepsis, and mortality. Clinicaltrials.govNCT02307409.

Plasma D-dimer as a novel biomarker for predicting poor outcomes in HBV-related decompensated cirrhosis

This study aim was to evaluate whether plasma D-dimer levels could serve as a novel prognostic biomarker for 1-month mortality in patients with HBV-related decompensated cirrhosis (HBV-DeCi).This was a retrospective study that enrolled 132 HBV-DeCi patients. Univariate and multivariate regression models were used to identify risk factors for mortality. The area under the receiver operating characteristic curve was calculated to estimate and compare the predictive values of different prognostic markers.In the present study, the plasma D-dimer levels were higher in the nonsurviving group than in the surviving group. Additionally, the D-dimer level was positively correlated with the model for end-stage liver disease (MELD) score. The results of multivariate analysis showed that both the MELD score and D-dimer level are independent predictors of 1-month mortality in HBV-DeCi patients (both P < .01).Plasma D-dimer can be considered a new additional prognostic marker for 1-month mortality in HBV-DeCi patients.

Portal vein thrombosis in cirrhosis: Why a well-known complication is still matter of debate

Portal vein thrombosis (PVT) represents a well-known complication during the natural course of liver cirrhosis (LC), ranging from asymptomatic cases to life-threating conditions related to portal hypertension and hepatic decompensation. Portal flow stasis, complex acquired hypercoagulable disorders and exogenous factors leading to endothelial dysfunction have emerged as key factors for PVT development. However, PVT occurrence remains unpredictable and many issues regarding its natural history, prognostic significance and treatment are still elusive. In particular although spontaneous resolution or disease stability occur in most cases of PVT, factors predisposing to disease progression or recurrence after spontaneous recanalization are not clarified as yet. Moreover, PVT impact on LC outcome is still debated, as PVT may represent itself a consequence of liver fibrosis and hepatic dysfunction progression. Anticoagulation and transjugular intrahepatic portosystemic shunt are considered safe and effective in this setting and are recommended in selected cases, even if the safer therapeutic option and the optimal therapy duration are still unknown. Nevertheless, their impact on mortality rates should be addressed more extensively. In this review we present the most debated questions regarding PVT, whose answers should come from prospective cohort studies and large sample-size randomized trials.

Preoperative D-dimer and Gamma-Glutamyltranspeptidase Predict Major Complications and Survival in Colorectal Liver Metastases Patients After Resection

OBJECTIVES: To investigate the predictive value of the pre-operative D-dimer and gamma-glutamyltranspeptidase (GGT) for the prognosis in colorectal liver metastases (CRLM) patients after hepatic resection. METHODS: Two hundred and ninety-two patients between December 2008 and December 2016 and 101 patients at our center from January 2017 to December 2018 were selected as a training set and validation set, respectively. The combination of the pre-operative D-dimer and GGT status (CPDG score) was scored as follows: elevated D-dimer levels with elevated GGT levels was allocated a score of 2, decreased D-dimer levels with decreased GGT levels was allocated a score of 0, and all other combinations were allocated a score of 1. In the training set, a logistic regression was applied to explore potential predictors of major postoperative complications. A Cox proportional hazards analysis was used to analyze survival. We further verified our findings in the validation set. RESULTS: Major complications occurred in 43 (14.7%) and 25 (24.8%) patients in the training set and validation set, respectively. In the training set, multivariate analysis showed that elevated GGT levels and elevated D-dimer levels independently predicted major complications respectively. In the multivariate analyses, elevated pre-operative D-dimer levels remained independently associated with decreased overall survival (OS) (hazard ratio [HR] = 1.751, 95% confidence interval [CI]: 1.139-2.691, P = .01). The CPDG score was an independent prognostic factor for major complications and OS in the multivariate analyses. The predictive ability of the CPDG score was higher than either factor alone. A Kaplan-Meier survival analysis showed that compared with patients with CPDG score = 1 or CPDG score = 0, patients with a CPDG score = 2 had worsened OS. Furthermore, for OS comparisons, the differences between any two groups were significant. In the validation set, elevated GGT and D-dimer were also suggested to predict worse progression-free survival (PFS) and to be independently associated with major complications. CONCLUSIONS: The pre-operative D-dimer levels, GGT levels and CPDG score are reliable biomarkers to predict post-operative major complications or survival in CRLM patients after hepatic resection, which make it useful for CRLM patients in guiding surveillance approaches and prognosis assessments.

The risk factors of portal vein thrombosis in patients with liver cirrhosis

This study was designed to identify and assess risk factors for portal vein thrombosis (PVT) in patients with cirrhosis. A total of 98 cirrhosis patients with PVT were identified and 101 cirrhosis patients without PVT were chosen as the control group in this retrospective study. Several variables were measured and the two groups PVT and non-PVT were compared statistically. PVT was identified in 98 patients (10%). Significant differences in hematocrit, international normalized ratio, albumin, bilirubin and glucose were determined between the groups (P<0.05). Out of the thrombophilic risk factors in the patients with PVT factor V Leiden was identified in 8.8%, prothrombin gene 6.6% and methylenetetrahydrofolate reductase 2.2%. There was no difference in survival time between groups (P>0.05).

D-dimer plasmatic levels as a marker for diagnosis and prognosis of hepatocellular carcinoma patients with portal vein thrombosis

Purpose

Portal vein thrombosis (PVT) is one of the severe complications of hepatocellular carcinoma (HCC). PVT deteriorates the liver, and its dysfunction increases the risk of bleeding, influencing the prognosis of patients with liver cirrhosis and HCC. The aim of our study was to investigate whether D-dimer testing could be a sensitive marker for the diagnosis and prognosis of HCC patients with PVT.

Patients and methods

Between June 2010 and December 2015, 118 HCC patients were admitted to Cannizzaro Hospital, Catania, and 50 controls were recruited from their relatives for health examinations. All enrolled patients were diagnosed and pathologically confirmed as having HCC. D-dimer was measured with an enzyme-linked immunosorbent assay using 2 monoclonal antibodies against nonoverlapping determinants of D-dimer.

Results

D-dimer levels in HCC patients with PVT were significantly higher vs HCC patients without PVT, P<0.002, and vs controls, P<0.001.

Conclusion

Plasma D-dimer is a sensitive marker of fibrin turnover and allows for the recognition of activated coagulation which may be manifested in HCC with PVT.

D-dimer level in liver transplant recipients on the first day after surgery is correlated with postoperative thrombosis recurrence

OBJECTIVE

This study aimed to investigate the relationship between plasma D-dimer level, preoperative complications, and thrombosis in liver transplant recipients.

METHODS

The clinical data of 525 liver transplant recipients with end-stage liver disease (ESLD) in the First Affiliated Hospital of Zhejiang University from October 2012 to December 2015 were retrospectively analyzed. The patients were grouped based on thrombosis before and after surgery to determine the risk factors for postoperative thrombosis recurrence.

RESULTS

Of the preoperative complications assessed, esophageal varices and thrombosis were significantly correlated (P = 0.000); ascites, spontaneous bacterial peritonitis, and hepatic encephalopathy were significantly correlated with preoperative D-dimer level (P < 0.001, P < 0.001, and P = 0.002, respectively); during the first week after surgery, the D-dimer level was significantly and consecutively higher than that before surgery and was significantly higher in the group with both preoperative and postoperative thrombosis than in the other groups on the first day after surgery (P < 0.001); the area under the curve (AUC) for diagnosis of postoperative thrombosis recurrence in the preoperative thrombosis group using plasma D-dimer level on the first day after surgery was 0.698 (P = 0.001); Cox regression analysis showed that D-dimer was an independent risk factor for postoperative thrombosis recurrence (HR = 3.062, P = 0.029).

CONCLUSION

D-dimer level on the first day after liver transplant is related to thrombosis recurrence and is an independent risk factor for postoperative thrombosis recurrence.

P-Selectin Level at First and Third Day After Portal Hypertensive Splenectomy for Early Prediction of Portal Vein Thrombosis in Patients With Cirrhosis

We aimed to investigate the changes in p-selectin (p-sel), thrombus precursor protein, and D-dimer (D-D) in patients with cirrhosis after portal hypertensive splenectomy and explore its values on the prediction of postoperative portal vein thrombosis (PVT) formation. A total of 144 patients with cirrhosis with portal hypertension who underwent portal hypertensive splenectomy from January 2009 to December 2016 were enrolled in this study and divided into the thrombus and nonthrombus groups. The levels of p-sel, thrombus precursor protein (TpP), and D-D were measured by flow cytometry, enzyme-linked immunosorbent assay, and immunoturbidimetry, respectively. Sensitivity, specificity, and other values for p-sel, TpP, and D-D were calculated. The linear discriminant, logistic regression, and decision tree methods were used to analyze the p-sel value on the prediction of PVT formation. Seventy-nine patients were confirmed having postoperative PVT, with the incidence rate of 54.86%. No significant differences were observed in the p-sel, TpP, and D-D between the thrombus and nonthrombus groups before surgery, but these 3 indexes were obviously elevated in the thrombus group after operation (P < .01). P-selectin level on first day showed the highest positive predictive value (91.0%) and diagnostic coincidence rate (83.3%), while negative expected value (76.6%) was lower than those of TpP and D-D. Multiple analyses showed the prediction accuracy of PVT was 61.1% (P = .023), 97.2% (P < .001), and 97.2% (P < .001), respectively. P-selectin has a significant value in predicting PVT. P-selectin level on first and third day is valuable and feasible for the early prediction of PVT.

[Anticoagulation in Patients with Liver Cirrhosis]

Cirrhotic patients have bleeding tendencies due to the lack of coagulation factors and thrombocytopenia. However, decreased levels of procoagulants are also accompanied by decreased levels of natural anticoagulants. However, there have been contrasting reports. It has been reported that patients with cirrhosis are at risk for thrombotic complications, including portal vein thrombosis and venous thromboembolism. Physicians consider active anticoagulation for prophylaxis and treatment of portal vein thrombosis and/or venous thromboembolism in cirrhotic patients with high risk of thrombosis. Concurrently, there are safety concerns regarding the risk of bleeding from anticoagulants in people with advanced liver disease. Further prospective studies are required to determine not only if cirrhotic patients benefit from receiving anticoagulation therapy for preventing thrombotic complications, but also to determine which prophylactic regimen is most appropriate.

Hemostasis, bleeding and thrombosis in liver disease

The presence of cirrhosis poses an increased risk of both thrombosis and bleeding in individuals with chronic liver disease. This duality is a result of a dynamic disequilibrium between procoagulant and anticoagulant states in individuals with cirrhosis. The mechanism of this imbalance in cirrhosis remains unclear. It is known that the progression of cirrhosis leads to decreased synthetic function and a concurrent lack of natural anticoagulants. Other proposed mechanisms contributing to this hemostatic imbalance include decreased platelet production, increased platelet destruction from hypersplenism, decreased synthesis of Vitamin K-dependent and independent clotting factors and anticoagulant factors, and alterations in purinergic signaling pathways.

Given the current state of flux in our understanding of bleeding and thrombophilia in cirrhosis, the recommendations for treatment of these conditions are still evolving.

We provide a current update on the proposed pathophysiology of altered hemostasis and thrombophilia in cirrhosis. We discuss recent studies in portal vein thrombosis (PVT) and venous thromboembolism (VTE), which are the common thrombotic consequences of cirrhosis, resulting in substantive morbidity and mortality. To address these, we discuss new prophylactic interventions and current treatment options to manage the heightened risk of thrombosis in cirrhosis, while limiting hemorrhagic complications.

Risk factors for portal vein thrombosis in cirrhotic patients: A meta-analysis

AIM

To identify the risk factors for portal vein thrombosis (PVT) in cirrhotic patients.

METHODS

We searched the PubMed, CNKI and Wanfang Databases up to Aug 2015 to retrieve case-controlled studies about the risk factors for PVT in cirrhotic patients for meta-analysis. The odds ratio or weighted mean difference (WMD) of each risk factor was estimated and the 95% confidence interval (95%CI) was calculated. RevMan 5.0 software provided by the Library of Cochrane was used for meta-analysis.

RESULTS

Nine case-controlled studies were included. The risk factors for PVT included D-dimer (WMD = 0.34, 95%CI: 0.21-0.46), portal vein diameter (WMD = 1.67, 95%CI: 1.36-1.97), portal venous flow [WMD = -2.32, 95%CI: -3.63-(-1.01)], and splenic thickness (WMD = 8.57, 95%CI: 4.14-12.99). There were no significant differences between patients with and without PVT in terms of sex, age, platelet, prothrombin time, activated partial thromboplastin time, and fibrinogen.

CONCLUSION

The risk factors for PVT in cirrhotic patients include D-dimer, portal vein diameter, portal venous flow, and splenic thickness.

Portal vein thrombosis in cirrhosis is not associated with intestinal barrier disruption or increased platelet aggregability

OBJECTIVE

Portal vein thrombosis (PVT) is a common complication of cirrhosis, but its pathogenesis is unclear. We tested the hypotheses that PVT is the result of platelet hyperactivity or intestinal barrier disruption.

METHODS

This study included 49 patients with cirrhosis (15 females) of mixed etiology. Based on spiral computed-tomography, the patients were divided into two groups: with PVT (n=16) and without PVT (n=33). Serum biomarkers of intestinal barrier integrity were endotoxins and zonulin, and platelet activity was assessed with multiple electrode aggregometry.

RESULTS

The levels of endotoxin (43.5±18.3ng/ml vs. 36.9±7.5ng/ml; P=0.19) and zonulin (56.3±31.1ng/ml vs. 69.3±63.1ng/ml; P=0.69) were not different between the patients with and without PVT. Moreover, endotoxin and zonulin did not correlate with the coagulation and platelet parameters. The platelet aggregability measured with the TRAP and the ADP tests was decreased in PVT patients. In the logistic regression analysis the PVT incidence was related to the levels of D-dimer and bilirubin as well as the TRAP test results. Patients with PVT presented with significantly higher levels of D-dimer (4.45±2.59 vs. 3.03±2.97mg/l; P<0.05) and prothrombin levels (175±98.8μg/ml vs. 115±72.9μg/ml; P<0.05) than patients without thrombosis. PVT could be excluded with a 90% negative predictive value when the D-dimer level was below 1.82mg/l.

CONCLUSIONS

Endotoxemia and platelet activity are not determinants of PVT in patients with cirrhosis. The D-dimer measurement has diagnostic significance for PVT in patients with liver cirrhosis.

Is Post-TIPS Anticoagulation Therapy Necessary in Patients with Cirrhosis and Portal Vein Thrombosis? A Randomized Controlled Trial

Purpose To determine whether posttransjugular intrahepatic portosystemic shunt (TIPS) placement anticoagulation therapy could benefit patients with cirrhosis and portal vein thrombosis (PVT) from the perspective of a change in portal vein patency status and clinical outcomes. Materials and Methods The study was approved by the institutional review board, and informed consent was obtained from each patient. From October 2012 to February 2014, patients with cirrhosis and PVT who underwent TIPS placement were randomly assigned to the anticoagulation therapy or control group. All patients were followed at 1, 3, 6, and 12 months after the TIPS procedure. Outcome measures were a change of portal vein patency status and clinical measures including gastrointestinal rebleeding, shunt dysfunction, hepatic encephalopathy, and survival. Student t test, χ(2) test, Fisher exact test, Mann-Whitney U test, and logistical regression were applied where appropriate. Results A total of 64 patients were enrolled in the study, with 31 allocated to the anticoagulation group and 33 allocated to the control group. Overall, thrombi were improved in 61 patients (96.8%) after the procedure. PVT recanalization (ie, complete disappearance; reconstruction of cavernous transformation) was achieved in 26 patients (83.9%) in the anticoagulation therapy group and in 23 (71.8%) patients in tthe control group (P = .252). The presence of a superior mesenteric vein thrombus may help predict recanalization failure (unadjusted relative risk = 0.243; 95% confidence interval: 0.070, 0.843; P = .026). Clinical outcomes were also similar between the two groups. Conclusion Anticoagulation therapy may not be necessary in certain patients with PVT because TIPS placement alone can achieve a high persistent recanalization rate. (©) RSNA, 2015.

Thrombotic Venous Diseases of the Liver

Thrombotic venous diseases of the liver do not occur frequently, but when they do, they can present as difficult diagnostic and therapeutic challenges. The aim of this article is to review the epidemiology, pathogenesis, diagnosis, and therapeutic options of these serious vascular problems.

Procoagulant imbalance aggravated with falling liver function reserve, but not associated with the presence of portal vein thrombosis in cirrhosis

OBJECTIVES

Hypercoagulability, hemodynamic changes, and endothelial injury are the three major contributors to the development of thrombosis. However, the role of hypercoagulability in portal vein thrombosis (PVT) in liver cirrhosis is still controversial. The aim of this study is to elucidate the relationship between procoagulant imbalance and PVT in patients with liver cirrhosis.

METHODS

This study included 151 patients with cirrhosis with (n=20) or without PVT (n=131). Levels of procoagulant factor (FVIII) and anticoagulants [protein C (PC), protein S (PS), and antithrombin (AT)] were measured. Procoagulant imbalance was also evaluated using a thrombin generation test with/without Protac and the results were expressed as Protac-induced coagulation inhibition percentage (PICI%). The lower the PICI% value, the greater the procoagulant imbalance.

RESULTS

The levels of PC (P<0.001), PS (P<0.05), and AT (P<0.001) decreased progressively from Child-Pugh A to C in all patients, whereas the levels of FVIII did not alter with the severity of cirrhosis (P>0.05), which indicated the balance tilting toward procoagulation in liver cirrhosis. Similarly, the PICI% values decreased from Child-Pugh A to C (P<0.001). However, there were no differences in the levels of PC, PS, AT, FVIII or PICI% between patients with and without PVT (P>0.05), even after stratification by Child-Pugh classification (P>0.05).

CONCLUSION

Procoagulant imbalance is not associated with the presence of PVT in patients with cirrhosis, although the imbalance worsens with the severity of cirrhosis.

Role of D-dimer in the Development of Portal Vein Thrombosis in Liver Cirrhosis: A Meta-analysis

BACKGROUND AND AIMS

A meta-analysis was performed to explore the role of the D-dimer in the development of portal vein thrombosis (PVT) in liver cirrhosis.

METHODS

All papers were searched via PubMed, EMBASE, China National Knowledge Infrastructure, Wan Fang, and VIP databases. A standardized mean difference (SMD) with 95% confidence interval (CI) was pooled.

RESULTS

Overall, 284 studies were initially identified, of which 21 were included. Cirrhotic patients with PVT had a significantly higher D-dimer concentration than those without PVT (pooled SMD = 1.249, 95%CI = 0.740-1.758). After the portal hypertension-related surgery, cirrhotic patients with PVT had a similar preoperative D-dimer concentration to those without PVT (pooled SMD = 0.820, 95%CI = -0.122-0.286), but a higher postoperative value of D-dimer concentration than those without PVT (pooled SMD = 2.505, 95%CI = 0.975-4.036). Notably, the D-dimer concentration at the 1 st postoperative day was similar between cirrhotic patients with and without PVT (pooled SMD = 0.137, 95%CI = -0.827-1.101), but that at the 7 th post-operative day was higher in cirrhotic patients with PVT than in those without PVT (pooled SMD = 1.224, 95%CI = 0.277-2.171).

CONCLUSION

D-dimer might be regarded as a diagnostic marker for PVT in liver cirrhosis. In addition, postoperative D-dimer testing is worthwhile for the diagnosis of PVT after portal hypertension-related surgery.

Microbiome Disturbances and Autism Spectrum Disorders

Autism spectrum disorders (ASDs) are considered a heterogenous set of neurobehavioral diseases, with the rates of diagnosis dramatically increasing in the past few decades. As genetics alone does not explain the underlying cause in many cases, attention has turned to environmental factors as potential etiological agents. Gastrointestinal disorders are a common comorbidity in ASD patients. It was thus hypothesized that a gut-brain link may account for some autistic cases. With the characterization of the human microbiome, this concept has been expanded to include the microbiota-gut-brain axis. There are mounting reports in animal models and human epidemiologic studies linking disruptive alterations in the gut microbiota or dysbiosis and ASD symptomology. In this review, we will explore the current evidence that gut dysbiosis in animal models and ASD patients correlates with disease risk and severity. The studies to date have surveyed how gut microbiome changes may affect these neurobehavioral disorders. However, we harbor other microbiomes in the body that might impact brain function. We will consider microbial colonies residing in the oral cavity, vagina, and the most recently discovered one in the placenta. Based on the premise that gut microbiota alterations may be causative agents in ASD, several therapeutic options have been tested, such as diet modulations, prebiotics, probiotics, synbiotics, postbiotics, antibiotics, fecal transplantation, and activated charcoal. The potential benefits of these therapies will be considered. Finally, the possible mechanisms by which changes in the gut bacterial communities may result in ASD and related neurobehavioral disorders will be examined.

Prominent protein Z-induced thrombin inhibition in cirrhosis: a new functional assay for hypercoagulability assessment

BACKGROUND AND AIMS

Protein Z (PZ) is an anticoagulant that accelerates the inhibitory effect of PZ-dependent protease inhibitor (ZPI) on coagulation factor Xa. We assessed functional status of PZ system in 158 patients with liver cirrhosis and 59 healthy controls.

METHODS

Plasma PZ and ZPI levels were measured by enzyme immunoassay. Thrombin generation assays (TGA) were performed with and without thrombomodulin (TM) or PZ, and the ratios were calculated by dividing TGA values with TM or PZ by values without TM or PZ.

RESULTS

PZ and ZPI levels were reduced and elevated in advanced cirrhosis, respectively. The lag time ratio-PZ was significantly higher in cirrhosis patients than controls and correlated with the model for end-stage liver disease score. The peak thrombin ratio-PZ and endogenous thrombin potential (ETP) ratio-PZ were significantly lower in cirrhosis patients than controls and correlated with the severity of liver cirrhosis. The peak thrombin ratio-PZ was dramatically reduced in advanced cirrhosis. Cirrhosis patients had a significantly higher ETP ratio-TM than the controls, although the ratio was not correlated with cirrhosis severity. The lag time ratio-PZ and peak time ratio-PZ were significantly correlated with the levels of all coagulation and anticoagulation factors. Interestingly, the lag time ratio-PZ and peak thrombin ratio-PZ were significantly associated with thrombotic events.

CONCLUSION

The anticoagulant role of PZ is insufficient in advanced stages of cirrhosis. Our newly developed functional assay for measuring the PZ system is expected to reflect the ongoing hypercoagulability of cirrhosis.

Early joint application of anticoagulant drugs to prevent portal vein thrombosis after splenectomy and devascularization

AIM: To assess the preventive effects of early joint application of anticoagulant drugs on portal vein thrombosis after splenectomy and devascularization and to explore the possible mechanism

METHODS: One hundred and twenty-eight patients with portal hypertension who underwent splenectomy and devascularization were included, including 28 patients with early application of low molecular heparin calcium (heparin group), 42 with joint application of low molecular heparin calcium and low molecular dextran (joint group), and 58 without the use of anticoagulant drugs (control group). The rate of postoperative thrombosis, postoperative platelet count, and prothrombin time (PT) were compared among the three groups. The indexes of portal vein blood flow were also recorded.

RESULTS: One month after surgery, portal vein thrombosis developed in 5 (8.57%) cases in the heparin group, in 1 (2.38%) case in the joint group, and in 14 (24.13%) cases in the control group. The rate of postoperative portal vein thrombosis was significantly higher in the control group than in the heparin group (P < 0.05), and in the heparin group than in the joint group (P < 0.05).

CONCLUSION: Early anticoagulation use can effectively prevent the formation of portal vein thrombosis after splenectomy, and combined use of low molecular heparin calcium and low molecular dextran has better effects.

Association between D-dimer level and portal venous system thrombosis in liver cirrhosis: a retrospective observational study

OBJECTIVE

This study aimed to explore the association between D-dimer levels and presence of portal venous system thrombosis (PVST) in liver cirrhosis.

METHODS

All consecutive patients with a diagnosis of liver cirrhosis who underwent D-dimer test were retrospectively enrolled. Normal reference range of D-dimer level was 0-0.3 µg/mL. PVST was diagnosed on the basis of contrast-enhanced computed tomography and/or magnetic resonance imaging scans.

RESULTS

Of the 66 included patients, 24 were diagnosed with PVST. Mean D-dimer level was 0.51±0.72 µg/mL (range: 0.10-3.44). Mean D-dimer level was not significantly different between PVST and non-PVST groups (0.68±0.93 µg/mL versus 0.41±0.56 µg/mL, P=0.146). Area under the receiver operating curve for D-dimer level for predicting the presence of PVT was 0.606 (95% confidence interval: 0.478-0.724, P=0.1393). The optimal cut-off value for D-dimer was 0.22 with a sensitivity of 58.3% and a specificity of 69.0%. The subgroup analyses of patients without splenectomy or those with different Child-Pugh classes demonstrated no significant difference in the D-dimer level between PVST and non-PVST groups.

CONCLUSION

D-dimer might not be useful to identify the presence of PVST in liver cirrhosis. However, given the retrospective nature of this study, further well-designed prospective study should be necessary to confirm this finding.

Management of portal vein thrombosis in liver cirrhosis

Portal vein thrombosis (PVT) is a fairly common complication of liver cirrhosis. Importantly, occlusive PVT might influence the prognosis of patients with cirrhosis. Evidence from a randomized controlled trial has shown that anticoagulation can prevent the occurrence of PVT in patients with cirrhosis without prior PVT. Evidence from several case series has also demonstrated that anticoagulation can achieve portal vein recanalization in patients with cirrhosis and PVT. Early initiation of anticoagulation therapy and absence of previous portal hypertensive bleeding might be positively associated with a high rate of portal vein recanalization after anticoagulation. However, the possibility of spontaneous resolution of partial PVT questions the necessity of anticoagulation for the treatment of partial PVT. In addition, a relatively low recanalization rate of complete PVT after anticoagulation therapy suggests its limited usefulness in patients with complete PVT. Successful insertion of a transjugular intrahepatic portosystemic shunt (TIPS) not only recanalizes the thrombosed portal vein, but also relieves the symptomatic portal hypertension. However, the technical difficulty of TIPS potentially limits its widespread application, and the risk and benefits should be fully balanced. Notably, current recommendations regarding the management of PVT in liver cirrhosis are insufficient owing to low-quality evidence.

Does decreased fibrinolysis have a role to play in the development of non-neoplastic portal vein thrombosis in patients with hepatic cirrhosis?

Hepatic cirrhosis is characterized by complex abnormalities of the fibrinolytic system. Little is known about the possible association between these alterations and thrombosis. The aim of this study was to evaluate the fibrinolytic profile in cirrhotic individuals with and without portal vein thrombosis (PVT). We measured thrombin activatable fibrinolysis inhibitor (TAFI), total amount of activated TAFI (TAFIa/ai), plasminogen activator inhibitor (PAI-1), plasminogen and fibrinogen plasma levels in 66 cirrhotic patients (33 with and 33 without PVT) and in 66 healthy volunteers. TAFI plasma levels (median [range]) were significantly lower in cirrhotic individuals (5.6 μg/ml [1.7-11.7]) than in controls (10.1 μg/ml [6.6-14.2], p < 0.0001), while TAFIa/ai levels were significantly higher in cases (18.3 ng/ml [0.3-35.4]) than in controls (15.9 ng/ml [7.4-41], p = 0.02). Cirrhotic patients with PVT had higher TAFI (6.6 μg/ml [2.9-10.1]), TAFIa/ai (19.2 ng/ml [11.6-35.4]) and PAI-1 (33.1 ng/ml [27.6-56.3]) plasma levels than those without PVT (3.9 μg/ml [1.7-11.7], p = 0.001; 15.6 ng/ml [10.3-33.9], p = 0.037; 15.9 ng/ml [2.5-29.1], p = 0.004. The fibrinolytic profile in cirrhotic individuals with PVT is characterized by higher levels of TAFI, TAFIa/ai and PAI-1 than in those without PVT. These alterations identify a hypofibrinolytic condition that may increase the risk of developing a thrombotic event.

Point of care perioperative coagulation management in liver transplantation and complete portal vein thrombosis

Liver transplantation (LT) is a serious hemostatic challenge in patients with portal vein thrombosis (PVT). Advances in monitoring systems have improved surgery in this setting. We report the successful application of a point-of-care (POC) rotational viscoelastic thromboelastometry-guided (TEM) testing system (ROTEM) which allowed management of coagulation during LT in a 64-year-old cirrhotic patient with a model for end-stage liver disease (MELD) score of 16. Perioperatively, the patient showed complete PVT, hepatomegaly, splenomegaly, recanalization of the umbilical vein, and portosystemic shunt. Macroscopic liver and spleen adherences with collateral circulation were evident. Coagulation factors and fibrinolysis were assessed preoperatively and at graft reperfusion to evaluate the need of hemostatic therapy. Based on ROTEM findings, the patient received 16 g of human fibrinogen concentrate, half preoperatively (with prothrombin complex concentrate 2000 IU, tranexamic acid 1 g, and platelets 2 IU), and two doses of 4 g before and after graft reperfusion; we achieved normalization of all monitored parameters. No ischemia-reperfusion syndrome was present. Postoperatively portal vein flux at Color-Doppler ultrasonography was normal. After a 3-day ICU stay, the patient was moved to the Department of Surgery and discharged on day 14. The postoperative course was uneventful and did not require any further haemostatic therapy.

Higher prognostic value of soluble fibrin complexes than D-dimer and fibrin degradation product for disseminated intravascular coagulation in patients with liver cirrhosis

Fibrin-related markers may help differentiate disseminated intravascular coagulation (DIC) from liver cirrhosis-associated dysfunctional coagulation. We investigated the significance of three fibrin-related markers [D-dimer, fibrin degradation product (FDP), and soluble fibrin complexes (sFC)] for the assessment of DIC status and prognosis. We classified 235 patients with suspected DIC into two groups according to their condition: the liver cirrhosis group (n = 47) and the no liver cirrhosis group (n = 188). Prothrombin time (PT), and fibrinogen, sFC, D-dimer, antithrombin, and protein C concentrations were measured and DIC scores were calculated using four parameters: platelet count, D-dimer, fibrinogen, and PT. In the liver cirrhosis group, the sFC concentration increased significantly in accordance with DIC score compared with the no liver cirrhosis group, and this increase was more prominent than D-dimer and FDP concentration increases. For the diagnosis of overt DIC in patients with liver cirrhosis, the area under the concentration curve (AUC) was larger for sFC (0.746) than for D-dimer (0.733) and FDP (0.687). Cox analysis also indicated that an elevated sFC concentration is a more significant prognostic factor of DIC than D-dimer or FDP (hazard ratio: 10.78; P = 0.036) in liver cirrhosis group; however, it was not a prognostic factor in the no liver cirrhosis group. sFC is a powerful diagnostic and prognostic marker of DIC in patient with liver cirrhosis. The use of sFC is expected to enhance the diagnosis and prognosis of DIC, particularly in patients with liver cirrhosis.

The significance of platelet consumption in the development of thrombocytopenia in patients with cirrhosis

INTRODUCTION

Thrombocytopenia in cirrhosis is mainly explained by accelerated platelet destruction/sequestration because of hypersplenism or by decreased thrombopoietin levels. Excessive platelet consumption because of cirrhosis-related hypercoagulability has also been assumed to be an etiopathologic factor in thrombocytopenia. To clarify whether excessive platelet consumption (eg, venous thrombosis and disseminated intravascular coagulation) contributes to thrombocytopenia in cirrhosis, the following autopsy-based study was performed.

METHODS

Ninety-nine autopsies of chronic liver disease (80 cirrhosis and 19 noncirrhosis) were examined retrospectively. Platelet count, weight of spleen and thrombotic complications were checked in autopsy protocols. Megakaryocytes in bone marrow were counted under high-power microscopic view. Univariate and multivariate analyses were performed to evaluate significances of these factors in thrombocytopenia.

RESULTS

The platelet count was significantly lower in the cirrhosis cases (88 ± 51 × 10/L) than in the noncirrhosis cases (150 ± 120 × 10/L). The megakaryocyte count was also lower in the cirrhosis cases (1.5 ± 0.6 per high-power field) than in the noncirrhosis cases (1.9 ± 0.5 per high-power field). The weight of the spleen was greater in the cirrhosis cases (264 ± 179 g) than in the noncirrhosis cases (142 ± 82 g). Thrombotic complications had been recorded in 29 cases, whose platelet count (70 ± 41 × 10/L) was lower than that of those without these complications (113 ± 80 × 10/L). Multivariate analysis revealed that these 3 factors (megakaryocyte count, weight of spleen, and thrombotic complications) were independently correlated with the platelet count.

CONCLUSIONS

These results suggest that the imbalance of platelet production-destruction/sequestration-consumption contributes to thrombocytopenia in cirrhosis. Excessive platelet consumption cannot be ignored to explain this complex condition, especially in patients with major thrombotic events.

Hemostasis, coagulation abnormalities, and liver disease

Coagulopathy-related bleeding events are a major concern in the management of acute and chronic liver disease. The liver attempts to maintain a balance between procoagulant and anticoagulant factors, and providers struggle with poor prognostic indicators to manage bleeding and critical complications. Subtle changes in patient presentation that may require extensive provider-directed interventions, such as blood transfusions, intravenous fluid management, mitigating possible sepsis, and evaluating appropriate pharmacologic treatment, are discussed.

Risk factors and clinical characteristics of portal vein thrombosis after splenectomy in patients with liver cirrhosis

BACKGROUND

Portal vein thrombosis (PVT) is a potential lethal complication and may have negative influence on the prognosis after splenectomy in patients with liver cirrhosis. Prevention and timely detection of PVT are quite significant. There is a lack of knowledge about the clinical features and risk factors of PVT. Our study aimed to investigate the risk factors and clinical characteristics of PVT in order to figure out the high-risk individuals.

METHODS

We collected the clinical data of 472 consecutive patients with non-neoplastic liver cirrhosis who had undergone splenectomy from January 2008 to December 2010 in our institution. Clinical and surgical characteristics of patients who developed PVT postoperatively and those who did not develop PVT were compared. Univariate and multivariate analyses of risk factors of PVT were performed. The mortality and rebleeding rate of the patients were also evaluated.

RESULTS

Of the 472 patients, 52 were excluded from the study. PVT developed in 71 (71/420, 16.9%) patients. Multivariate analysis revealed that wider preoperative portal vein diameter, postoperative thrombocytosis, prolonged prothrombin time and periesophagogastric devascularization were significantly correlated with PVT development [odds ratio (OR): 5.701, 2.807, 1.850 and 2.090, respectively]. The incidence of PVT in patients who took antiplatelet drugs was not lower than that in those who did not. Follow-up showed that patients in the PVT group had a tendency towards reduced overall survival but it was not statistically significant. Gastrointestinal bleeding occurred more often in the PVT group than that in the non-PVT group (P=0.044).

CONCLUSIONS

Wider preoperative portal vein diameter, postoperative thrombocytosis, prolonged prothrombin time and periesophagogastric devascularization are independent risk factors of PVT. PVT is related with higher risk of postoperative gastrointestinal hemorrhage but has no significant impact on the overall survival.

Association of hepatitis C with markers of hemostasis in HIV-infected and uninfected women in the women's interagency HIV study (WIHS)

BACKGROUND

Coinfection with HIV and hepatitis C virus (HCV) is common. HIV infection and treatment are associated with hypercoagulability; thrombosis in HCV is underinvestigated. Proposed markers of hemostasis in HIV include higher D-dimer, Factor VIII%, and plasminogen activator inhibitor-1 (PAI-1) antigen and lower total Protein S% (TPS) but have not been examined in HCV. We assessed the independent association of HCV with these 4 measures of hemostasis in a multicenter, prospective study of HIV: the Women's Interagency HIV Study.

METHODS

We randomly selected 450 HCV-infected (anti-HCV+ with detectable plasma HCV RNA) and 450 HCV-uninfected (anti-HCV-) women. HCV was the main exposure of interest in regression models.

RESULTS

Four hundred forty-three HCV+ and 425 HCV- women were included. HCV+ women had higher Factor VIII% (124.4% ± 3.9% vs. 101.8% ± 3.7%, P < 0.001) and lower TPS (75.7% ± 1.1% vs. 84.3% ± 1.1%, <0.001) than HCV- women, independent of HIV infection and viral load; there was little difference in PAI-1 or log10 D-dimer. After adjustment for confounders, these inferences remained. HIV infection was independently associated with higher Factor VIII% and log10 D-dimer and lower TPS.

CONCLUSIONS

HCV was independently associated with higher Factor VIII% and lower TPS consistent with hypercoagulability. Higher Factor VIII% and D-dimer and lower TPS were also strongly associated with HIV infection and levels of HIV viremia, independent of HCV infection. Further investigation is needed to determine if there is increased thrombotic risk from HCV. Studies examining hemostasis markers in HIV infection must also assess the contribution of HCV infection.

Effect of antithrombin, protein C and protein S on portal vein thrombosis in liver cirrhosis: a meta-analysis

BACKGROUND

The effects of antithrombin (AT), protein C (PC) and protein S (PS) on the pathogenesis of portal vein thrombosis (PVT) in liver cirrhosis remain controversial in different studies. In this study, a systematic review and meta-analysis to examine this issue were performed.

METHODS

PubMed database was employed to identify all studies in which AT, PC and PS concentrations were measured in both cirrhotic patients with and without PVT. A standardized mean difference (SMD) with 95% confidence interval (CI) was calculated to evaluate the effect of AT, PC and PS on PVT. Data were pooled using both fixed-effect and random-effect models. Only the pooled data using random-effect model were considered appropriate, when significant heterogeneity was observed.

RESULTS

Nine studies involving 160 cirrhotic patients with PVT and 428 cirrhotic patients without PVT were eligible. AT and PC concentrations were similar between PVT and non-PVT groups (AT: SMD = -0.21, 95% CI = -0.56 to 0.14, P = 0.24; PC: SMD = -0.23, 95% CI = -0.55 to 0.09, P = 0.16). But PS concentration was significantly lower in the PVT group than in the non-PVT group (SMD = -0.29, 95% CI = -0.49 to -0.08, P = 0.006). Subgroup analyses were further conducted in 4 studies in which baseline liver function was similar between cirrhotic patients with and without PVT, showing similar AT, PC and PS concentrations between the 2 groups (AT: SMD = -0.10, 95% CI = -0.36 to 0.16, P = 0.57; PC: SMD = -0.18, 95% CI = -0.62 to 0.25, P = 0.41; PS: SMD = -0.10, 95% CI = -0.59 to 0.39, P = 0.69).

CONCLUSIONS

AT, PC and PS concentrations might not be associated with the pathogenesis of PVT in liver cirrhosis, especially when the impact of liver function was excluded.

Value of D-dimer and protein S for diagnosis of portal vein thrombosis in patients with liver cirrhosis

OBJECTIVE

To investigate the value of D-dimer and protein S plasma concentrations for diagnosis of portal vein thrombosis (PVT) in patients with liver cirrhosis.

METHODS

D-dimer and protein S were quantified, PVT was diagnosed by dynamic enhanced computed tomography and liver function was classified using the Child-Pugh system. Receiver operating curve analysis was performed.

RESULTS

D-dimer increased, and protein S decreased, with decreasing liver function in the total study population (n = 188). D-dimer concentrations were significantly higher and protein S concentrations were significantly lower in patients with (n = 51) than those without PVT (n = 137). D-dimer had high specificity and negative predictive value (NPV) in Child-Pugh class A or B patients (cut-off values>0.56 mg/l and >1.18 mg/l, respectively). In class C patients>0.77 mg/l D-dimer had high sensitivity and NPV. Protein S had high sensitivity but low specificity in class A or B patients (cut-off values < 17.4 mg/l and <19.2 mg/l, respectively).

CONCLUSION

Plasma D-dimer and protein S are potential biomarkers for PVT diagnosis in patients with cirrhosis. PVT can be excluded when D-dimer is low and protein S is elevated.

Proteomics reveals plasma profiles for monitoring the toxicity caused by chromium compounds

BACKGROUND

Today, various heavy metals are widespread in the ecosystem and have become important environmental contaminants. Exposure to these hazardous metals such as chromium usually results in cytotoxicity and large-scale protein changes which reflect pathologic states.

METHODS

We used a comprehensive proteomic tool to survey changes in plasma proteins elicited by two chromium species (Cr(6+) and Cr(3+)). RT-PCR was applied to evaluate levels of cytokines associated with adverse responses. Lectin blotting was used to investigate the contents of fucosylated proteins.

RESULTS

Protein profiles revealed statistically significant changes in the intensity of 12 proteins. The network analysis implied that Cr(6+) application strongly induced the IL-6-stimulated inflammatory pathway. mRNA levels of specific cytokines were also correlated with inflammatory events. Increased IL-6 modulation of the fucosylation of haptoglobin was also identified in Cr(6+)-treated samples.

CONCLUSIONS

These results suggest that Cr(6+) may induce IL-6-mediated inflammatory responses which result in hepatic injury. This paper highlights the applications of functional proteomics of plasma profiles and fucosylated glycoproteins as a predictive tool to monitor human health in contact with chromium.

Coagulation imbalance may not contribute to the development of portal vein thrombosis in patients with cirrhosis

INTRODUCTION

The relationship between the imbalance in pro- and anti-coagulant factors and portal vein thrombosis (PVT) in individuals with cirrhosis is unclear. The aim of this study was to determine whether the imbalance in pro- and anti-coagulant factors contributes to the development of PVT in cirrhotic patients.

MATERIALS AND METHODS

Blood samples were collected from 30 consecutive cirrhotic patients with PVT and 30 age-, sex-, and Child-Pugh score-matched cirrhotic patients without PVT (controls), and the plasma levels of coagulation factors II, V, VII, VIII, IX, X, XI and XII and of protein C (PC), protein S (PS) and antithrombin (AT) were analyzed. The ratios of pro- vs. anti-coagulant factors were further investigated.

RESULTS

The levels of pro- and anti-coagulant factors were not statistically different between the PVT and control groups. Similar results were obtained when the patients were divided according to Child-Pugh classification. No difference was observed for the ratios of pro- vs. anti-coagulant factors between the two groups but the ratios of factor II-to-PC and factor VII-to-PC which were significantly decreased in the PVT group. Most of the ratios did not reach statistical significance in each Child-Pugh category except the followings: factor VIII-to-PS, factor XII-to-PC and factor XII-to-PS in class A patients; factor II-to-PS, factor VII-to-PC and factor VII-to-PS in class B patients. But the difference might not be so convincing.

CONCLUSIONS

PVT in cirrhotic patients may not result from coagulation imbalance.

Enoxaparin prevents portal vein thrombosis and liver decompensation in patients with advanced cirrhosis

BACKGROUND & AIMS

We performed a randomized controlled trial to evaluate the safety and efficacy of enoxaparin, a low-molecular-weight heparin, in preventing portal vein thrombosis (PVT) in patients with advanced cirrhosis.

METHODS

In a nonblinded, single-center study, 70 outpatients with cirrhosis (Child-Pugh classes B7-C10) with demonstrated patent portal veins and without hepatocellular carcinoma were assigned randomly to groups that were given enoxaparin (4000 IU/day, subcutaneously for 48 weeks; n = 34) or no treatment (controls, n = 36). Ultrasonography (every 3 months) and computed tomography (every 6 months) were performed to check the portal vein axis. The primary outcome was prevention of PVT. Radiologists and hepatologists that assessed outcomes were blinded to group assignments. Analysis was by intention to treat.

RESULTS

At 48 weeks, none of the patients in the enoxaparin group had developed PVT, compared with 6 of 36 (16.6%) controls (P = .025). At 96 weeks, no patient developed PVT in the enoxaparin group, compared with 10 of 36 (27.7%) controls (P = .001). At the end of the follow-up period, 8.8% of patients in the enoxaparin group and 27.7% of controls developed PVT (P = .048). The actuarial probability of PVT was lower in the enoxaparin group (P = .006). Liver decompensation was less frequent among patients given enoxaparin (11.7%) than controls (59.4%) (P < .0001); overall values were 38.2% vs 83.0%, respectively (P < .0001). The actuarial probability of liver decompensation was lower in the enoxaparin group (P < .0001). Eight patients in the enoxaparin group and 13 controls died. The actuarial probability of survival was higher in the enoxaparin group (P = .020). No relevant side effects or hemorrhagic events were reported.

CONCLUSIONS

In a small randomized controlled trial, a 12-month course of enoxaparin was safe and effective in preventing PVT in patients with cirrhosis and a Child-Pugh score of 7-10. Enoxaparin appeared to delay the occurrence of hepatic decompensation and to improve survival.