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Kataria S, Juneja D, Singh O. Approach to thromboelastography-based transfusion in cirrhosis: An alternative perspective on coagulation disorders. World J Gastroenterol 2023; 29:1460-1474. [PMID: 36998429 PMCID: PMC10044856 DOI: 10.3748/wjg.v29.i9.1460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 01/12/2023] [Accepted: 02/27/2023] [Indexed: 03/07/2023] Open
Abstract
Viscoelastic tests, specifically thromboelastography and rotational thromboelastometry, are increasingly being used in the management of postoperative bleeding in surgical intensive care units (ICUs). However, life-threatening bleeds may complicate the clinical course of many patients admitted to medical ICUs, especially those with underlying liver dysfunction. Patients with cirrhosis have multiple coagulation abnormalities that can lead to bleeding or thrombotic complications. Compared to conventional coagulation tests, a comprehensive depiction of the coagulation process and point-of-care availability are advantages favoring these devices, which may aid physicians in making a rapid diagnosis and instituting early interventions. These tests may help predict bleeding and rationalize the use of blood products in these patients.
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Affiliation(s)
- Sahil Kataria
- Institute of Critical Care Medicine, Max Super Speciality Hospital, New Delhi 110017, India
| | - Deven Juneja
- Institute of Critical Care Medicine, Max Super Speciality Hospital, New Delhi 110017, India
| | - Omender Singh
- Institute of Critical Care Medicine, Max Super Speciality Hospital, New Delhi 110017, India
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2
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Huang X, Zhang M, Ai Y, Jiang S, Xiao M, Wang L, Jian Y, Zhuge Y, Zhang C, Chen S. Characteristics of myeloproliferative neoplasm-associated portal hypertension and endoscopic management of variceal bleeding. Ther Adv Chronic Dis 2022; 13:20406223221125691. [PMID: 36172080 PMCID: PMC9511301 DOI: 10.1177/20406223221125691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 08/25/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Myeloproliferative neoplasms (MPNs) are a rare yet important clinical cause of portal hypertension, which may cause recurrent gastroesophageal variceal bleeding (GVB). MPN-associated variceal bleeding lacks specific guidelines and clinical consensus and desiderates cohort studies. We performed a multicenter retrospective study to investigate the efficacy of endoscopic management of bleeding in MPNs. Methods: We included consecutive MPN patients with gastroesophageal varices in eight tertiary university hospitals between January 2007 and March 2020. The clinical characteristics of participants were summarized. MPN patients with a history of GVB were followed up for the rebleeding and death, compared with controls suffering from schistosomiasis-associated portal hypertension who received endoscopic treatment for variceal bleeding at the same period. Results: A total of 62 MPN patients with gastroesophageal varices were identified, and 37 had a history of GVB. Of these, 24 patients received endoscopic variceal ligation and endoscopic injection of cyanoacrylate for the prophylaxis of variceal rebleeding. Endoscopic treatment significantly reduced the rebleeding rate in MPN patients with a history of GVB (28.2% versus 68.3%, p = 0.0269). Multivariable Cox regression indicated that endoscopic treatment (HR = 0.10, 95% CI: 0.02–0.54, p = 0.008) was the independent protective factor for decreasing the 3-year rebleeding rate, while the use of non-selective beta-blockers (NSBB) (HR = 13.41, 95% CI: 2.15–83.42, p = 0.005) was the risk factor for increasing the 3-year rebleeding rate. As for the efficacy of endoscopic management, 3-year rebleeding rate was significantly lower in MPN patients in contrast to 46 controls with schistosomiasis-associated variceal bleeding (32.9% versus 59.0%, p = 0.0346). Conclusion: Endoscopic treatment might be a feasible and potent approach in the management of gastroesophageal variceal rebleeding in MPNs, while NSBB might be ineffective.
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Affiliation(s)
- Xiaoquan Huang
- Department of Gastroenterology and Hepatology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ming Zhang
- Department of Gastroenterology, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, China
| | - Yingjie Ai
- Department of Gastroenterology and Hepatology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Siyu Jiang
- Department of Gastroenterology and Hepatology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Mei Xiao
- Department of Gastroenterology, Anhui Provincial Hospital, Hefei, China
| | - Lifen Wang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Yourong Jian
- Department of Gastroenterology and Hepatology, Minhang Hospital, Fudan University, Shanghai, China
| | - Yuzheng Zhuge
- Department of Gastroenterology, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, China
| | - Chunqing Zhang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Shiyao Chen
- Department of Gastroenterology and Hepatology, Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai 200032, China.,Center of Evidence-based Medicine, Fudan University, Shanghai, China.,Department of Gastroenterology and Hepatology, Minhang Hospital, Fudan University, Shanghai, China
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3
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Retrospective evaluation of early thrombosis in transjugular intrahepatic portosystemic polytetrafluoroethylene-coated shunts under 2-day postinterventional heparinization. Sci Rep 2022; 12:10506. [PMID: 35732875 PMCID: PMC9217914 DOI: 10.1038/s41598-022-14388-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 06/06/2022] [Indexed: 11/08/2022] Open
Abstract
The development of acute thrombosis within the TIPS tract may be prevented by prophylactic anticoagulation; however, there is no evidence of the correct anticoagulation regimen after TIPS placement. The purpose of this single-center retrospective study was to evaluate the short-term occlusion rate of transjugular intrahepatic portosystemic shunts (TIPSs) with polytetrafluorethylene (PTFE)-coated stents under consequent periprocedural full heparinization (target partial thromboplastin time [PTT]: 60–80 s). We analyzed TIPS placements that were followed up over a six-month period by Doppler ultrasound in 94 patients and compared the study group of 54 patients who received intravenous periprocedural full heparinization (target PTT: 60–80 s) without any other anticoagulation to patients with prolonged anticoagulation medication. The primary endpoint was TIPS patency after six months. The primary patency rate was 88.3% overall, and in the study group, 90.7%, with an early thrombosis rate of 3.2% (study group: 1.9%) and a primary assisted patency rate of 95.7% (study group: 96.3%). In the study group, one case of TIPS thrombosis occurred on the 23rd day after TIPS placement. Two patients underwent reintervention because of stenosis or buckling. Moreover, the target PTT was not attained in 8 of the 54 patent TIPSs. Four patients had an increased portosystemic pressure gradient, without stenosis, and the flow rate was corrected by increasing the TIPS diameter by dilation. Two-day heparinization seems sufficient to avoid early TIPS thrombosis over a six-month period.
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EASL Clinical Practice Guidelines on prevention and management of bleeding and thrombosis in patients with cirrhosis. J Hepatol 2022; 76:1151-1184. [PMID: 35300861 DOI: 10.1016/j.jhep.2021.09.003] [Citation(s) in RCA: 128] [Impact Index Per Article: 64.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 09/13/2021] [Indexed: 12/11/2022]
Abstract
The prevention and management of bleeding and thrombosis in patients with cirrhosis poses several difficult clinical questions. These Clinical Practice Guidelines have been developed to provide practical guidance on debated topics, including current views on haemostasis in liver disease, controversy regarding the need to correct thrombocytopenia and abnormalities in the coagulation system in patients undergoing invasive procedures, and the need for thromboprophylaxis in hospitalised patients with haemostatic abnormalities. Multiple recommendations in this document are based on interventions that the panel feels are not useful, even though widely applied in clinical practice.
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De Maria C, Galante A, Fasoli A, De Gottardi A. When and how to use direct oral anticoagulants in patients with advanced chronic liver disease? Curr Opin Pharmacol 2021; 60:111-116. [PMID: 34403992 DOI: 10.1016/j.coph.2021.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 07/07/2021] [Indexed: 11/29/2022]
Abstract
Direct oral anticoagulants (DOACs) emerged as effective and safe alternatives to traditional anticoagulants for the prevention and treatment of venous thromboembolic disease and the prevention of stroke in non-valvular atrial fibrillation. Patients with advanced chronic liver disease (ACLD) have a higher risk of thromboembolism and bleeding than patients with normal liver function. Therefore, anticoagulation and, in particular, direct oral anticoagulants play a central role. Portal vein thrombosis is a relatively frequent complication in patients with ACLD, but its treatment remains challenging. DOACs have been introduced in clinical practice and demonstrated similar efficacy and safety profiles compared with vitamin K antagonist and heparins. However, further data about the use of DOACs in patients suffering from ACLD are needed. This review summarizes current knowledge in terms of anticoagulation in patients with ACLD and focuses on the available data about the use of DOACs in this population.
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Affiliation(s)
- Costanza De Maria
- Gastroenterology and Hepatology, Ente Ospedaliero Cantonale, Switzerland
| | - Antonio Galante
- Gastroenterology and Hepatology, Ente Ospedaliero Cantonale, Switzerland
| | - Alberto Fasoli
- Gastroenterology and Hepatology, Ente Ospedaliero Cantonale, Switzerland
| | - Andrea De Gottardi
- Gastroenterology and Hepatology, Ente Ospedaliero Cantonale, Switzerland; Facoltà di Scienze Biomediche, Università Della Svizzera Italiana, Lugano, Switzerland.
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Kirschner M, do Ó Hartmann N, Parmentier S, Hart C, Henze L, Bisping G, Griesshammer M, Langer F, Pabinger-Fasching I, Matzdorff A, Riess H, Koschmieder S. Primary Thromboprophylaxis in Patients with Malignancies: Daily Practice Recommendations by the Hemostasis Working Party of the German Society of Hematology and Medical Oncology (DGHO), the Society of Thrombosis and Hemostasis Research (GTH), and the Austrian Society of Hematology and Oncology (ÖGHO). Cancers (Basel) 2021; 13:2905. [PMID: 34200741 PMCID: PMC8230401 DOI: 10.3390/cancers13122905] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 06/03/2021] [Accepted: 06/04/2021] [Indexed: 12/20/2022] Open
Abstract
Patients with cancer, both hematologic and solid malignancies, are at increased risk for thrombosis and thromboembolism. In addition to general risk factors such as immobility and major surgery, shared by non-cancer patients, cancer patients are exposed to specific thrombotic risk factors. These include, among other factors, cancer-induced hypercoagulation, and chemotherapy-mediated endothelial dysfunction as well as tumor-cell-derived microparticles. After an episode of thrombosis in a cancer patient, secondary thromboprophylaxis to prevent recurrent thromboembolism has long been established and is typically continued as long as the cancer is active or actively treated. On the other hand, primary prophylaxis, even though firmly established in hospitalized cancer patients, has only recently been studied in ambulatory patients. This recent change is mostly due to the emergence of direct oral anticoagulants (DOACs). DOACs have a shorter half-life than vitamin K antagonists (VKA), and they overcome the need for parenteral application, the latter of which is associated with low-molecular-weight heparins (LMWH) and can be difficult for the patient to endure in the long term. Here, first, we discuss the clinical trials of primary thromboprophylaxis in the population of cancer patients in general, including the use of VKA, LMWH, and DOACs, and the potential drug interactions with pre-existing medications that need to be taken into account. Second, we focus on special situations in cancer patients where primary prophylactic anticoagulation should be considered, including myeloma, major surgery, indwelling catheters, or immobilization, concomitant diseases such as renal insufficiency, liver disease, or thrombophilia, as well as situations with a high bleeding risk, particularly thrombocytopenia, and specific drugs that may require primary thromboprophylaxis. We provide a novel algorithm intended to aid specialists but also family practitioners and nurses who care for cancer patients in the decision process of primary thromboprophylaxis in the individual patient.
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Affiliation(s)
- Martin Kirschner
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, 52074 Aachen, Germany; (M.K.); (N.d.Ó.H.)
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), 52074 Aachen, Germany
| | - Nicole do Ó Hartmann
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, 52074 Aachen, Germany; (M.K.); (N.d.Ó.H.)
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), 52074 Aachen, Germany
| | - Stefani Parmentier
- Oncology and Hematology, Tumor Center, St. Claraspital, 4058 Basel, Switzerland;
| | - Christina Hart
- Department of Hematology and Oncology, Internal Medicine III, University Hospital Regensburg, 93053 Regensburg, Germany;
| | - Larissa Henze
- Department of Medicine, Clinic III—Hematology, Oncology, Palliative Medicine, Rostock University Medical Center, 18057 Rostock, Germany;
| | - Guido Bisping
- Department of Medicine I, Mathias Spital Rheine, 48431 Rheine, Germany;
| | - Martin Griesshammer
- University Clinic for Hematology, Oncology, Haemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, University of Bochum, 32429 Minden, Germany;
| | - Florian Langer
- II.Medical Clinic and Polyclinic, Center for Oncology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany;
| | - Ingrid Pabinger-Fasching
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, 1090 Vienna, Austria;
| | - Axel Matzdorff
- Department of Internal Medicine II, Asklepios Clinic Uckermark, 16303 Schwedt, Germany;
| | - Hanno Riess
- Medical Department, Division of Oncology and Hematology, Campus Charité Mitte, Charité Universitätsmedizin Berlin, 13353 Berlin, Germany;
| | - Steffen Koschmieder
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, 52074 Aachen, Germany; (M.K.); (N.d.Ó.H.)
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), 52074 Aachen, Germany
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Ahmed Z, Singal AK, Kamath PS. Anticoagulants and Their Monitoring. Clin Liver Dis (Hoboken) 2020; 16:146-148. [PMID: 33163166 PMCID: PMC7609710 DOI: 10.1002/cld.946] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 02/11/2020] [Indexed: 02/04/2023] Open
Affiliation(s)
- Zunirah Ahmed
- Division of Gastroenterology and HepatologyBaylor College of MedicineHoustonTX
| | - Ashwani K. Singal
- Division of Transplant HepatologyAvera Transplant InstituteUniversity of South Dakota Sanford School of MedicineSioux FallsSD
| | - Patrick S. Kamath
- Division of Gastroenterology and HepatologyMayo Clinic and Mayo Medical SchoolRochesterMN
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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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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: 52] [Impact Index Per Article: 13.0] [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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Acute Portal Vein Thrombosis Treated with Recombinant Human Soluble Thrombomodulin Combined with Antithrombin III. Case Rep Med 2020; 2020:8268016. [PMID: 32328109 PMCID: PMC7174955 DOI: 10.1155/2020/8268016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 03/23/2020] [Indexed: 11/18/2022] Open
Abstract
Portal vein thrombosis is a major complication associated with liver cirrhosis. In cirrhotic patients, a decrease in procoagulant and anticoagulant factors and an unstable balance between them is observed, and a relative decrease in the activation of anticoagulant drivers is one of the main causes of portal vein thrombosis (PVT). Herein, we report a case of acute portal thrombosis associated with liver cirrhosis and treated with a recombinant form of soluble thrombomodulin (thrombomodulin alpha, TM-α) in combination with antithrombin III. TM-α was administered in accordance with the dosage and route of administration for disseminated intravascular coagulation therapy and resulted in dissolution of PVT with a gradual decrease in D-dimer levels. No adverse events were observed during the course of treatment. In the future, in addition to conventional anticoagulation therapy using heparin or antivitamin K drugs, novel therapies targeting protein C activation using a recombinant form of soluble thrombomodulin may play an important role in the treatment of acute PVT.
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Thromboelastography-guided Blood Product Transfusion in Cirrhosis Patients With Variceal Bleeding: A Randomized Controlled Trial. J Clin Gastroenterol 2020; 54:255-262. [PMID: 31008867 DOI: 10.1097/mcg.0000000000001214] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
GOALS The aim of this study was to assess the use of thromboelastography (TEG)-directed blood product transfusion in cirrhotic patients with acute variceal bleeding compared with conventional transfusion for correction of coagulopathy. BACKGROUND Coagulopathy is common in patients with cirrhosis. Recommendations for correction of conventional parameters of coagulation-platelets and the international normalized ratio before endoscopy in patients with acute variceal bleeding-need more validation. STUDY In this randomized controlled trial, cirrhotic patients with severe coagulopathy and acute variceal bleeding were randomized to either TEG-guided blood product transfusion or conventional transfusion from March 2017 to December 2017. The primary outcome was the difference in the amount of fresh frozen plasma and platelet units transfused between the groups. Secondary outcomes were rebleeding at 5 days and 42 days, and 6-week mortality. RESULTS Of the 60 recruited patients, 30 each were randomized to the TEG and conventional transfusion groups. There were no differences in baseline characteristic and endoscopic findings between the 2 groups. Four subjects in the TEG group received blood product transfusions versus all in the conventional transfusion group (13.3% vs. 100%; P<0.001). The control of bleeding on initial endoscopy was similar in the 2 groups. Rebleeding in the TEG and conventional transfusion groups at 5 days was similar [1 (3.3%) vs. 4 (13.3%), P=0.167], whereas it was significantly less in the TEG group at 42 days [3 (10%) vs. 11 (36.7%), P=0.012]. Mortality at 6 weeks was seen in 4 (13.3%) in the TEG group and in 8 (26.7%) patients in the conventional transfusion group (P=0.176). CONCLUSIONS TEG-guided strategy was associated with reduced blood product transfusion to correct coagulopathy without compromising hemostasis in cirrhotic patients (Clinical trial ID: CTRI/2017/02/007864).
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Whitsett M, Wilcox J, Yang A, Zhao L, Rinella M, VanWagner LB. Atrial fibrillation is highly prevalent yet undertreated in patients with biopsy-proven nonalcoholic steatohepatitis. Liver Int 2019; 39:933-940. [PMID: 30536602 PMCID: PMC6483865 DOI: 10.1111/liv.14018] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 11/21/2018] [Accepted: 11/29/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Nonalcoholic steatohepatitis (NASH) is associated with increased cardiovascular disease. Atrial fibrillation is a prominent risk marker for underlying cardiovascular disease with a prevalence of 2% in patients <65 years old. Atrial fibrillation prevalence in NASH is unknown. We sought to assess the prevalence and impact of atrial fibrillation on healthcare utilization in NASH. METHODS Patients were identified from a tertiary care centre Electronic Database from 2002 to 2015. International Classification of Diseases 9 (ICD9) codes identified comorbidities and atrial fibrillation. Descriptive statistics were used to compare characteristics between patients with NASH with and without atrial fibrillation. RESULTS Of 9108 patients with ICD9 diagnosis of NASH, 215 (2.3%, mean age 57 years, 32% male) had biopsy-proven NASH. Atrial fibrillation prevalence was 4.6%. Patients with NASH and atrial fibrillation had a higher prevalence of heart failure (54.5% vs 8.8%, P < 0.001) and cerebrovascular (27.3% vs 2.0%, P < 0.001) or vascular disease (54.5% vs 13.2%, P = 0.002), compared to NASH without atrial fibrillation. All patients with NASH and atrial fibrillation had a CHA2DS2VASc score ≥2 indicating high stroke risk and need for anticoagulation. Eight of 10 patients were eligible for anticoagulation and 5 of 8 (62.5%) received appropriate therapy. CONCLUSION Atrial fibrillation prevalence is two-fold higher in patients with NASH compared to the general population. Patients with NASH have a high risk of stroke; however, many do not receive appropriate guideline-directed therapy. Future studies are needed to identify whether guideline-based management of atrial fibrillation in NASH reduces cardiovascular morbidity and mortality.
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Affiliation(s)
| | - Jane Wilcox
- Divison of Cardiology, Northwestern University Feinberg School of Medicine
| | - Amy Yang
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine
| | - Lihui Zhao
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine
| | - Mary Rinella
- Divison of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine
| | - Lisa B. VanWagner
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine,Divison of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine
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Intagliata NM, Caldwell SH, Tripodi A. Diagnosis, Development, and Treatment of Portal Vein Thrombosis in Patients With and Without Cirrhosis. Gastroenterology 2019; 156:1582-1599.e1. [PMID: 30771355 DOI: 10.1053/j.gastro.2019.01.265] [Citation(s) in RCA: 199] [Impact Index Per Article: 39.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Revised: 01/11/2019] [Accepted: 01/21/2019] [Indexed: 02/06/2023]
Abstract
Portal vein thrombosis unrelated to solid malignancy is common in patients with cirrhosis, but less frequently observed in patients without cirrhosis. Prompt diagnosis and management of acute symptomatic portal vein thrombosis are essential. Failure to detect and treat thromboses can result in mesenteric ischemia, chronic cavernous transformation, and complications of portal hypertension. In patients with cirrhosis, development of portal vein thrombosis is often insidious and remains undetected until its incidental detection. Management of portal vein thrombosis in patients with cirrhosis is more controversial. However, there are data to support treatment of specific patients with anticoagulation agents. We review the common and distinct features of portal vein thromboses in patients without liver tumors, with and without cirrhosis.
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Affiliation(s)
- Nicolas M Intagliata
- Division of Gastroenterology and Hepatology, University of Virginia Medical CenterCharlottesville, Virginia.
| | - Stephen H Caldwell
- Division of Gastroenterology and Hepatology, University of Virginia Medical CenterCharlottesville, Virginia
| | - Armando Tripodi
- Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Cà Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milano, Italy
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Ruiz-Ruiz F, Medrano F, Santos-Lozano J, Rodríguez-Torres P, Navarro-Puerto A, Calderón E. Tratamiento anticoagulante en pacientes médicos con situaciones clínicas complejas. Rev Clin Esp 2019; 219:34-43. [DOI: 10.1016/j.rce.2018.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Accepted: 04/17/2018] [Indexed: 11/16/2022]
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Anticoagulant treatment of medical patients with complex clinical conditions. Rev Clin Esp 2019. [DOI: 10.1016/j.rceng.2018.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Zhou J, Luo B, Liu C, Zhu F. Effects of early antiplatelet therapy after splenectomy with gastro-oesophageal devascularization. ANZ J Surg 2018; 88:E725-E729. [PMID: 29396900 PMCID: PMC6175465 DOI: 10.1111/ans.14395] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Revised: 12/17/2017] [Accepted: 12/19/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND This study aimed to explore the effects of early antiplatelet therapy (APT) for portal vein thrombosis (PVT) in patients with cirrhotic portal hypertension after splenectomy with gastro-oesophageal devascularization. METHODS We retrospectively analysed 139 patients who underwent splenectomy with gastro-oesophageal devascularization for portal hypertension due to cirrhosis between April 2010 and December 2016. Based on the post-operative platelet values, we used two different APT regimens: APT was started when platelet counts were increased to 200 × 109 /L or above (group A, n = 64) or 300 × 109 /L or above (group B, n = 75). We took note of the patients' clinical symptoms, operative factors and biochemical indicators. RESULTS Platelet count, mean platelet volume, D-dimer and pancreatic fistula were closely related to the development of PVT. Early APT was an independent protective factor for PVT. The incidence of post-operative PVT was 15.1% (21/139) overall, 4.7% (3/64) in group A and 24% (18/75) in group B; there was a significant difference between groups A and B (χ2 = 10.042, P = 0.002). CONCLUSION Platelet count, mean platelet volume, D-dimer and pancreatic fistula were independent risk factors for the development of PVT after splenectomy with gastro-oesophageal devascularization. Selection of the appropriate timing for early APT according to the post-operative platelet count was feasible. Moreover, the use of aspirin combined with dipyridamole was safe and effective for early prevention of PVT.
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Affiliation(s)
- Jin‐Bao Zhou
- Department of General SurgeryThe Third Affiliated Hospital of Soochow UniversityChangzhouChina
| | - Bao‐Yang Luo
- Department of General SurgeryThe Third Affiliated Hospital of Soochow UniversityChangzhouChina
| | - Chi‐Wen Liu
- Department of General SurgeryThe Third Affiliated Hospital of Soochow UniversityChangzhouChina
| | - Feng Zhu
- Department of General SurgerySir Run Run Hospital of Nanjing Medical UniversityNanjingChina
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Ruiz-Ruiz F, Medrano F, Navarro-Puerto M, Rodríguez-Torres P, Romero-Alonso A, Santos-Lozano J, Alonso-Ortiz del Rio C, Varela-Aguilar J, Calderón E, Marín-León I. Delphi-RAND consensus of the Spanish Society of Internal Medicine on the controversies in anticoagulant therapy and prophylaxis in medical diseases. INTROMBIN Project (Uncertainty in thromboprophylaxis in internal medicine). Rev Clin Esp 2018. [DOI: 10.1016/j.rceng.2018.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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18
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Delphi-RAND consensus of the Spanish Society of Internal Medicine on the controversies in anticoagulant therapy and prophylaxis in medical diseases. INTROMBIN Project (Uncertainty in thromboprophylaxis in internal medicine). Rev Clin Esp 2018; 218:358-371. [PMID: 29793759 DOI: 10.1016/j.rce.2018.04.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Accepted: 04/17/2018] [Indexed: 11/20/2022]
Abstract
The aim of this study was to determine the opinion of internists on the management of anticoagulation and thromboembolism prophylaxis in complex clinical scenarios in which the risk-benefit ratio of surgery is narrow and to develop a consensus document on the use of drugs anticoagulant therapy in this patient group. To this end, we identified by consensus the clinical areas of greatest uncertainty, a survey was created with 20 scenarios laid out in 40 clinical questions, and we reviewed the specific literature. The survey was distributed among the internists of the Spanish Society of Internal Medicine (SEMI) and was completed by 290 of its members. The consensus process was implemented by changing the Delphi-RAND appropriateness method in an anonymous, double-round process that enabled an expert panel to identify the areas of agreement and uncertainty. In our case, we also added the survey results to the panel, a methodological innovation that helps provide additional information on the standard clinical practice. The result of the process is a set of 19 recommendations formulated by SEMI experts, which helps establish guidelines for action on anticoagulant therapy in complex scenarios (high risk or active haemorrhage, short life expectancy, coexistence of antiplatelet therapy or comorbidities such as kidney disease and liver disease), which are not uncommon in standard clinical practice.
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Lee KH, Joung B, Lee SR, Hwang YM, Park J, Baek YS, Park YM, Park JK, Park HC, Park HW, Lee YS, Choi KJ. 2018 KHRS Expert Consensus Recommendation for Oral Anticoagulants Choice and Appropriate Doses: Specific Situation and High Risk Patients. ACTA ACUST UNITED AC 2018. [DOI: 10.3904/kjm.2018.93.2.110] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Hernández Conde M, Llop Herrera E, de la Revilla Negro J, Pons Renedo F, Fernández Puga N, Martínez Porras JL, Trapero Marugan M, Cuervas-Mons V, Sánchez Turrión V, Calleja Panero JL. Prevalence and outcome of portal thrombosis in a cohort of cirrhotic patients undergoing liver transplantation. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 108:716-720. [PMID: 27756145 DOI: 10.17235/reed.2016.4211/2016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
INTRODUCTION The prevalence of portal vein thrombosis (PVT) in patients that have undergone liver transplantation (LT) is 9.7% (SD 4.5). The aim of our study was to determine the prevalence, assess the factors that are associated with PVT and clarify their association with prognosis in patients with liver cirrhosis (LC) and LT. AIMS AND METHODS From 2005 to 2014, laboratory, radiological and surgical data were collected from patients with LC in our center who had undergone LT for the first time. RESULTS One hundred and ninety-one patients were included. The mean age was 55 (SD 9), 75.4% of patients were male and 48.7% had HCV. The Child-Pugh scores were A/B/C 41.9%/35.9%/25.5% and the MELD score was 15 (SD 6). Previous decompensations were: ascites (61.4%), hepatic encephalopathy (34.4%), variceal bleeding (25.4%), hepatocellular carcinoma (48.9%) and spontaneous bacterial peritonitis (SPB) (14.3%). The mean post-transplant follow-up was 42 months (0-113). PVT was diagnosed at LT in 18 patients (9.4%). Six patients were previously diagnosed using imaging tests (33.3%): 2 patients (11.1%) by DU and 4 patients (22.2%) by CT scan. All patients with PVT had DU in a mean time of 6 months before LT (0-44) and 90 patients (47.1%) had a CT scan in a median time of 6 months before LT (0-45). PVT was significantly related to the presence of SBP (33.3% vs 12.6%; p = 0.02) and lower levels of albumin (3.1g/dl vs 3.4g/dl; p = 0.05). MELD was higher in patients with PVT (16.6 vs 14.9; p = 0.3). There were no significant differences with regard to the need for transfusion of blood components. Moreover, the surgery time was similar in both groups. PVT correlated with a higher mortality in the first 30 days (8.8% vs 16.7%; p = 0.2). CONCLUSION Prior history of SBP and lower levels of albumin were identified as factors associated with PVT. The pre-transplant diagnosis rate is very low and the presence of PVT may have implications for short-term mortality.
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Affiliation(s)
- Marta Hernández Conde
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro Majadahonda, Spain
| | - Elba Llop Herrera
- Department of Gastroenterology and Hepatology,Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro Majadahonda
| | - Juan de la Revilla Negro
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro Majadahonda
| | - Fernando Pons Renedo
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro Majadahonda
| | - Natalia Fernández Puga
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro Majadahonda
| | | | - María Trapero Marugan
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro Majadahonda
| | - Valentín Cuervas-Mons
- Department of Internal Medicine, Hospital Universitario Puerta de Hierro Majadahonda
| | | | - José Luis Calleja Panero
- Department of Gastroenterology and Hepatology, Universitario Puerta de Hierro Majadahonda, España
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Martín-Llahí M, Albillos A, Bañares R, Berzigotti A, García-Criado MÁ, Genescà J, Hernández-Gea V, Llop-Herrera E, Masnou-Ridaura H, Mateo J, Navascués CA, Puente Á, Romero-Gutiérrez M, Simón-Talero M, Téllez L, Turon F, Villanueva C, Zarrabeitia R, García-Pagán JC. Enfermedades vasculares del hígado. Guías Clínicas de la Sociedad Catalana de Digestología y de la Asociación Española para el Estudio del Hígado. GASTROENTEROLOGIA Y HEPATOLOGIA 2017; 40:538-580. [DOI: 10.1016/j.gastrohep.2017.03.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 03/29/2017] [Indexed: 12/11/2022]
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Lisman T, Porte RJ. Pathogenesis, prevention, and management of bleeding and thrombosis in patients with liver diseases. Res Pract Thromb Haemost 2017; 1:150-161. [PMID: 30046685 PMCID: PMC6058283 DOI: 10.1002/rth2.12028] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 06/21/2017] [Indexed: 12/14/2022] Open
Abstract
Patients with liver diseases may develop alterations in all components of the hemostatic system. Thrombocytopenia, low levels of coagulation factors and inhibitors, low levels of fibrinolytic proteins, and increased levels of endothelial-derived proteins such as von Willebrand factor are all part of the coagulopathy of liver disease. Due to concomitant changes in pro- and antihemostatic drivers, the net effects of these complex hemostatic changes have long been unclear. According to current concepts, the hemostatic system of patients with liver disease is in an unstable balance, which explains the occurrence of both bleeding and thrombotic complications. This review will discuss etiology and management of bleeding and thrombosis in liver disease and will outline unsolved clinical questions. In addition, we will discuss the role of intrahepatic activation of coagulation for progression of liver disease, a novel paradigm with potential consequences for the general management of patients with liver disease.
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Affiliation(s)
- Ton Lisman
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver TransplantationDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Robert J. Porte
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver TransplantationDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
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Orale Antikoagulation mit Vitamin K-Antagonisten – ein Update. Wien Med Wochenschr 2017; 168:121-132. [DOI: 10.1007/s10354-017-0577-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 05/22/2017] [Indexed: 10/19/2022]
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Li CJ, Yang ZH, Shi XL, Lu FG, Liu DL. Risk factors for portal vein thrombosis in cirrhotic patients: A meta-analysis. Shijie Huaren Xiaohua Zazhi 2017; 25:241-251. [DOI: 10.11569/wcjd.v25.i3.241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
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.
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Ribic C, Crowther M. Thrombosis and anticoagulation in the setting of renal or liver disease. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2016; 2016:188-195. [PMID: 27913479 PMCID: PMC6142494 DOI: 10.1182/asheducation-2016.1.188] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
Thrombosis and bleeding are among the most common causes of morbidity and mortality in patients with renal disease or liver disease. The pathophysiology underlying the increased risk for venous thromboembolism and bleeding in these 2 populations is distinct, as are considerations for anticoagulation. Anticoagulation in patients with kidney or liver disease increases the risk of bleeding; this risk is correlated with the degree of impairment of anticoagulant elimination by the kidneys and/or liver. Despite being in the same pharmacologic category, anticoagulant agents may have varied degrees of renal and liver metabolism. Therefore, specific anticoagulants may require dose reductions or be contraindicated in renal impairment and liver disease, whereas other drugs in the same class may not be subject to such restrictions. To minimize the risk of bleeding, while ensuring an adequate therapeutic effect, both appropriate anticoagulant drug choices and dose reductions are necessary. Renal and hepatic function may fluctuate, further complicating anticoagulation in these high-risk patient groups.
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Affiliation(s)
- Christine Ribic
- Department of Medicine and Department of Pathology and Molecular Medicine, McMaster University, and St Joseph's Healthcare, Hamilton, ON, Canada
| | - Mark Crowther
- Department of Medicine and Department of Pathology and Molecular Medicine, McMaster University, and St Joseph's Healthcare, Hamilton, ON, Canada
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Evidence-based clinical practice guidelines for liver cirrhosis 2015. J Gastroenterol 2016; 51:629-50. [PMID: 27246107 DOI: 10.1007/s00535-016-1216-y] [Citation(s) in RCA: 223] [Impact Index Per Article: 27.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 04/12/2016] [Indexed: 02/04/2023]
Abstract
The Japanese Society of Gastroenterology revised the evidence-based clinical practice guidelines for liver cirrhosis in 2015. Eighty-three clinical questions were selected, and a literature search was performed for the clinical questions with use of the MEDLINE, Cochrane, and Igaku Chuo Zasshi databases for the period between 1983 and June 2012. Manual searching of the latest important literature was added until August 2015. The guidelines were developed with use of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. This digest version in English introduces selected clinical questions and statements related to the management of liver cirrhosis and its complications. Branched-chain amino acids relieve hypoalbuminemia and hepatic encephalopathy and improve quality of life. Nucleoside analogues and peginterferon plus ribavirin combination therapy improve the prognosis of patients with hepatitis B virus related liver cirrhosis and hepatitis C related compensated liver cirrhosis, respectively, although the latter therapy may be replaced by direct-acting antivirals. For liver cirrhosis caused by primary biliary cirrhosis and active autoimmune hepatitis, urosodeoxycholic acid and steroid are recommended, respectively. The most adequate modalities for the management of variceal bleeding are the endoscopic injection sclerotherapy for esophageal varices and the balloon-occluded retrograde transvenous obliteration following endoscopic obturation with cyanoacrylate for gastric varices. Beta-blockers are useful for primary prophylaxis of esophageal variceal bleeding. The V2 receptor antagonist tolvaptan is a useful add-on therapy in careful diuretic therapy for ascites. Albumin infusion is useful for the prevention of paracentesis-induced circulatory disturbance and renal failure. In addition to disaccharides, the nonabsorbable antibiotic rifaximin is useful for the management of encephalopathy. Anticoagulation therapy is proposed for patients with acute-onset or progressive portal vein thrombosis.
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Görtzen J, Hunka LM, Vonnahme M, Praktiknjo M, Kaifie A, Fimmers R, Jansen C, Heine A, Lehmann J, Goethert JR, Gattermann N, Goekkurt E, Platzbecker U, Brossart P, Strassburg CP, Brummendorf TH, Koschmieder S, Wolf D, Trebicka J. γ-Glutamyl Transferase Is an Independent Biomarker of Splanchnic Thrombosis in Patients With Myeloproliferative Neoplasm. Medicine (Baltimore) 2016; 95:e3355. [PMID: 27196445 PMCID: PMC4902387 DOI: 10.1097/md.0000000000003355] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Myeloproliferative neoplasms (MPNs) are associated with an increased risk of thrombotic events and constitute the major risk factor of splanchnic venous thrombosis (SVT) in Western countries. Although timely anticoagulation resolves SVT, unrecognized SVT frequently leads to portal hypertension and, potentially, variceal bleeding, which may render anticoagulation difficult. Thus, early identification of SVT development is clinically relevant in MPN patients.In this retrospective analysis, we included 126 patients with MPN and/or SVT referred to our hospital between 2009 and 2014. A total of 86 patients diagnosed with MPN formed the first cohort (PV n = 18, ET n = 16, and MF n = 40), whereas 40 patients who had SVT without adjunct MPN formed a control cohort. Median follow-up period was 960 days. Clinical and laboratory data were collected and analyzed for the identification of potential biomarkers applying descriptive statistics, nonparametric testing, Kaplan-Meier, and logistic regression analysis. The relevance of the identified biomarkers was evaluated in an independent 2nd cohort of 181 patients from the MPN registry of the Study Alliance of Leukemia (SAL-MPN).Thirty-three MPN patients (38%) in the 1st cohort had SVT. Elevated levels of aspartate aminotransferase, alanine aminotransferase, serum bilirubin, or γ-GT were significantly correlated to the presence of SVT. In multivariate testing, CRP and aspartate aminotransferase were predictors for survival and γ-GT remained the only significant variable associated with SVT in MPN patients (P < 0.05). These findings were confirmed in the 2nd cohort comprising 42% of patients with MPN suffering from SVT.Elevated γ-GT levels indicate SVT in MPN patients, whereas CRP levels are independent predictors of patient survival.
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Affiliation(s)
- Jan Görtzen
- From the Department of Internal Medicine I (GJ, HLM, PM, JC, LJ, SC, TJ); Department of Medical Clinic III, University of Bonn, Bonn (VM, HA, BP, WD); Department of Hematology, Oncology, Hemostaseology, and SCT, Faculty of Medicine, University Hospital of the RWTH Aachen University, Aachen (KA, BTH, KS); Department of Biometrics, Informatics and Epidemiology, University of Bonn, Bonn (FR); Department for Hematology, University Hospital Essen, Essen (GJ); Department for Hematology, Oncology and Clinical Immunology, University Hospital Duesseldorf, Duesseldorf (GN); Practice for Hematology-Oncology Eppendorf, Hamburg (GE); and Department for Hematology, University Hospital Dresden, Dresden, Germany (PU)
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Hemostatic balance in patients with liver cirrhosis: Report of a consensus conference. Dig Liver Dis 2016; 48:455-467. [PMID: 27012444 DOI: 10.1016/j.dld.2016.02.008] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 02/18/2016] [Indexed: 12/11/2022]
Abstract
Patients with cirrhosis present with hemostatic alterations secondary to reduced availability of pro-coagulant and anti-coagulant factors. The net effect of these changes is a rebalanced hemostatic system. The Italian Association of the Study of the Liver (AISF) and the Italian Society of Internal Medicine (SIMI) promoted a consensus conference on the hemostatic balance in patients with cirrhosis. The consensus process started with the review of the literature by a scientific board of experts and ended with a formal consensus meeting in Rome in December 2014. The statements were graded according to quality of evidence and strength of recommendations, and approved by an independent jury. The statements presented here highlight strengths and weaknesses of current laboratory tests to assess bleeding and thrombotic risk in cirrhotic patients, the pathophysiology of hemostatic perturbations in this condition, and outline the optimal management of bleeding and thrombosis in patients with liver cirrhosis.
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Riess H, Habbel P, Jühling A, Sinn M, Pelzer U. Primary prevention and treatment of venous thromboembolic events in patients with gastrointestinal cancers - Review. World J Gastrointest Oncol 2016; 8:258-270. [PMID: 26989461 PMCID: PMC4789611 DOI: 10.4251/wjgo.v8.i3.258] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 11/08/2015] [Accepted: 01/04/2016] [Indexed: 02/05/2023] Open
Abstract
Venous thromboembolism event (VTE) is a common and morbid complication in cancer patients. Patients with gastrointestinal cancers often suffer from symptomatic or incidental splanchnic vein thrombosis, impaired liver function and/or thrombocytopenia. These characteristics require a thorough risk/benefit evaluation for individual patients. Considering the risk factors for the development of VTE and bleeding events in addition to recent study results may be helpful for correct initiation of primary pharmacological prevention and treatment of cancer-associated thrombosis (CAT), preferably with low molecular weight heparins (LMWH). Whereas thromboprophylaxis is most often recommended in hospitalized surgical and non-surgical patients with malignancy, there is less agreement as to its duration. With regard to ambulatory cancer patients, the lack of robust data results in low grade recommendations against routine use of anticoagulant drugs. Anticoagulation with LMWH for the first months is the evidence-based treatment for acute CAT, but duration of secondary prevention and the drug of choice are unclear. Based on published guidelines and literature, this review will focus on prevention and treatment strategies of VTE in patients with gastrointestinal cancers.
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Cho J, Choi SM, Yu SJ, Park YS, Lee CH, Lee SM, Yim JJ, Yoo CG, Kim YW, Han SK, Lee J. Bleeding complications in critically ill patients with liver cirrhosis. Korean J Intern Med 2016; 31:288-95. [PMID: 26805633 PMCID: PMC4773709 DOI: 10.3904/kjim.2014.152] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Revised: 11/10/2014] [Accepted: 12/17/2014] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND/AIMS Patients with liver cirrhosis (LC) are at risk for critical events leading to Intensive Care Unit (ICU) admission. Coagulopathy in cirrhotic patients is complex and can lead to bleeding as well as thrombosis. The aim of this study was to investigate bleeding complications in critically ill patients with LC admitted to a medical ICU (MICU). METHODS All adult patients admitted to our MICU with a diagnosis of LC from January 2006 to December 2012 were retrospectively assessed. Patients with major bleeding at the time of MICU admission were excluded from the analysis. RESULTS A total of 205 patients were included in the analysis. The median patient age was 62 years, and 69.3% of the patients were male. The most common reason for MICU admission was acute respiratory failure (45.4%), followed by sepsis (27.3%). Major bleeding occurred in 25 patients (12.2%). The gastrointestinal tract was the most common site of bleeding (64%), followed by the respiratory tract (20%). In a multivariate analysis, a low platelet count at MICU admission (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.97 to 0.99) and sepsis (OR, 8.35; 95% CI, 1.04 to 67.05) were independent risk factors for major bleeding. The ICU fatality rate was significantly greater among patients with major bleeding (84.0% vs. 58.9%, respectively; p = 0.015). CONCLUSIONS Major bleeding occurred in 12.2% of critically ill cirrhotic patients admitted to the MICU. A low platelet count at MICU admission and sepsis were associated with an increased risk of major bleeding during the MICU stay. Further study is needed to better understand hemostasis in critically ill patients with LC.
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Affiliation(s)
- Jaeyoung Cho
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Sun Mi Choi
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Su Jong Yu
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Young Sik Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Chang-Hoon Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Sang-Min Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jae-Joon Yim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Chul-Gyu Yoo
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Young Whan Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Sung Koo Han
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jinwoo Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Correspondence to Jinwoo Lee, M.D. Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea Tel: +82-2-2072-7593 Fax: +82-2-762-9662 E-mail:
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Ha NB, Regal RE. Anticoagulation in Patients With Cirrhosis: Caught Between a Rock-Liver and a Hard Place. Ann Pharmacother 2016; 50:402-9. [PMID: 26861989 DOI: 10.1177/1060028016631760] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE To review current literature for anticoagulation in patients with cirrhosis and provide a summary of the effects of cirrhosis on the coagulation cascade, therapeutic monitoring through interpretation of antifactor Xa (anti-Xa), activated partial thromboplastin time (aPTT), and international normalized ratio (INR) as well as current prophylaxis and treatment recommendations in cirrhotic patients. METHODS A systematic electronic literature search was conducted in PubMed using the key termsanticoagulation, warfarin, low-molecular-weight heparin(LMWH),unfractionated heparin(UFH),target-specific oral anticoagulants, deep-vein thrombosis(DVT),pulmonary embolism(PE),portal vein thrombosis(PVT),venous thromboembolism, anti-Xa, activated partial thromboplastin time, anticoagulation therapeutic monitoring, coagulopathy, coagulation cascade, chronic liver disease, cirrhosis, anddecompensated liver disease STUDY SELECTION Studies written in the English language from January 2000 to December 2015 were considered for this review article. All search results were reviewed, and the relevance of each article was determined by authors independently. CONCLUSIONS Patients with cirrhosis are at higher risk for both bleeding and thrombosis-related complications. Cirrhosis affects production of both procoagulant and anticoagulant factors, thus resulting in increased INR and aPTT levels and decreased anti-Xa levels. LMWH is the treatment of choice for the prevention and treatment of DVT/PE/PVT in patients with cirrhosis, and monitoring with anti-Xa levels for dose adjustment is not recommended. UFH is an alternative in cirrhotic patients for shorter-term use and in cases of severe renal dysfunction and/or hemodynamic instability. Cirrhotic patients on anticoagulation therapy should be monitored closely for signs and symptoms of bleeding and thrombosis.
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Affiliation(s)
- Nghi B Ha
- University of Michigan Health System, Ann Arbor, MI, USA University of Michigan, College of Pharmacy, Ann Arbor, MI, USA
| | - Randolph E Regal
- University of Michigan Health System, Ann Arbor, MI, USA University of Michigan, College of Pharmacy, Ann Arbor, MI, USA
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EASL Clinical Practice Guidelines: Vascular diseases of the liver. J Hepatol 2016; 64:179-202. [PMID: 26516032 DOI: 10.1016/j.jhep.2015.07.040] [Citation(s) in RCA: 451] [Impact Index Per Article: 56.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 07/20/2015] [Indexed: 12/11/2022]
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Pasta L, Pasta F. PAI-1 4G-4G and MTHFR 677TT in non-hepatitis C virus/hepatitis B virus-related liver cirrhosis. World J Hepatol 2015; 7:2920-2926. [PMID: 26689658 PMCID: PMC4678379 DOI: 10.4254/wjh.v7.i29.2920] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 09/04/2015] [Accepted: 11/25/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the different roles of thrombophilia in patients with and without viral etiology. The thrombophilic genetic factors (THRGFs), PAI-1 4G-4G, MTHFR 677TT, V Leiden 506Q and prothrombin 20210A, were studied as risk factors in 1079 patients with liver cirrhosis (LC), enrolled from January 2000 to January 2014.
METHODS: All Caucasian LC patients consecutively observed in a fourteen-year period were included; the presence of portal vein thrombosis (PVT) and Budd Chiari syndrome (BCS) was registered. The differences between the proportions of each THRGF with regard to the presence or absence of viral etiology and the frequencies of the THRGF genotypes with those predicted in a population by the Hardy-Weinberg equilibrium were registered.
RESULTS: Four hundred and seventeen/one thousand and seventy-six patients (38.6%) showed thrombophilia: 217 PAI-1 4G-4G, 176 MTHFR C677TT, 71 V Leiden factor and 41 prothrombin G20210 A, 84 with more than 1 THRGF; 350 presented with no viral liver cirrhosis (NVLC) and 729 with, called viral liver cirrhosis (VLC), of whom 56 patients were hepatitis C virus + hepatitis B virus. PAI-1 4G-4G, MTHFR C677TT, the presence of at least one TRHGF and the presence of > 1 THRGF, were statistically more frequent in patients with NVLC vs patients with VLC: All χ2 > 3.85 and P < 0.05. Patients with PVT and/or BCS with at least one TRHGF were 189/352 (53.7%). The Hardy-Weinberg of PAI-1 and MTHFR 677 genotypes deviated from that expected from a population in equilibrium in patients with NVLC (respectively χ2 = 39.3; P < 0.000 and χ2 = 27.94; P < 0.05), whereas the equilibrium was respected in VLC.
CONCLUSION: MTHFR 677TT was nearly twofold and PAI-1 4G-4G more than threefold more frequently found in NVLC vs patients with VLC; the Hardy-Weinberg equilibrium of these two polymorphisms confirms this data in NVLC. We suggest that PAI-1 4G-4G and MTHFR 677TT could be considered as factors of fibrosis and thrombosis mechanisms, increasing the inflammation response, and causing the hepatic fibrosis and augmented intrahepatic vascular resistance typical of LC. PAI-1 4G-4G and MTHFR 677TT screening of LC patients could be useful, mainly in those with NVLC, to identify patients in which new drug therapies based on the attenuation of the hepatic stellate cells activation or other mechanisms could be more easily evaluated.
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Rodriguez-Castro KI. Anticoagulation for portal vein thrombosis in cirrhosis: Response to Naeshiro and collaborators. Hepatol Res 2015; 45:1256-7. [PMID: 25594445 DOI: 10.1111/hepr.12491] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 01/11/2015] [Indexed: 12/24/2022]
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Blasi A. Coagulopathy in liver disease: Lack of an assessment tool. World J Gastroenterol 2015; 21:10062-10071. [PMID: 26401071 PMCID: PMC4572787 DOI: 10.3748/wjg.v21.i35.10062] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2015] [Revised: 05/29/2015] [Accepted: 08/25/2015] [Indexed: 02/06/2023] Open
Abstract
There is a discrepancy between the information from clotting tests which have routinely been used in clinical practice and evidence regarding thrombotic and bleeding events in patients with liver disease. This discrepancy leads us to rely on other variables which have been shown to be involved in haemostasis in these patients and/or to extrapolate the behaviour of these patients to other settings in order to decide the best clinical approach. The aims of the present review are as follows: (1) to present the information provided by clotting tests in cirrhotic patients; (2) to present the factors that may influence clotting in these patients; (3) to review the clinical evidence; and (4) to put forward a clinical approach based on the first 3 points.
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Efficacy and safety of anticoagulation therapy with different doses of enoxaparin for portal vein thrombosis in cirrhotic patients with hepatitis B. Eur J Gastroenterol Hepatol 2015; 27:914-9. [PMID: 25856686 DOI: 10.1097/meg.0000000000000351] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patients with cirrhosis have a high incidence of portal vein thrombosis (PVT), and optimal management of PVT in cirrhotic patients remains unclear. Currently, there is no paper on optimal doses of enoxaparin for the management of PVT with cirrhosis. AIMS To evaluate the efficacy and safety of anticoagulation therapy with different doses of enoxaparin for PVT in cirrhotic patients with hepatitis B. MATERIALS AND METHODS Sixty-five patients with hepatitis B-related cirrhosis and acute PVT were treated by different doses of enoxaparin. All the patients were assigned randomly to two groups: one group received enoxaparin 1 mg/kg subcutaneously every 12 h and the other group received enoxaparin 1.5 mg/kg subcutaneously every 24 h. Clinical, biochemical evaluation, Doppler ultrasound, and contrast-enhanced computed tomography were performed during the anticoagulation treatment. RESULTS Of the 65 patients, 51 patients (78.5%) achieved complete/partial recanalization of PVT after 6 months of anticoagulation therapy. Child-Pugh scores were lower in the 51 patients who achieved complete/partial recanalization than those of the 14 nonresponders (P<0.01). No patients showed variceal bleeding during anticoagulation therapy in the two groups. The rates of nonvariceal bleeding with the use of 1.5 mg/kg every 24 h (23.5%) were higher than those with the use of 1 mg/kg every 12 h (6.4%). CONCLUSION Anticoagulation therapy with different doses of enoxaparin for PVT in hepatitis B patients with cirrhosis is efficient and safe, and 1 mg/kg enoxaparin subcutaneously every 12 h is a better anticoagulation regimen in the treatment of PVT in cirrhotic patients.
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Rodríguez-Castro KI, Antonello A, Ferrarese A. Spontaneous bleeding or thrombosis in cirrhosis: What should be feared the most? World J Hepatol 2015; 7:1818-1827. [PMID: 26207163 PMCID: PMC4506939 DOI: 10.4254/wjh.v7.i14.1818] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Revised: 03/30/2015] [Accepted: 05/06/2015] [Indexed: 02/06/2023] Open
Abstract
The more modern and accurate concept of a rebalanced hemostatic status in cirrhosis is slowly replacing the traditional belief of patients with cirrhosis being “auto-anticoagulated”, prone only to bleeding complications, and protected from thrombotic events. With greater attention to clinical thrombotic events, their impact on the natural history of cirrhosis, and with the emergence and increased use of point-of-care and global assays, it is now understood that cirrhosis results in profound hemostatic alterations that can lead to thrombosis as well as to bleeding complications. Although many clinical decisions are still based on traditional coagulation parameters such as prothrombin (PT), PT, and international normalized ratio, it is increasingly recognized that these tests do not adequately predict the risk of bleeding, nor they should guide pre-emptive interventions. Moreover, altered coagulation tests should not be considered as a contraindication to the use of anticoagulation, although this therapeutic or prophylactic approach is not at present routinely undertaken. Gastroesophageal variceal bleeding continues to be one of the most feared and deadly complications of cirrhosis and portal hypertension, but great progresses have been made in prevention and treatment strategies. Other bleeding sites that are frequently part of end-stage liver disease are similar to clinical manifestations of thrombocytopenia, with gum bleeding and epistaxis being very common but fortunately only rarely a cause of life-threatening bleeding. On the contrary, manifestations of coagulation factor deficiencies like soft tissue bleeding and hemartrosis are rare in patients with cirrhosis. As far as thrombotic complications are concerned, portal vein thrombosis is the most common event in patients with cirrhosis, but venous thromboembolism is not infrequent, and results in important morbidity and mortality in patients with cirrhosis, especially those with decompensated disease. Future studies and the more widespread use of point-of-care tests in evaluating hemostasis will aid the clinician in decision making when facing the patient with bleeding or with thrombotic complications, with both ends of a continuum being potentially fatal.
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Riva N, Ageno W, Poli D, Testa S, Rupoli S, Santoro R, Lerede T, Piana A, Carpenedo M, Nicolini A, Ferrini PM, Tosetto A. Safety of vitamin K antagonist treatment for splanchnic vein thrombosis: a multicenter cohort study. J Thromb Haemost 2015; 13:1019-27. [PMID: 25845412 DOI: 10.1111/jth.12930] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Accepted: 03/16/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND The treatment of splanchnic vein thrombosis (SVT) is challenging, due to the increased risk of bleeding and potentially life-threatening complications. Current recommendations are based on evidence from the treatment of venous thrombosis in usual sites, but small observational studies in SVT population suggest that the bleeding risk may offset the benefit of anticoagulant treatment in this setting. The aim of this study was to evaluate the safety of vitamin K antagonists (VKAs) in SVT patients. METHODS We retrospectively included SVT patients treated with VKAs followed by 37 Italian anticoagulation clinics, until June 2013. The primary outcome was the incidence of major bleeding (MB), according to the ISTH definition, during VKA treatment. Vascular events, including both arterial and venous thrombosis, and mortality were also documented. RESULTS Three hundred and seventy-five patients were included (median age 53 years; 54.7% males). During a median VKA treatment duration of 1.98 years, 15 MB events occurred, corresponding to an incidence rate of 1.24 (95% confidence interval [CI], 0.75-2.06) per 100 patient-years. Gastrointestinal bleeding represented 40% of all MB events. At multivariate analysis, the presence of esophageal varices emerged as independent predictor of MB (hazard ratio 5.4; 95% CI, 1.4-21.1). The incidence rate of vascular events on treatment was 1.37 (95% CI, 0.84-2.23) per 100 patient-years and the mortality rate was 0.83 (95% CI, 0.44-1.54) per 100 patient-years. CONCLUSIONS Selected SVT patients followed by anticoagulation clinics for the management of VKA treatment show a low rate of major bleeding and vascular events.
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Affiliation(s)
- N Riva
- Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | - W Ageno
- Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | - D Poli
- Department of Heart and Vessels, Thrombosis Centre, AOU-Careggi, Florence, Italy
| | - S Testa
- Haemostasis and Thrombosis Centre, AO Istituti Ospitalieri, Cremona, Italy
| | - S Rupoli
- Division of Hematology, Haemostasis and Thrombosis Center, AOU Ospedali Riuniti Umberto I, G.M. Lancisi, G. Salesi, Ancona, Italy
| | - R Santoro
- Hemostasis and Thrombosis Unit, Hemophilia Center, Azienda Ospedaliera "Pugliese-Ciaccio", Catanzaro, Italy
| | - T Lerede
- Department of Immunohematology and Transfusion Medicine, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - A Piana
- Department of Internal Medicine, Ospedale S. Martino, Genoa, Italy
| | - M Carpenedo
- Department of Hematology and Transplant Unit, AO San Gerardo, Monza, Italy
| | - A Nicolini
- Department of Internal Medicine, Arcispedale Santa Maria Nuova, Reggio Emilia, Italy
| | - P M Ferrini
- Dipartimento Emergenza-Urgenza e Area Medica e Specialistica, AOU Parma, Parma, Italy
| | - A Tosetto
- Department of Hematology, Hemostasis and Thrombosis Center, S. Bortolo Hospital, Vicenza, Italy
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Dai J, Qi X, Li H, Guo X. Role of D-dimer in the Development of Portal Vein Thrombosis in Liver Cirrhosis: A Meta-analysis. Saudi J Gastroenterol 2015; 21:165-74. [PMID: 26021776 PMCID: PMC4455147 DOI: 10.4103/1319-3767.157567] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
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.
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Affiliation(s)
- Junna Dai
- Postgraduate School, Dalian Medical University, Dalian, China
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China
| | - Xingshun Qi
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China
- Address for correspondence: Prof. Hongyu Li, Prof. Xiaozhong Guo, Dr. Xingshun Qi, Department of Gastroenterology, General Hospital of Shenyang Military Area, No. 83 Wenhua Road, Shenyang, China. E-mail: , ,
| | - Hongyu Li
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China
- Address for correspondence: Prof. Hongyu Li, Prof. Xiaozhong Guo, Dr. Xingshun Qi, Department of Gastroenterology, General Hospital of Shenyang Military Area, No. 83 Wenhua Road, Shenyang, China. E-mail: , ,
| | - Xiaozhong Guo
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China
- Address for correspondence: Prof. Hongyu Li, Prof. Xiaozhong Guo, Dr. Xingshun Qi, Department of Gastroenterology, General Hospital of Shenyang Military Area, No. 83 Wenhua Road, Shenyang, China. E-mail: , ,
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Abdel-Razik A, Mousa N, Elhelaly R, Tawfik A. De-novo portal vein thrombosis in liver cirrhosis: risk factors and correlation with the Model for End-stage Liver Disease scoring system. Eur J Gastroenterol Hepatol 2015; 27:585-592. [PMID: 25769098 DOI: 10.1097/meg.0000000000000325] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND OBJECTIVES Portal vein thrombosis (PVT) is a potential lethal complication in late liver cirrhosis. There is a lack of knowledge of the clinical features and risk factors of PVT. We aimed to investigate the clinical and radiological characteristics, and biochemical markers of cirrhotic patients to determine the high-risk individuals for PVT attending our center. PATIENTS AND METHODS Of 426 cirrhotic patients, only 120 consecutive patients were included. Clinical, biochemical, immunological, Model for End-stage Liver Disease (MELD) score, portal vein patency, and flow velocity were measured in all patients at baseline and every 6 months thereafter. Variables that could predict the development of PVT within 1 year were identified by multiple logistic regression. RESULTS Only 95 patients completed the study; PVT was found in 17 (17.9%) patients. PVT was observed mainly in the portal trunk, superior mesenteric vein, and splenic vein. Univariate analysis showed that diabetes mellitus, lower levels of hemoglobin, platelet counts, and portal vein flow velocity as well as increased MELD scores, platelet indices, portal vein diameter, and splenic thickness were associated with PVT patients than in non-PVT patients (all P<0.01). CONCLUSION The incidence of PVT was 17.9%. PVT occurred mainly in the portal vein trunk, superior mesenteric vein, and splenic vein. Diabetes mellitus, lower levels of hemoglobin, platelet count and portal vein flow velocity as well as increased MELD score, platelet indices, portal vein diameter, and splenic thickening were associated with PVT. Splenic thickening, marked reduced of mean portal flow velocity, and diabetes mellitus may be risk factors for PVT.
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Affiliation(s)
- Ahmed Abdel-Razik
- Departments of aTropical Medicine bClinical Pathology cDiagnostic and Interventional Radiology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
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Zhou J, Yang JH. Progress in treatment of nontumoral portal vein thrombosis in liver cirrhosis. Shijie Huaren Xiaohua Zazhi 2015; 23:735-740. [DOI: 10.11569/wcjd.v23.i5.735] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Portal vein thrombosis (PVT) is not uncommon in patients with liver cirrhosis, and it increases the risk of gastroesophageal hemorrhage. At present, pharmacological treatment is the preferred selection of management of PVT. Studies have shown that anticoagulation therapy does not increase the risk of gastrointestinal bleeding. Therefore, patients having indications should be given anticoagulation therapy as early as possible. When patients fail to respond to anticoagulation therapy, interventional therapy or surgery may be considered. This article reviews the recent knowledge about the treatment of PVT and discusses the progress in treatment of nontumoral PVT in liver cirrhosis.
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Lee SJ, Uhm JS, Kim JY, Pak HN, Lee MH, Joung B. The safety and efficacy of vitamin K antagonist in patients with atrial fibrillation and liver cirrhosis. Int J Cardiol 2015; 180:185-91. [DOI: 10.1016/j.ijcard.2014.11.183] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Revised: 10/14/2014] [Accepted: 11/23/2014] [Indexed: 01/15/2023]
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Qi X, De Stefano V, Li H, Dai J, Guo X, Fan D. Anticoagulation for the treatment of portal vein thrombosis in liver cirrhosis: a systematic review and meta-analysis of observational studies. Eur J Intern Med 2015; 26:23-9. [PMID: 25566699 DOI: 10.1016/j.ejim.2014.12.002] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Revised: 12/03/2014] [Accepted: 12/09/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Systematic review and meta-analysis were performed to evaluate the safety and efficacy of anticoagulation for the treatment of portal vein thrombosis (PVT) in cirrhotic patients. METHODS The PubMed, EMBASE, Cochrane Library, and ScienceDirect databases were searched. The rates of bleeding complications and portal vein recanalization in patients who received anticoagulant therapy were pooled. The odds ratio (OR) with 95% confidence interval (CI) was calculated to express the difference in the rate of portal vein recanalization between anticoagulation and non-anticoagulation groups. All meta-analyses were conducted by using a random-effects model. RESULTS Sixteen of 960 initially identified papers were included. Two studies reported a low incidence of major anticoagulation-related complications (4% [2/55] and 3% [1/33]), but no lethal complications occurred. The rate of anticoagulation-related bleeding ranged from 0% to 18% with a pooled rate of 3.3% (95% CI=1.1%-6.7%). The heterogeneity was not significant in the meta-analysis. The total rate of portal vein recanalization ranged from 37% to 93% with a pooled rate of 66.6% (95% CI=54.7%-77.6%). The rate of complete portal vein recanalization ranged from 0% to 75% with a pooled rate of 41.5% (95% CI=29.2%-54.5%). However, the heterogeneity was significant in the 2 meta-analyses. The rate of complete portal vein recanalization was significantly higher in anticoagulation group than in non-anticoagulation group (OR=4.16, 95% CI=1.88-9.20, P=0.0004). The heterogeneity was not significant in the meta-analysis. CONCLUSION Anticoagulation could achieve a relatively high rate of portal vein recanalization in cirrhotic patients with PVT. Given that only a small number of non-randomized comparative studies are reported, randomized controlled trials are warranted to confirm the risk-to-benefit of anticoagulation in such patients, especially anticoagulation-related bleeding.
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Affiliation(s)
- Xingshun Qi
- Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China; Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China.
| | | | - Hongyu Li
- Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China.
| | - Junna Dai
- Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China.
| | - Xiaozhong Guo
- Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China.
| | - Daiming Fan
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China.
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Aiyappan SK, Ranga U, Veeraiyan S. Unusual cause for abdominal pain in cirrhosis : thrombosed intrahepatic portal vein aneurysms. J Clin Diagn Res 2014; 8:MD01-2. [PMID: 25478385 DOI: 10.7860/jcdr/2014/9536.4940] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2014] [Accepted: 07/08/2014] [Indexed: 11/24/2022]
Abstract
Portal venous system aneurysm is a rare condition with very few reported cases in English literature. With the increasing availability of advanced imaging modalities like Doppler ultrasound, computed tomography and magnetic resonance imaging, portal venous system aneurysms are being increasingly reported. Here, we report a rare case of multiple intrahepatic portal venous system aneurysms complicated by thrombosis in a young patient with chronic liver disease and portal hypertension.
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Affiliation(s)
- Senthil Kumar Aiyappan
- Associate Professor, Department of Radiodiagnosis and Imaging, Saveetha Medical College and Hospital , Thandalam, Kancheepuram, Tamilnadu, India
| | - Upasana Ranga
- Associate Professor, Department of Radiodiagnosis and Imaging, Saveetha Medical College and Hospital , Thandalam, Kancheepuram, Tamilnadu, India
| | - Saveetha Veeraiyan
- Professor, Department of Radiodiagnosis and Imaging, Saveetha Medical College and Hospital , Thandalam, Kancheepuram, Tamilnadu, India
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Cerini F, Garcia-Pagán JC. Thromboprophylaxis with heparin in hospitalized patients with cirrhosis: friend or foe. Liver Int 2014; 34:971-3. [PMID: 24382271 DOI: 10.1111/liv.12453] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Accepted: 12/22/2013] [Indexed: 02/13/2023]
Affiliation(s)
- Federica Cerini
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, IDIBAPS and CIBERehd, Hospital Clinic, IMDIM, Barcelona, Spain
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Aggarwal A, Puri K, Liangpunsakul S. Deep vein thrombosis and pulmonary embolism in cirrhotic patients: Systematic review. World J Gastroenterol 2014; 20:5737-5745. [PMID: 24914335 PMCID: PMC4024784 DOI: 10.3748/wjg.v20.i19.5737] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Revised: 12/31/2013] [Accepted: 02/27/2014] [Indexed: 02/06/2023] Open
Abstract
Patients with liver cirrhosis were traditionally believed to be protected against development of blood clots. Lately, studies have shown that these patients may probably be at an increased risk of venous thrombotic complications. Although the hemostatic changes in the chronic liver disease patients and the factors that may predict bleeding vs thrombotic complications remains an area of active research, it is believed that the coagulation cascade is delicately balanced in these patients because of parallel reduced hepatic synthesis of pro and anticoagulant factors. Thrombotic state in cirrhotic patients is responsible for not only portal or non-portal thrombosis [deep vein thrombosis (DVT) and pulmonary embolism (PE)]; it has also been associated with progression of liver fibrosis. The use of anticoagulants in cirrhosis patients is a challenging, and often a scary situation. This review summarizes the current literature on the prevalence of venous thrombosis (DVT and PE), risk factors and safety of prophylactic and therapeutic anticoagulation in patients with chronic liver disease.
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Intagliata NM, Henry ZH, Shah N, Lisman T, Caldwell SH, Northup PG. Prophylactic anticoagulation for venous thromboembolism in hospitalized cirrhosis patients is not associated with high rates of gastrointestinal bleeding. Liver Int 2014; 34:26-32. [PMID: 23758818 DOI: 10.1111/liv.12211] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Accepted: 04/29/2013] [Indexed: 02/13/2023]
Abstract
BACKGROUND Hospitalized patients with cirrhosis are at risk to develop venous thromboembolism. Although current guidelines support the routine administration of thromboprophylaxis to hospitalized patients, there is limited data regarding the safety or efficacy of this practice in hospitalized cirrhosis patients. AIMS We aimed to determine if administration of thromboprophylaxis was associated with increased complication rates for hospitalized cirrhosis patients. METHODS Data were collected on patients admitted to the University of Virginia between 2007 and 2010. Study personnel systematically collected data on complications, including gastrointestinal bleed, venous thromboembolism and death directly from the medical record. RESULTS A total of 235 patients (accounting for 355 discrete hospitalizations in which thromboprophylaxis was administered) met inclusion criteria accounting for 1660 person-days of thromboprophylaxis administered to patients. The mean age at admission was 58 (95% CI 57.1-59.2) years and 217 (61%) were male patients. The mean admission model for end-stage liver disease (MELD) score was 16.2 (95% CI 15.5-16.9). The mean hospital length of stay was 6.5 (95% CI 5.9-7.4) days. In patients who received thromboprophylaxis, the mean treatment length was 4.7 days (95% CI 4.2-5.2). There were nine gastrointestinal bleeding events (2.5% of admissions), five venous thromboembolisms (1.4% of admissions), two cases of heparin-induced thrombocytopenia (0.5% of admissions) and 14 deaths overall (3.9% of admissions). CONCLUSIONS The use of thromboprophylaxis in hospitalized cirrhosis patients is not associated with high rates of gastrointestinal bleeding or death.
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Affiliation(s)
- Nicolas M Intagliata
- Division of Gastroenterology and Hepatology, Center for Coagulation Disorders in Liver Disease, University of Virginia, Charlottesville, VA, USA
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Abstract
Portal vein thrombosis (PVT) can contribute to significant morbidity and mortality; in patients with cirrhosis, this can make transplant more technically challenging. Additionally, the clot may extend further into the mesenteric and splenic veins, and disturbance of the hepatic blood flow may lead to faster progression of the cirrhosis. Development of PVT is associated with local risk factors, and many patients have associated systemic prothrombotic factors. Anticoagulation in noncirrhotic patients should be initiated at diagnosis, using low-molecular-weight heparin overlapping with vitamin K antagonists. Cirrhotic patients with PVT should be screened for varices and then anticoagulated with low-molecular-weight heparin for at least a 6-month period. All patients should be assessed for triggering factors and tumors, as well as systemic prothrombotic factors. Newer evidence suggests that prophylactic anticoagulation in patients with cirrhosis may have a role in clinical management with decreased incidence of PVT and improved survival; further study is needed.
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Affiliation(s)
- Stephen E Congly
- Department of Medicine, University of Calgary Liver Unit, 3330 Hospital Drive NW, Calgary, AB, Canada, T2N 4N1
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Husic-Selimovic A, Gornjakovic S, Schuchmann M, Vukobrat-Bijedic Z. Evaluation of portal vein thrombosis in liver graft ten years after liver transplantation due to budd-Chiari syndrome using Doppler ultrasound. Acta Inform Med 2013; 20:194-5. [PMID: 23322979 PMCID: PMC3508857 DOI: 10.5455/aim.2012.20.194-195] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Accepted: 07/20/2012] [Indexed: 11/07/2022] Open
Abstract
Budd-Chiari syndrome is a rare but life-threatening disorder characterized by obstruction of the hepatic venous outflow. Treatment depends on underlying cause, extent of the obstruction and functional capacity of the liver. When all other therapy options are unsuccessful, liver transplant should be considered. Portal vein thrombosis (PVT) is a frequent event in patients with cirrhosis which can be treated with anticoagulants, but there are limited data regarding safety and efficacy of this approach.
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Affiliation(s)
- Azra Husic-Selimovic
- Gastroenterohepatology Department, Clinical center of University of Sarajevo, Sarajevo, Bosnia and Herzegovina
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